Johan Bergström

On the rationale of resilience in the domain of safety: A literature review

Resilience is becoming a prevalent agenda in safety research and organisational practice. In this study we examine how the peer-reviewed safety science literature (a) formulates the rationale behind the study of resilience; (b) constructs resilience as a scientific object; and (c) constructs and locates the resilient subject. The results suggest that resilience engineering scholars typically motivate the need for their studies by referring to the inherent complexities of modern socio-technical systems; complexities that make these systems inherently risky. The object of resilience then becomes the capacity to adapt to such emerging risks in order to guarantee the success of the inherently risky system. In the material reviewed, the subject of resilience is typically the individual, either at the sharp end or at higher managerial levels. The individual is called-upon to adapt in the face of risk to secure the continuous performance of the system. Based on the results from how resilience has been introduced in safety sciences we raise three ethical questions for the field to address: (1) should resilience be seen as people thriving despite of, or because of, risk?; (2) should resilience theory form a basis for moral judgement?; and finally (3) how much should resilience be approached as a trait of the individual?

Complicated, complex, and compliant: best practice in obstetrics

In this study, the distinction between complicated and complex is used to shed some light on compliance with best practice guidelines. Data were gathered related to obstetric practice in labor wards and operating theaters at two Scandinavian hospitals, one of them being a university hospital, and in a training facility. The complexity of obstetrical intervention is analyzed in this paper, as is the potential of compliance-based routines in obstetrics. Complex situations are different from complicated ones and patient safety management efforts should recognize and enhance the sort of diversity that helps the emergence of resilience in complex situations.

Team Coordination in Escalating Situations: An Empirical Study Using Mid-Fidelity Simulation

The performance of teams, with different levels of domain and crisis management experience, managing unexpected and escalating situations was observed using a mid-fidelity ship-bridge simulation and analysed by applying the central concepts of joint activity coordination as well as Woodss theory building on data overload. The coordination strategies used by the teams were evaluated by applying coordination process indicators and the concept of control. The paper discusses how different aspects of team coordination in unexpected and escalating situations, e.g. that teams that maintain a high level of control in escalating situations, avoid or minimize the effects of data overload by using explicit and agreed-upon goals rather than sharing as much incoming information as possible. The results presented in this paper show the benefits of applying a broad set of theoretical concepts to shed light on the actual demands that escalating situations pose on peoples data processing capacities and processes. It also provides guidance on the successful performance of teams in such situations and thus support for the development of successful strategies for their management.

Bridging the macro and the micro by considering the meso: reflections on the fractal nature of resilience

We pursued the following three interconnected points: (1) there are unexplored opportunities for resilience scholars from different disciplines to cross-inspire and inform, (2) a systems perspective may enhance understanding of human resilience in health and social settings, and (3) resilience is often considered to be fractal, i.e., a phenomenon with recognizable or recurring features at a variety of scales. Following a consideration of resilience from a systems perspective, we explain how resilience can, for analytic purposes, be constructed at four scales: micro, meso, macro, and cross-scale. Adding to the cross-scale perspective of the social-ecological field, we have suggested an analytical framework for resilience studies of the health field, which incorporates holism and complexity by embracing an ecological model of cognition, something supported by empirical studies of organizations in crisis situations at various spatial as well as temporal scales.

Anaesthesia monitor alarms: a theory-driven approach

The development of physiologic monitors has contributed to the decline in morbidity and mortality in patients undergoing anaesthesia. Diverse factors (physiologic, technical, historical and medico-legal) create challenges for monitor alarm designers. Indeed, a growing body of literature suggests that alarms function sub-optimally in supporting the human operator. Despite existing technology that could allow more appropriate design, most anaesthesia alarms still operate on simple, pre-set thresholds. Arguing that more alarms do not necessarily make for safer alarms is difficult in a litigious medico-legal environment and a competitive marketplace. The resultant commitment to the status quo exposes the risks that a lack of an evidence-based theoretical framework for anaesthesia alarm design presents. In this review, two specific theoretical foundations with relevance to anaesthesia alarms are summarised. The potential significance that signal detection theory and cognitive systems engineering could have in improving anaesthesia alarm design is outlined and future research directions are suggested. Practitioner Summary: The development of physiologic monitors has increased safety for patients undergoing anaesthesia. Evidence suggests that the full potential of the alarms embedded within those monitors is not being realised. In this review article, the authors propose a theoretical framework that could lead to the development of more ergonomic anaesthesia alarms.

Mind the gap between recommendation and implementation—principles and lessons in the aftermath of incident investigations: a semi-quantitative and qualitative study of factors leading to the successful implementation of recommendations

Objectives Using the findings of incident investigations to improve patient safety management is well-established and mandatory under Swedish law. This study seeks to identify the mechanisms behind successful implementation of the recommendations of incident investigations. Setting This study was based in a university hospital in southern Sweden. Participants A sample of 55 incident investigations from 2008 to 2010 were selected from the hospitals incident reporting system by staff in the office of the chief medical officer. These investigations were initiated by 23 different commissioning bodies and contained 289 separate recommendations. We used a three-stage method: content analysis to code the recommendations, semi-structured interviews with the commissioning bodies focusing on which recommendations had been implemented and why, and data analysis of the coded recommendations together with data from the interviews. Results We found that a clear majority (70%) of the recommendations presented to the commissioning bodies were targeted at the micro-level of the organisation. In nearly half (45%) of all recommendations, actions had been taken and a clear majority (73%) of these were at the micro-level. Changes in the management positions of the commissioning bodies meant that very little further action was taken. Other actions, independent of incident investigations, were often taken within the organisation. Conclusions We conclude that two principles (‘close in space’ and ‘close in time’) seem to be important for bridging the gap between recommendation and implementation. The micro-level focus was expected because of the method of investigation used. Adverse events trigger organisational action independently of incident investigations.

Defining the functional resonance analysis space: Combining Abstraction Hierarchy and FRAM

System-thinking and related systemic methods enhance traditional risk and hazard assessments and accident analysis, as well as system design. The Functional Resonance Analysis Method (FRAM) is a recently developed method for systemic analysis. FRAM facilitates descriptions of the functional relations among system elements. In case of large systems (e.g. several agents, multiple procedures, many technical equipment), building a FRAM model may become a difficult task, moreover resulting in a complex model, with limited benefits for the purpose of the analysis.

Modelling complexity in everyday operations: functional resonance in maritime mooring at quay

Maritime operations are complex socio-technical activities, with many interacting agents. Such agents are acting based on different, sometimes conflicting, goals. The traditional approach for safety, based on decomposition and bimodality, might lead to ineffective analyses, ignoring the transient and hidden links among activities as they are performed in everyday work. In this sense, the Functional Resonance Analysis Method (FRAM) offers a representation of work-as-done, acknowledging variability as unavoidable and desirable in order to avoid failures and maintain production. This paper adopts FRAM in combination with an Abstraction/Agency framework to understand and contribute with new perspectives to the complexity of processes. This approach, in line with the principles of Resilience Engineering, is adopted in the traditionally underspecified operation of mooring at quay. The detailed model confirms the benefits of FRAM in representing complex highly coupled tasks, especially in combination with an analysis at different levels of abstractions. The outcomes of the study show how a FRAM model offers systemic and punctual insights for understanding emergent criticalities, analysing complex incident scenarios, identifying potential mitigating actions, exploring different varieties of work and gaining systemic knowledge.

How to assess team performance in terms of control: a protocol based on cognitive systems engineering

This article presents a protocol for assessing team performance in terms of control based on cognitive systems engineering theory. The protocol changes the focus of team performance assessment from good and bad behaviours towards team activity. By using Hollnagel’s contextual control model (COCOM), a protocol is developed so that team activity can be described as four control modes. Data is collected through observation and questionnaires and is analysed in time intervals. Each time interval is then given a control mode. Based on how the control mode changes over time, the performance of the team can be assessed. The protocol was tested in a pilot study where commanding staff exercises were analysed. The results show that the protocol can be used to identify differences in team performance. The study also gives empirical validity to COCOM in that the loss of control in emergencies corresponds to an opportunistic or a scrambled control mode.

The social process of escalation: a promising focus for crisis management research

BackgroundThis study identifies a promising, new focus for the crisis management research in the health care domain. After reviewing the literature on health care crisis management, there seems to be a knowledge-gap regarding organisational change and adaption, especially when health care situations goes from normal, to non-normal, to pathological and further into a state of emergency or crisis.DiscussionBased on studies of escalating situations in obstetric care it is suggested that two theoretical perspectives (contingency theory and the idea of failure as a result of incomplete interaction) tend to simplify the issue of escalation rather than attend to its complexities (including the various power relations among the stakeholders involved). However studying the process of escalation as inherently complex and social allows us to see the definition of a situation as normal or non-normal as an exercise of power in itself, rather than representing a putatively correct response to a particular emergency.ImplicationsThe concept of escalation, when treated this way, can help us further the analysis of clinical and institutional acts and competence. It can also turn our attention to some important elements in a class of social phenomenon, crises and emergencies, that so far have not received the attention they deserve. Focusing on organisational choreography, that interplay of potential factors such as power, professional identity, organisational accountability, and experience, is not only a promising focus for future naturalistic research but also for developing more pragmatic strategies that can enhance organisational coordination and response in complex events.