Aim: The aim of this study was to visualize vulnerabilities and explore the dynamics of inter-professional collaboration and organizational adaptability in the context of care transitions for patients with complex care needs.

Design: An ethnographic design using multiple convergent data collection techniques.

Methods: Data collection involved document review, participant observations and interviews with healthcare and social care professionals (HSCPs). Narrative analysis was employed to construct two illustrative patient scenarios, which were then examined using the Functional Resonance Analysis Method (FRAM). Thematic analysis was subsequently applied to synthesize the findings.

Results: Inconsistencies in timing and precision during care transitions pose risks for patients with complex care needs as they force healthcare systems to prioritize structural constraints over individualized care, especially during unforeseen events outside regular hours. Such systemic inflexibility can compromise patient safety, increase the workload for HSCPs and strain resources. Organizational adaptability is crucial to managing the inherent variability of patient needs. Our proposed ‘safe care transition pathway’ addresses these issues, providing proactive strategies such as sharing knowledge and increasing patient participation, and strengthening the capacity of professionals to meet dynamic care needs, promoting safer care transitions.

Conclusion: To promote patient safety in care transitions, strategies must go beyond inter-professional collaboration, incorporating adaptability and flexible resource planning. The implementation of standardized safe care transition pathways, coupled with the active participation of patients and families, is crucial. These measures aim to create a resilient, person-centred approach that may effectively manage the complexities in care transitions.

Implications: The recommendations of this study span the spectrum from policy-level changes aimed at strategic resource allocation and fostering inter-professional collaboration to practical measures like effective communication, information technology  integration, patient participation and family involvement. Together, the recommendations offer a holistic approach to enhance care transitions and, ultimately, patient outcomes.

The challenge of ensuring patient safety and continuity of care during complex care transitions necessitates a deeper understanding beyond what traditional research methodologies typically offer. This study explores the integration of the Functional Resonance Analysis Method (FRAM) with ethnographically derived patient scenarios to thoroughly investigate the complexities, variabilities, and unforeseen dynamics within these transitions.

Adopting an ethnographic methodology, patient scenarios were developed through comprehensive document reviews, participant observations and interviews with 37 healthcare professionals across multiple healthcare environments. These scenarios set the stage for applying the FRAM analysis, enabling an in-depth analysis of the care transition process. This approach is pivotal for identifying critical moments and decisions that significantly affect patient safety and for revealing potential system vulnerabilities.

The findings shed light on the daily practices and challenges healthcare professionals face during complex care transitions. The study highlights systemic vulnerabilities and areas prone to risks while emphasizing effective practices. The study further underscores the importance of patient and family participation in facilitating safe and seamless transitions. From the findings, a "safe care transition pathway” is presented, offering a structured approach that encapsulates strategies for patient and family participation, and recommendations for overcoming identified vulnerabilities.

The study demonstrates that combining the FRAM with ethnographic research and patient scenarios offers a comprehensive and nuanced methodology for analyzing complex healthcare processes. This approach is particularly valuable for uncovering the variabilities and emergent behaviors that can affect care transitions. The study provides a scaffold for future nursing research and practice to improve understanding and management of complex care transitions in healthcare environments.In presenting at the FRAMily workshop, the goal is to showcase this study as a practical application of the FRAM in nursing research, illustrating its capacity to uncover and address the multifaceted factors impacting patient safety during care transitions. The presentation will not only disseminate the findings of the study but also stimulate discussion on the practical implications for nursing practice and policy, advocating for wider implementation of the FRAM to enhance the analysis and improvement of complex healthcare processes.

Background

Navigating care transitions for patients with complex care needs represent a formidable challenge, where resilience becomes a crucial benchmark for quality and safety. There is a need to develop a healthcare infrastructure that not only reacts to disruptions but also proactively strengthens its capacity for continuity and patient safety. By addressing vulnerabilities and enhancing systemic responsiveness, the study illustrates how a coordinated, patient-centered approach is pivotal in building a healthcare infrastructure that can effectively navigate and adapt to challenges, thereby embodying the essence of resilient healthcare.

Objective

The aim of the study was to visualize vulnerabilities inherent in care transitions and to demonstrate how resilience—manifested through interprofessional collaboration and organizational adaptability—can fortify these critical junctures for patients with complex care needs.

Methods

Employing an ethnographic methodology, we engaged in document review, participant observations, and interviews with an array of healthcare and social care professionals involved in the care trajectory of patients with complex care needs. Narrative analysis was employed to construct two illustrative patient scenarios, which were then examined using the Functional Resonance Analysis Method (FRAM). Thematic analysis was subsequently applied to synthesize the findings.

Results

Our findings reveal that timing and precision variability during care transitions not only exacerbate vulnerabilities but also jeopardize patient safety. The inherent systemic rigidity, particularly during non-standard hours, amplifies the strain on resources and escalates the demands placed on care providers. In the face of patient needs' inherent unpredictability, the capacity of an organization to adapt is not just advantageous but essential. The crux of resilience in this context is interprofessional collaboration, which empowers healthcare teams to manage care proactively and navigate transitions more securely. Through collaborative practices, professionals are equipped to pool knowledge, predict fluctuations in patient conditions, and proactively coordinate responses to unexpected situations.

Conclusions

We advocate for a resilient model of care transition that is anchored in the collaborative synergy of healthcare teams, strategic resource management, and robust communication infrastructures. This model advocates for the vital contributions of frontline workers, patients, and their families, suggesting that their involvement is key in overcoming systemic obstacles and championing integrated, person-centered care. Our proposed pathway seeks to foster a healthcare environment where resilience is ingrained in the culture and practices, thereby ensuring safe, continuous, and responsive care transitions for all patients, particularly those with complex care needs.

Hospitals work to provide quality, safety, and availability to patients with a wide variety of care needs, which makes efficient prioritisation and resource utilisation essential. Anticipation of each patients' trajectory, while monitoring available resources across the hospital, are major challenges for patient flow management. This study focuses on how hospital patient flow management is realised in situ with the help of concepts from cognitive systems engineering. Five semi-structured interviews with high level managers and shadowing observations of seven full work-shifts with management teams were conducted, to explore how patient flow is coordinated and communicated across the hospital. The data has been analysed using qualitative content analysis. The results describe patient flow management using an adapted Extended Control Model (ECOM) and reveal how authority and information might be better placed closer to clinical work for increased efficiency of patient flow.

Practitioner summary: This study describes how a large tertiary paediatric hospital's patient flow management functions. The results offer a new understanding of how patient flow management is communicated and coordinated across organisational levels of the hospital and how authority and information might be better placed closer to clinical work for increased efficiency.

Objectives: The highly differentiated and specialized healthcare systems are not optimally designed to provide patients with chronic conditions in need of treatment from multi-professional teams with a smooth and seamless care trajectory. Care transitions, especially hospital discharge, tend to be critical for patients' safety and health outcomes. Interprofessional team collaboration across care providers is crucial for efficient and safe care transitions, depending on dynamic and adaptive teams in the unavoidable uncertainty characterizing today's healthcare systems. 

This study explores adaptation and maladaptations in horizontal team collaboration in care transitions of vulnerable patients with complex care needs at discharge from hospital to their private homes.

Methods: The study was conducted in a southern region in Sweden using an ethnographic methodology with participatory observations, document review and interviews. A total of 77 professionals from hospital and primary care participated. A purposive sampling strategy was utilized to capture the interprofessional team collaboration across organizations in the patient's care transition from hospital to home. The comprehensive data was then applied to two patient cases and analysed with the Functional Resonance Analysis Method.

Results: Successful team adaptations as well as maladaptations are revealed as homecare team and patients attempt to manage the uncontrolled conditions in the home after discharge. Maladaptations occur as the organizational capacity is insufficient to meet the needs of the patients in their home environment. The demands challenge the resources of the patient, his or her family, and the homecare team must anticipate and adapt to the unexpected to maintain patient safety. Whether the team adaptations of preparing discharge were successful or not will be revealed through adaptive outcomes or adverse events. 

Information sharing emerges as a central prerequisite for successful team collaboration in care transitions. Flawed or insufficient access to information affected the team performance by hindering anticipating and planning for the care at home. In exacerbations of the chronic illness, information access and communication are needed to obtain a holistic view and respond to the altered care needs. For the team to adapt to the new demands, each team member require a clear understanding of their own as well as other team member’s roles and responsibilities. Ambiguity or imprecision could lead to uncertainty of who does what and where lines are drawn between organizations. 

By interprofessional collaboration during the discharge planning, a shared understanding of treatment and care needed at home is distributed to the team as a collective cognitive mind. Through a shared mental model, the team may anticipate and prepare for the patient's arrival home. When the team collaboration failed or communication was insufficient, gaps appeared, which pressed the need for further adaptations. Successful adaptations could bridge the gaps, maintaining safe and secure care for the patient, while maladaptations posed a risk of patient harm or re-hospitalisation.

Conclusion: To maintain patient safety in transitional care from hospital to home, adaptations to the variability of the system are not to be stifled. Instead, the system needs to allow for flexibility, promoting availability of all resources needed since these are hard to predict. Responding to unexpected events and variations requires allocated resources in the first few days of homecoming, allowing for flexibility and thus increasing patient safety.

The maritime industry is experiencing a steady evolution towards a concept of fully automated ship operation. The implementation and use of automated systems have been debated for many decades, and yet substantial issues remain regarding its achievements in terms of improved safety and efficiency (Wiener and Curry, 1980). The assessment of potential impacts (i.e. risk assessment) emerging from the introduction of automation remains a key challenge. The integration and streamlining of operations significantly increase complexity, and the transformations that are introduced tend to produce unforeseen side effects, often with serious safety consequences (Dekker et al., 2011). © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

Non-technical skills (NTS) training is an important part of frontline operator training across many high-risk domains. Within maritime education and training (MET), NTS are trained as part of Maritime Resource Management (MRM) courses. MRM represents the maritime adaptation of the original crew resource management training from the aviation domain. While the ambition of resource management training is to enhance team performance, research reports a strong focus on the assessment and measurement of NTS on an individual level, not always taking the team as unit of analysis into concern. Therefore, this paper aims to contribute to a critical discussion of the relationship between NTS and teamperformance. It explores how to potentially analyze the relationship between NTS and experiences of operational resilience an presents an attempt to operationalize NTS and resilience cornerstones (REC) in a questionnaire for maritime trainees. While the questionnaire focuses on the maritime domain, the lessons learned from the construction of items may guide the development of further operationalization in other high-risk domains.

This article presents a proposal for a debriefing tool developed to support the development of bridge resource management skills of nautical science students. This debriefing tool consists of a set of questions that aim to trigger reflection about the bridge team’s performance during simulator exercises. The tool has been tested by students in conjunctions with the ship handling exercises. After this test, feedback from the students has been obtained through a focus group. The results show constrains that may jeopardize the utilization of a debriefing tool, but also encourages discussions regarding undesirable and desirable outcomes, gathering a channel for feedbacks. The study also indorsed this tool as a way of enhancing performance through the understanding, development and training of individual competences needed for a safe onboard work.

This paper presents a comparative study of training of non-technical skills in the maritime and lignite power domains. Non-technical skills (NTS) are the cognitive, social and personal resource skills that complement technical skills in operations within high-risk domains. Training NTS is essential to maintain safety in operational contexts, such as onboard a merchant vessel or in the operation of a lignite power plant. Contextual interviews and observations have been conducted across 8 operator training courses, three maritime and five lignite power. The results indicate that the training approaches and their execution differs greatly despite having a common theoretical basis. While training in the observed maritime courses often combined longer theoretical lectures with group exercises and high-fidelity simulations, the focus of the training remained on the use of specific NTS techniques or tools to prevent accidents and incidents. In contrast to this approach, the training in the lignite power domain primarily focused on how to integrate selected NTS into daily operations. While the lignite training also utilized incident examples and shorter lectures, the focus remained on simulating everyday work tasks and to apply newly learned practices as part of routine operations and standard operational procedures. Further, trainees in the lignite training courses were empowered to take charge of their learning processes, as parts of the training let them recreate situations from their work within the simulator. This article highlights lessons learned from each domain with the goal of improving training practices for NTS in high-risk operations.

This pilot study serves as a starting point to explore the process of finding and evaluating YouTube videos for non-technical skills training for crew resource management courses. Five videos on situation awareness were identified using a combination of Boolean search strategies, relevance of the content and ratings from YouTube users. In the next step, the videos were evaluated, showing variations in education quality between videos. Moreover, preliminary finding show that user-generated comments and ratings might be of little use for guiding the search for high-quality content on YouTube. A closer analysis of the content shows how tensions between scientific concepts and practical illustrations of situation awareness is seen in the videos. This might create a dilemma for teachers in choosing between theoretically complete and authentic content. Research that further explores the ways discursive transformations of human factors concepts occur through everyday uses in popular media such as YouTube is suggested.