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Safeguard Magazine

Creating resilient systems

Dr CARL HORSLEY says viewing resilience as a system property provides a way to improve the design of work to improve staff wellbeing, patient experience, and organisational performance.

Modern healthcare is recognised as one of the most complex industries in existence. It relies on a massive, distributed network of people and technologies interacting across various system boundaries to deliver high quality care.

Additionally, healthcare systems must deliver the efficiency required to meet the ever-increasing demands of the entire population, while still meeting the individual needs of patients, and all within the backdrop of a need to constrain escalating costs. This is the reality of everyday work experienced by those working in healthcare.

In the last 20 years, there has been a recognition that this system, evolved to care for patients, is the same system that inadvertently harms so many, both patients and staff. Efforts to improve this reality have had limited results, despite much effort and attention (Wears & Sutcliffe, 2020).

One potential reason that healthcare remains an “error prone activity” (Paget, 2004) is because the work is intrinsically uncertain and experimental, with care based on a working theory of the problem at hand. This is especially true in settings with high degrees of urgency and clinical issues that evolve unpredictably, such as Emergency Medicine and Intensive Care. In such settings, it is not possible to write rules to cover every eventuality and the work remains necessarily underspecified.


Healthcare workers must constantly navigate these dynamic, risky waters, working together to create safer care for our patients. It is their ability to recognise and respond to changing patient and system demands that is at the heart of “resilient performance” in healthcare (Hollnagel, Wears, & Braithwaite, 2015).

This resilient performance was particularly visible during both the Whakaari eruption disaster and the recent system wide response to Covid, as people, teams and communities found innovative solutions to unprecedented challenges. While we rightly celebrate these extraordinary responses, they were built on the same practices of navigating uncertainty and risk that are enacted every day.

Yet the question remains: when does adaptation represent “resilient performance”, a flexible response to conflicting and dynamic demands, and when does it become “adaptive coping” whereby staff paper over the cracks of an increasingly strained system? And what is the toll on staff when they carry the full weight of the system’s “resilience”?


Overseas, healthcare has been rocked by several high-profile cases where organisations had pursued financial and production goals at the expense of patient care, resulting in many excess deaths. Staff concerns about the increasing difficulties in providing safe care remained unaddressed, and patients experienced increasingly poor care.

One thing that stands out from the reports of these events is the link between the experiences of staff and the quality of the care that was received by patients. Provider wellbeing is now recognised as a key requirement for the delivery of safe, effective, patient-centred care (Bodenheimer & Sinsky, 2014), yet the impacts of staff well-being and experience often remain invisible in our current approaches to improving patient safety and are subsequently unaddressed.

For example, there is a growing recognition of the impacts that “incivility” has on team functioning ( Being subjected to rudeness or abuse reduces the quality of care provided by that staff member and may lead to incivility being passed on to patients. Even witnessing an episode of rudeness or abuse impacts team functioning, leading to disengagement and reduced discretionary effort. It is this loss of “psychological safety”, the shared belief that the team is safe for interpersonal risk-taking, that leads to reduced team functioning and learning (Edmondson, 1999).


Yet rather than seeing incivility as the actions of “bad apples”, it is worth instead considering the concept of “bad orchards”, that is, the conditions that make such behaviours seem appropriate and acceptable. For example, if the organisational focus is predominantly on increasing production, to what extent does this place increasing demands on staff to get the job done? Is a similar amount of attention paid to the way in which the job is done and the unintended consequences this creates?

In other words, what is the gap between what organisations say they value and what they pay the most attention to? Understanding the drivers of behaviour can be useful in making visible the “local rationality” of staff, explaining why their actions make sense given the demands, constraints and information available to them at the time.

Healthcare also faces a growing problem with staff burnout and disengagement, with up to 50% of those in acute specialities reporting such issues. It is no coincidence that these are the areas in healthcare where complexity and acuity are greatest. Yet, even when there has been recognition of the impacts of work on staff, improvement efforts often focus on the individual in isolation from the work context, such as through efforts to build “personal resilience” or individual well-being programmes

As worthy as these may be, they inadvertently avoid addressing the very conditions that create the need for such interventions (Ripullone & Womersley, 2019). It is only by seeing healthcare workers as situated within a work context that we can start to address the issues more fully.


How then should we proceed to improve the design of work to improve staff wellbeing, patient experience and organisational performance?

First, given the link between the experiences of healthcare workers and the quality and safety of the care they provide, healthcare worker well-being and engagement are central to improving patient safety. As such, staff health and safety are integral to the core functioning of healthcare organisations, focused on providing the conditions for a high functioning, engaged and innovative workforce.

Second, rather than focusing on building a “safety culture”, we should instead focus on understanding the safety implications of the organisational culture (or cultures). This means understanding the organisational priorities as experienced by staff and making visible the often-conflicting demands and constraints that staff must navigate.

Third, we need to understand that resilience is a system property, not just an individual one. Rather than loading the entire adaptive capacity on the frontline workforce, we need to think about the way our systems balance creativity and constraint. If our systems remain rigid, then they may become brittle in dynamic conditions. At the same time, constant adaptation is both exhausting and inefficient. The key is to support staff to recognise and respond flexibly when conditions are changing, rather than abandon them to cope unaided.

Fourth, for our interventions to be effective in supporting staff, they must be based on an understanding of “work-as-done”, the messy reality of everyday work. Without this understanding, it is likely our interventions will be poorly matched and remain ineffective.


The aim of this work is about more than just health and safety, it’s really about designing “better work”. It’s providing a workplace where staff feel valued and supported by the wider system and contribute effectively. Where the realities of frontline work are visible and the system as a whole responds flexibly to challenge and change. It’s about supporting the people within our systems to provide the best care they possibly can, because when staff are cared for, so are their patients.


Bodenheimer, T., & Sinsky, C. (2014). From triple to quadruple aim: care of the patient requires care of the provider.  Annals of family medicine, 12(6), 573-576. doi:10.1370/afm.1713

Edmondson, A. (1999). Psychological Safety and Learning Behavior in Work Teams.  Administrative Science Quarterly, 44(2), 350-383. doi:10.2307/2666999

Hollnagel, E., Wears, R. L., & Braithwaite, J. (2015).  From Safety-I to Safety-II: A White Paper. Denmark, USA, Australia: University of Southern Denmark, University of Florida, USA, and Macquarie University, Australia.

Paget, M. A. (2004).  The unity of mistakes : a phenomenological interpretation of medical work. Philadelphia: Temple University Press.

Ripullone, K., & Womersley, K. (2019). Is resilience a trainable skill?  BMJ, 365, l2162. doi:10.1136/bmj.l2162

Wears, R. L., & Sutcliffe, K. M. (2020).  Still Not Safe. New York: Oxford University Press.

Dr Carl Horsley is an intensivist in the Critical Care Complex at Middlemore Hospital. He is among the speakers at the 2021 Safeguard conference in June.

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