Two sides of the story: bridging organizational and individual resilience – a qualitative study | BMC Health Services Research

Self-determination theory (SDT) is a valuable theoretical framework for understanding and describing both individual and organizational consequences, making it particularly useful for exploring the aim of this study. SDT is a socio-cognitive theory, derived from motivation research [13]. SDT posits the impact of organisational factors (such as job design, managerial styles, pay) on workers motivations and experiences is mediated by three basic psychological need constructs: the need for autonomy, for competence, and for relatedness (Table 1) [14]. SDT posits that fulfilment of all three are essential for individual employee adjustment, wellbeing, and psychological growth [15], promoting autonomous motivation and high-quality performance [16]. There is considerable literature that demonstrates autonomous motivations (characterised by individuals being engaged in an activity with a full sense of willingness, volition and choice) optimises employee functioning (performance, well-being, workplace civility) more than controlled motivations (characterised by individuals’ reluctant engagement, often through compulsion) [16, 17]. Further, it has been shown that even when the organization is not supportive, clinicians draw from autonomous motivation to provide good patient care as a mediator for ongoing clinical performance [11].

Design and setting

The study made use of an explorative qualitative design, including both-semi structured focus group interviews pre- and post-intervention and observations from workshops in the data collection process.

This study is a part of the Resilience in Healthcare (RiH) project, opting to strengthen the Norwegian healthcare system through the development and implementation of a resilience learning tool to translate resilience to clinical practice. The resilience learning tool used in this study is the Resilience in Healthcare Reflection tool. The tool is comprised of three different elements. Element 1: ‘Mapping’, which aims to provide awareness of resilience within the participating unit; Element 2: ‘Scenarios’, which aims to create understanding among the participants of what works well and why in their unit; and Element 3 ‘Reflection list’ which aims to allow for short reflections over own practice in everyday work situations. Please see overview in Fig. 1. The full version of the tool can be found in both Norwegian and English at: For information about the development process of the tool, please see [18, 19].

Description of the RiH learning tool [18]

The RiH learning tool was implemented and evaluated in nine different healthcare sites across 27 different units over four months. The intervention design was based on a train-the-trainer methodology [20] where 1 or 2 representatives from each unit was trained by researchers in how to use the different sections of the tool (55 representatives in total). The TTT staff then participated in different learning tool related assignments with their colleagues at each respective unit. For TTT workshop no.1, the TTT staff was trained in how to use the ‘mapping’ section of the tool; for TTT workshop no.2, the TTT staff was trained in how to use the ‘scenarios’ section in the tool; and for TTT workshop no.3, the TTT staff was trained in how to use the ‘reflection list’ in the tool. Between each TTT workshop, the TTT staff was asked to undertake two different assignments. Both assignments corresponded with the respective topic for the previous TTT workshop. Focus group interviews were held pre and post implementation, while observations was done during each TTT Workshop, as depicted in Fig. 1. No data collection was gathered during the different task assignments.

Overview of the intervention design and activities for all participating units

The nine different Norwegian healthcare sites, comprised six nursing homes, two hospitals and one homecare service, tested the RiH learning tool. The 27 different units were located in five different municipalities of varying sizes, ranging from rural municipalities to big cities. Five nursing homes were owned by a private not-for-profit enterprise in a large city; the sixth was a public nursing home in a small municipality. Both the hospitals and the home care service were publicly funded. The inclusion of different healthcare settings and a diversity of locations allowed for more holistic understanding than seeking to explore a specific, homogenous setting.

Participants

The senior management from each of the units accepted to participate in the implementation decided themselves who were going to be the staff representing their unit in the intervention and as such become the TTT staff that were responsible for participating in all workshops and carry out the designated activities. A total of 55 participants were chosen, 1–3 staff from each unit to ensure representation at all workshops and activities. There were no requirements to who could become the unites representative, some units therefore chose the senior managers themselves, while others selected other types of leaders such as management assistants or team leaders, or registered nurses or assistants. All 55 were invited to contribute to all of the data collection activities and attended based on their availability, with a minimum of one representative from each unit at all activities.

Data collection

Pre- and post-focus group interviews

Eight Semi-structured focus group interviews were performed pre -intervention (n = 47) and six focus group interviews were held post-intervention (n = 32), see Fig. 2, and supplementary file 1 and 2. The difference in number of informants between the pre- and post-focus group interviews was due to workload at their respective units. The data collection took place in later stages of the COVID − 19 pandemic, and as many of the included units were at times heavily impacted staff were unable to leave their work to take part in the focus group interviews. All focus group interviews lasted for 60–90 min and at least 2 researchers were present in all focus group interviews. Focus group interviews were audio recorded and transcribed verbatim. The subject of the pre-intervention focus group interviews was the description of current work practices according to the ten different capacities for resilience (structure, competence, learning, alignment, coordination, risk awareness, leadership, involvement, champions, and communication) [3]. Topic of post intervention focus group interviews included participant experiences of using the learning tool and the implementation process.

Observations

30 h of observations were performed at a total of 15 workshops, one for each of the TTT workshops that were held. All participating units attended a set of three different TTT workshops, time and place for their attendance were based upon geographical location and availability (see Fig. 2 for overview of all activities). In total workshop one had 39 participants, workshop two had 31 participants and workshop three had 32 participants). Between 2 and 4 researchers took part in the observation of all workshops, and observation notes were collected through a template to ensure consistency across the sites. Observations were used as means to identify particulars about the work taking place [21] as well as interactions and dynamics when using the tool and between the participants and with the tool (see supplementary file 3). Thirty hours of observations of the 15 workshops were included and described in a pre-design observation template.

All data collection was conducted in Norwegian.

Data analysis

In this sub-analysis all translated focus group interviews were reanalysed using the six-step routine of a deductive-inductive thematic analysis by Braun and Clarke [22].

All transcribed focus group interviews and observation notes were included in the analysis. As the focus of this paper is to better understand the motivation of champions in terms of contributing to organizational resilience, questions directly concerning the role of champions made up most of the dataset for this study. Champions is one of the resilient capacities [3] addressed in the interview guide using the questions: Are there individuals in your organization who take on extra responsibilities and tasks? Are there individuals in your organization that engage in training of others? How are champions identified in your organization? How does the unit support these champions in their work? What is the role of champions in your unit? All data were included as the informants spoke about champions during their responses to other questions.

The data analysis followed the six steps of thematic analysis. Step one ‘Familiarize yourself with the data’: Both author CHD and HBL re-read all transcripts, noting down and discussing initial ideas with author CC. It became evident that the data were suitable to be reanalysed deductively according to the SDT constructs of autonomy, competence, and relatedness. An additional code for data related to motivation but not in accordance with the three concepts of SDT was included.

In the second round of analysis, conducted in accordance with the SDT framework, the dataset was explored from a different perspective. Champions are found important for resilient performance and as an organizational resource in the resilience in healthcare literature [3]. By examining the motivation of champions to act as an organizational capacity, we gained insights into how to support these champions effectively.

Author HBL led steps two and three ‘Generating initial code’s and ‘Searching for themes’: Participant perceptions were coded deductively to one or more of the three constructs, autonomy, competence, and relatedness, and the ‘other’ code. When the first deductive round of analysis was completed, a second round of analysis was completed whereby the data in each of the codes/themes were inductively analysed to explore what these themes entailed for this study. All inductive themes were then organised into categories within each SDT construct. Emerging inductive themes under the relatedness concept included: ‘Engagement culture’, ‘Aligning organizational and individual goals’, and ‘Relationship broker’. Inductive themes for the autonomy concept included: ‘Flexibility’ and ‘Initiating’, Inductive themes for the Competence concept included ‘Knowledge sharing’ and ‘Experts as resources’ and the other category included the inductive theme ‘Personal characteristics’.

Step four Reviewing themes: Authors CHD and HBL separately reviewed the inductive themes to make sure the work stood in relation to the coded extracts.

Steps five and six Defining and naming the themes and producing the report: all authors collaborated to define themes further and author CC assisted with interpretation and semantic translation to English to preserve, not change, initial meaning.