Haraldseid‑Driftland et al.

BMC Health Services Research (2022) 22:1091

https://doi.org/10.1186/s12913-022-08451-y

RESEARCH ARTICLE Open Access

The role of collaborative learning

in resilience in healthcare—a thematic
qualitative meta‑synthesis of resilience
narratives
Cecilie Haraldseid‑Driftland1* , Stephen Billett2, Veslemøy Guise1, Lene Schibevaag1, Janne Gro Alsvik1,
Birte Fagerdal1, Hilda Bø Lyng1 and Siri Wiig1

Abstract
Background: To provide high quality services in increasingly complex, constantly changing circumstances, health‑
care organizations worldwide need a high level of resilience, to adapt and respond to challenges and changes at all
system levels. For healthcare organizations to strengthen their resilience, a significant level of continuous learning is
required. Given the interdependence required amongst healthcare professionals and stakeholders when providing
healthcare, this learning needs to be collaborative, as a prerequisite to operationalizing resilience in healthcare. As
particular elements of collaborative working, and learning are likely to promote resilience, there is a need to explore
the underlying collaborative learning mechanisms and how and why collaborations occur during adaptations and
responses. The aim of this study is to describe collaborative learning processes in relation to resilient healthcare based
on an investigation of narratives developed from studies representing diverse healthcare contexts and levels.
Methods: The method used to develop understanding of collaborative learning across diverse healthcare contexts
and levels was to first conduct a narrative inquiry of a comprehensive dataset of published health services research
studies. This resulted in 14 narratives (70 pages), synthesised from a total of 40 published articles and 6 PhD synopses.
The narratives where then analysed using a thematic meta-synthesis approach.
Results: The results show that, across levels and contexts, healthcare professionals collaborate to respond and adapt
to change, maintain processes and functions, and improve quality and safety. This collaboration comprises activi‑
ties and interactions such as exchanging information, coordinating, negotiating, and aligning needs and developing
buffers. The learning activities embedded in these collaborations are both activities of daily work, such as discussions,
prioritizing and delegation of tasks, and intentional educational activities such as seminars or simulation activities.
Conclusions: Based on these findings, we propose that the enactment of resilience in healthcare is dependent on
these collaborations and learning processes, across different levels and contexts. A systems perspective of resilience
demands collaboration and learning within and across all system levels. Creating space for reflection and awareness
through activities of everyday work, could support individual, team and organizational learning.

*Correspondence: [email protected]
1
SHARE ‑ Centre for Resilience in Healthcare, Faculty of Health Sciences,
University of Stavanger, N‑4036 Stavanger, Norway
Full list of author information is available at the end of the article

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Haraldseid‑Driftland et al. BMC Health Services Research (2022) 22:1091 Page 2 of 12

Keywords: Resilience, Healthcare, Quality, Collaborative learning, Organizational learning, Systems perspective

Background effort [15]. This is not surprising given that the complex
Healthcare services worldwide are provided in increas- nature of healthcare organizations means that health-
ingly complex, and always changing circumstances [1]. care provision has increasingly become a shared effort
These challenges and changes comprise those associ- amongst the different stakeholders who work collabora-
ated with i) the healthcare issues faced by the popula- tively, often across different professions, levels and con-
tion, ii) the dynamic character, conditions, and existing texts to address patients’ and families’ needs [16]. More
health of that population, iii) emerging therapies and specifically, the ability to adapt and respond to chal-
practices, iv) shifts in policies and practices associated lenges and changes relates to the ability to both work and
with the physical, organisational, environmental, and v) learn, collaboratively, which enables healthcare profes-
social circumstances in which healthcare provisions are sionals to actively develop a shared understanding and
enacted. Addressing such complex changing circum- provide quality care [15].
stances, in terms of patients’ needs, emerging therapies This high level of interdependence amongst health-
and practices and settings, therefore, becomes a neces- care professionals and other healthcare stakehold-
sity for all healthcare systems and healthcare profes- ers mandates that enhanced collaborative learning
sionals [2]. Recently, these complexities and constant skills, such as good communication and coordination
changes have become more frequent and are of greater of work tasks, both within and across different profes-
amplitude, such as illustrated by the Covid-19 pandemic. sions, teams, and team members can play key roles in
This implies the ability to enact adaptions and address improved healthcare performance [17, 18]. Improved
these changes while continuing high quality service pro- healthcare provision is, therefore, not just about learn-
vision [3–6]. Resilience in healthcare is defined as the ing as individuals, but also about working and learning
capacity to adapt to challenges and changes at differ- collaboratively across stakeholders and system levels.
ent system levels, to maintain high quality care [7]. For There is no single definition of collaborative learning
healthcare organizations to strengthen their ability for through work. However, there is consensus that it com-
resilient performance, a significant level of continuous prises a group of learners, working together to solve a
learning is required [7, 8]. Lately, there has been a grow- problem or complete a task [19] and it is through these
ing consensus amongst safety experts, system engineers activities and interactions that participants’ learning
and healthcare professionals, calling for a new approach arises. In particular, it is through this joint problem
to learning, which is not just focused on learning from solving, between more and less experienced interlocu-
what goes wrong in healthcare, but also to take a more tors, that new insights, procedures, and sentiments are
proactive and reflective approach through learning from made accessible and learnt. Moreover, these engage-
what goes right in ordinary work processes [9–12]. ments are both generative of new knowledge and extend
Resilience in healthcare builds on theory from other what learners know, can do and value [20, 21]. This rec-
sectors such as societal safety, engineering (resilience ognition led to education models such as Reciprocal
engineering), social ecology and psychology, and is a the- Teaching and Learning [22], Cognitive Apprenticeships
oretical perspective that explores how complex adaptive [23] and Guided Learning at Work [24].
systems cope, respond, and adapt to stress [5, 7]. Differ- In a collaborative learning setting, the learners are
ent from more traditional ways of studying and explain- both informed by and challenged through listening to
ing healthcare quality, resilience in healthcare tends to different perspectives, defending own ideas and creating
focus on successful outcomes rather than failures [13, own unique understandings, based on their experiences.
14]. This approach provides a more holistic and dynamic Learning, therefore, occurs continuously in healthcare
understanding of healthcare systems as it attempts to systems through healthcare professionals engagement
understand and explain the underlying processes of what in clinical work, and by interacting with co-workers,
contributes to the ability to handle unforeseen events, patients, and other stakeholders [25]. Collaborative
changes, and innovations. Recent studies report that learning through engaging reciprocally with others
capacities such as coordination, involvement, commu- through work practices such as teamwork and problem
nication, leadership, and learning are key capacities for solving is also central in quality processes [26, 27] as
resilience in healthcare, all of which build on the need it is often in response to novel challenges of emerging
for engaging and interacting with a range of different problems. Researchers have, therefore, suggested prac-
stakeholders at different system levels in a collaborative titioners’ on-going learning across their working lives,
Haraldseid‑Driftland et al. BMC Health Services Research (2022) 22:1091 Page 3 of 12

and in particular collaborative learning, as a prerequi- This article contributes knowledge on the identification
site to operationalize resilience [5, 6, 15, 28, 29]. of how healthcare professionals and other stakeholders
Previous research shows how adaptation is linked to in the healthcare system collaborate and interact when
learning within the field of resilience [8, 30–32]. Yet only responding and adapting to challenges and changes. This
limited systematic attention has been given to the col- contribution is advanced from a resilient healthcare per-
laborative learning element in these adaptive capacities spective to elaborate on the role of collaborative learning.
[5, 7]. Most frequently, resilience studies adress learn-
ing as an outcome, pointing at specific adaptive prac- Methods
tices to handle capacity-demand misalignments, such as Design, sample selection and data collection
workarounds [33], secret second handovers [34], or next This study is an element of the longitudinal research
of kin agency [35, 36]. More recently, some studies have programme: Resilience in Healthcare (RiH), (2018–
focused on developing specific tools for strengthening 2023) [5]. The overall aim of the research programme
resilient capacities, such as serious games [37–40] and is to apply a collaborative interactive research design
reflective spaces or narratives [12, 28]. However, resil- to establish a comprehensive RIH framework aimed
ience studies are frequently tightly focused on individual at identifying and strengthening resilience in health-
learning,- such as people-technology interaction [41], care. The collaborative interactive design will, through
or openness for change,- [42], with only limited focus iterative cycles of different research activities (i.e.
on team learning or collaborative learning approaches. workshops, focus group interviews, individual inter-
Furthermore, only a few studies focus on strengthen- views), bring together key actors (i.e. multidisciplinary
ing resilient capacities in a team setting [43–45]. Recent researchers, practitioners, technology designers) in mul-
studies have, therefore, indicated that to advance the tiple phases of development, implementation, evalua-
field of resilience in healthcare there is a need to develop tion and improvement [5]. In this article, we report on
collaborative learning tools that aid healthcare organi- an explorative study of 14 empirical research projects
zations in strengthening their resilience performance from diverse healthcare settings, undertaken as part of
through collaborative efforts that helps create awareness the first explorative phase of the overall research pro-
of what goes right, and understanding the underlying gramme [5]. Please see supplementary file 1 for details of
factors contributing to the desired outcome [15, 46, 47]. the empirical research projects included.
Given the potential of these collaborative learning ele- During the explorative phase, the aim was to move
ments to promote resilience there is a need to explore beyond single-site, case-based studies to review resilient
the underlying collaborative learning processes and how capacities and collaborative learning processes across dif-
and why collaborations occur during adaptations, trade- ferent healthcare contexts and levels. The process there-
offs, and improvisations as a response to disruptions, fore commenced with the screening of a sample of 50
challenges, and changes [7, 46]. Exploring these under- research projects (i.e., post doctor projects, PhD projects
lying processes is the key to understanding how learn- and research project). The research projects were all associ-
ing resources should be developed to translate resilience ated with the SHARE-Centre for Resilience in Healthcare,
into practice and strengthen resilience capacities [46], in Norway. SHARE is Norway’s leading research Centre
and our study addresses this knowledge gap. within resilience, quality, and patient safety. The Centre
has studied a vast range of different resilience and patient
safety related issues over the last 15 years, within a range
Aim and research questions of healthcare settings and focused on a variety of different
The aim of this paper is to describe and discuss collabora- stakeholders. This variety of projects, contexts and stake-
tive learning processes in relation to resilient healthcare holders, therefore, represents an opportunity to explore
based on investigation of empirical findings from diverse collaborative learning across levels and contexts, thereby
healthcare contexts and levels. advancing the research beyond single-site, case-based stud-
The research questions are: ies towards cross-context multisite studies as suggested
in the literature [48]. The 50 projects were comprised of
1. For which purposes do stakeholders in the healthcare former and ongoing granted research projects at both
system collaborate? micro, meso and macro level, stemming from a variety
2. Which activities and interactions constitutes those of healthcare settings such as homecare, nursing homes,
collaborations? hospital, education, and prehospital care. Furthermore,
3. Through which processes does collaborative learning projects include multiple stakeholders (i.e., patients, next
arise? of kin, manager, healthcare professionals, students, and
Haraldseid‑Driftland et al. BMC Health Services Research (2022) 22:1091 Page 4 of 12

regulators) and a variety of quality dimensions (i.e., pat- • Resilience of what? (What materials and resources
ent safety, clinical effectiveness, coordination, patient cen- underpin resilience?)
tredness, patient safety). While all projects are related to • Resilience through what? (What mechanisms, activi-
healthcare and patient safety, it varied to which degree they ties and interactions enact resilience?)
focused on quality and resilience. Before being subjected to
further analysis all projects were therefore reviewed for rel- All narratives were developed by pairs of researchers
evance for the overall RiH-project through a screening pro- and subjected to an iterative process of discussions and
cess using an established screening protocol [5]. refinement to validate whether all important aspects of
The screening process entailed a six-step process with the project were included. The 14 narratives resulted in a
the aim of considering each project’s relevance for fur- total of 70 pages of text. (Please see [50] p. 4–5 for more
ther inclusion in relation to quality and resilience. The six details).
steps consisted of:
Analysis
1) Determine all projects with a SHARE affiliation Analysis of the 14 narratives was undertaken based on a
2) List all projects for initial screening thematic meta-synthesis approach inspired by J Thomas
3) Initial screening according to the Quality and Resilience and A Harden [51]. The analysis process is performed in
Trigger Tool three stages, Stage one; coding text, Stage two; developing
4) Second level screening of projects descriptive themes and Stage three: generating analytical
5) Group consensus for final inclusion themes. The analysis process was guided by the research
6) Summary of final project inclusion questions and each of the 14 narratives were analysed
to identify: i) purposes of the collaboration amongst
In step 3, Quality dimensions refers to patient expe- involved healthcare professionals at different levels (i.e.,
riences, patient safety, clinical effectiveness, and care why they collaborated), ii) which activities and interac-
coordination, while Resilience dimensions refers to indi- tions constituted those collaborations (i.e., how they
vidual-, team/unity-, organizational- or larger system collaborated), and the specific processes through which
capacity, that contributes to the capacity to adapt to chal- learning arises (i.e., which activities they could poten-
lenges and changes at different system levels, to maintain tially learn from). In Stage One all authors read the entire
high quality care [7]. For further details of the Screening data material, while author CHD and SB coded the nar-
Protocol and a Quality and Resilience Trigger Tool Please ratives and grouped the codes into suggestions for pre-
see Aase et al. [5] data supplement one and two. Based on liminary themes, separately. During this stage the authors
this screening process, 14 projects were developed into extracted each segment of the narratives that they found
narratives and included in the study. relevant for the purpose of the study and classified them
The 14 projects have generated a total of 40 published into three different themes related to the three research
articles and 6 PhD synopses. The data were collected questions (purpose, how and why). All segments were
from journal websites, databases, and a publicly available given a code. CHD then checked for consistency of inter-
database for Norwegian PhD theses, between February pretation throughout the codes. In the second stage there
2020 and September 2020. For details about the selected was a need for development of new themes since sev-
projects, please see additional file 1. eral of the codes did not fit into the preliminary themes,
Based on a predefined template developed by the while some themes contained a lot of codes, while other
research team, a narrative was prepared for each of the themes covered few codes. All codes under each theme
14 research projects The template that dictated how the were then regrouped by CHD into six new themes, and
narrative was to be written entailed (1) defining the phe- new codes were generated when needed. In step three
nomenon of resilience, (2) describing setting, system all authors discussed new themes and subthemes in two
level, stakeholders involved, professions, competence lev- joint workshops. After each workshop CHD regrouped
els and contextual conditions surrounding the project, (3) the codes under each new theme and subthemes. Finally,
Describing the content of the project in 4–7 pages. Defin- all authors agreed upon three main themes and eight
ing the phenomena of resilience was done according to C subthemes to best represent the content of the data. In
Macrae and S Wiig [49] four dimensions of resilience: Table 1, the three stages are set out in the left column,
a description of what they comprised in the middle col-
• Resilience for what? (What goals and objectives is umn, and participants in the analysis in the right column.
resilience supporting?) The findings from this three-staged process comprised
• Resilience to what? (What triggers, activates, or the identification of themes that permitted the categori-
necessitates resilience?) zation and analysis of the data.
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Table 1 Description of stages of the thematic meta-synthesis process

Stage Description of analysis process Participants

1. Coding text - Inductive, line-by-line coding to capture the meaning and content, keeping the CHD and SB separately
synthesis close to the original text. 138 codes by CHD and 146 codes by SB
-Grouping codes into suggestions for preliminary themes (three themes)
-Check for consistency and interpretation throughout the codes CHD
2. Developing descriptive themes - Re-grouping codes into new themes (six themes) CHD
-Generating new codes when needed
Drafting summary of findings
3. Generating analytical themes - Author discussions, comparing and revising themes (six themes became three themes All authors
with eight sub themes)
-Reorganizing codes under new themes CHD
- Theme labels were refined and revised, making sure they reflected the content All authors

Results 5 and 12), or simulation and training (in Narratives 5 and

The findings are presented through aligning them with 7). Other changes result in collaborative efforts only in
the research questions addressing: 1) purposes for collab- one level such as within a team or a specific context (in
oration, 2) activities and interactions that constitutes the Narratives 1–10). Examples of such changes are caring
collaborations and 3) processes through which learning for a patient with deteriorating health; involving next of
arise. An overview of the findings is provided in Table 2, kin in the care process; new leadership, alternations in
as presented under two columns, the right-hand one pre- team composition, or handling peak activity situations
senting the themes and the column to its left setting out or excess workload. The adaptations take different forms
associated sub themes. such as reallocation of responsibility or resources (in
Narratives 1,7,9), or local adaptations in procedures due
Purposes for collaboration to perceived flaws, insufficiencies, or inability to adhere
The three main purposes for stakeholders to collaborate to original outlines (in Narratives 13,7,11,12).
are: i) responding and adapting to change, ii) maintain Responding and adapting to change is a task that
processes and functions, and to iii) improve service qual- demands interactions and collaboration between dif-
ity and patient safety. These are now presented in turn. ferent stakeholders, across settings, between individu-
als and groups, within and between groups, or between
Respond and adapt to change individuals and systems, equipment, technology, or con-
The most frequent purpose of collaboration is respond- text. These changes are not, and cannot be addressed by
ing and adapting to change, due to the constant change individuals alone, as they require interaction and shared
of context that all the different stakeholders, both within activities with others.
and across system levels experience.
Some changes result in collaborative efforts both within Maintain processes and functions
and across all levels and settings, such as changes in legis- Next to responding and adapting to change, the stake-
lation, government-initiated reforms (in Narratives 3 and holders’ collaborative activities often have the purpose
4), budget cuts, introduction of new tools (in Narratives of maintaining normal functions and processes (in Nar-
rative 1–14). This requirement generates a high degree
Table 2 Overview of themes and subthemes of daily collaborations that are a product of how work
Themes Subthemes
is organized. All systems levels, from macro, to meso,
to micro are involved and are interdependent on each
Purposes for collaboration Respond and adapt to change other’s collaboration to perform everyday activities. For
Maintain processes and functions example, admissions and discharges are dependent on
Improve service quality and patient team contributions from stakeholders, such as physi-
safety
cians, nurses, next of kin and the patient themselves, but
Collaborative activities and Exchange information
interactions
also on collaborations between stakeholders across dif-
Coordination, negotiation and
aligning needs
ferent contexts and levels, such as leaders and healthcare
Develop buffers
professionals, home care providers and hospitals (in Nar-
Processes in which collaborative Activities of everyday work
rative 3,4). Collaboration is needed because a high degree
learning arise Intentional educational activities
of the tasks is dependent on those different stakeholders
Haraldseid‑Driftland et al. BMC Health Services Research (2022) 22:1091 Page 6 of 12

to inhabit different skills, knowledge, and responsibilities. 1) exchange information, 2) coordinate, negotiate and
For example, a team of anaesthetists, operating nurses align different needs, and 3) develop buffers, which are
and surgeons is needed to perform a surgery (in Narra- now presented in turn.
tive 6). Regulatory bodies, similarly, depend on collabo-
rations with hospital departments, management, and Exchange information
healthcare professionals to ensure adherence to policies Information exchange is found to be the most extensively
and guidelines (in Narratives 12,14). So, in these ways, used type of collaborative activity. The stakeholders col-
standard and enduring clinical practices are dependent laborate about information exchange within disciplines,
upon collaborative working and learning. between disciplines and across multiple settings and lev-
els. The information exchange is manifested in different
Improve service quality and patient safety ways, ranging from teaching next of kin to observe spe-
The third purpose for collaboration is when collabora- cific changes in the patient’s condition (in Narrative 7),
tions intentionally seek to improve service quality and to meetings with municipal managers to discuss major
patient safety. These interactions relate not only to a nec- reforms such as change of care district (in Narrative 2).
essary adaptation to a change or the maintenance of a There are different, often multiple goals for the infor-
process or function but aim at making an intentional and mation exchange, such as securing safe knowledge trans-
specific effort to improve the quality and safety of pro- fer (in Narrative 9) or preventing adverse events (in
cesses or functions. Narrative 7). However, most often the goal of the infor-
Collaborative efforts to improve quality and safety mation exchange is to optimize or improve healthcare
include introducing activities aimed at reducing variabil- services (in Narratives 5, 8, 7, 2,13).
ity and flexibility in clinical practice. Specific examples Participants make use of both explicit and tacit infor-
here include fixed work lists, routines, procedures, or tri- mation exchange practices to interact with patients, clini-
aging, to minimize variability and, thereby assist in ensur- cians, next of kin, and technology to be able to optimise
ing better work practices, all of which highly involves a care, anticipate, prepare, and plan for ongoing and future
collaborative element. For example, provision of digital events.
access to national guidelines to increase the chance of
adherence (in Narrative 12). Collaborative improvement Coordination, negotiation and aligning needs
efforts also include structures designed to reduce poten- In every collaboration the involved parties hold different
tial risk such as the development of risk-based selection needs, preferences, and desired outcomes of the collabo-
criteria in deciding where women in labour give births ration. A large part of the collaborative efforts, therefore,
(in Narrative 1). Improvement efforts also involved pri- is coordinating, negotiating, and aligning the different
oritizing support and development opportunities (in needs within each collaboration. This means that a lot of
Narratives 1,5,12), and the provision of meeting places their activity concerns verbal and non-verbal interactions
for knowledge exchange, aiming at improvement of the both within and between system levels and contexts to
healthcare services provided (in Narratives 4,7,8). clarify trade-off situations, prioritize and make decisions.
Adapting, maintaining, or improving services are not For instance, this is seen when regulatory investigators
mutually exclusive. In fact, they are often intertwined, involve next of kin in investigations of adverse events,
and shift rapidly. Stakeholders can collaborate for one, with the dual purpose of extracting new information,
several or all purposes at once. For example, after the acknowledging the importance of involving different
introduction of a change such as a peak activity situation, stakeholders and introducing a quality assurance element
stakeholders could both adapt to the change in demand in the process (in Narrative 8).
through reallocating resources, to maintain an adequate Lack of resources often fosters negotiation amongst
level of healthcare service quality, while at the same time different stakeholders concerning which tasks to prior-
changing team composition to improve collaborations itize or whether to provide poorer care or involve next
and improve healthcare provision (in Narrative 1). In of kin in care activities to compensate for lack of health-
these ways, improving care quality and safety inherently care professionals (in Narrative 7), which service levels
aligned with collaborative working and learning. have the responsibility for what (in Narratives 3,4,14),
or which perspectives and needs that should be prior-
itized (in Narratives 1, 2, 3, 4, 9, 7, 11,12). An example
Collaborative activities and interactions
of negotiations relates to granting patients an x-ray that
To achieve or work towards the desired purposes of a
the physician believes is unwarranted, thus using pre-
collaboration, the participants need to make use of and
cious resources, yet providing the patient with the sense
optimise a range of different activities and interactions.
of being heard and involved (narrative 12).
These have been divided into three different categories;
Haraldseid‑Driftland et al. BMC Health Services Research (2022) 22:1091 Page 7 of 12

Different stakeholders are placed in numerous situ- The common denominator of all these activities is that
ations where they need to collaborate, to align differ- they entail interactions or activities where knowledge is
ent needs and handle trade-off situations and carefully expressed, shown, or shared and thus provides learning
navigate through different ethical and practical dilem- opportunities for the ones involved. Examples of collab-
mas such as who to involve, when and why, and who orative activities of everyday work include when next of
have responsibilities for what. In these ways, collabora- kin provides information about a patient’s status to the
tive working, and learning are essential for realising these nurse that comes on duty (in Narrative 6); or a discussion
kinds of needs that are central to care quality and safety. amongst nurses regarding dosage and administration of
a drug (in Narrative 8). So, again, these practices require
Develop buffers interaction and interdependence amongst participants.
Collaborative activities also concern the creation of buff-
ers in the system, aimed at anticipating future events Intentional educational activities
and thereby, proactively preventing problems or aid- Intentional educational activities include the types of
ing healthcare provision. These buffers are developed at learning activities that are planned or scheduled with an
different levels and involve outcomes in diverse forms intention to educate the involved parties. Although pre-
and shapes and are either part of organizational struc- sent in the data material, this type of learning activity
tures or dependent on individual efforts. Organizational is less evident in the findings compared to learning as a
structures comprise scheduled simulation-based sce- result of everyday work activities.
nario training, (in Narrative 5) to be better prepared for Examples of intentional educational activities are work-
diverse situations or having a designated section coor- shops, debriefs, seminars or simulation-based training
dinator who can handle peak activity situations through exercises. The purpose of these activities mainly relates
accessing and reallocating resources (in Narrative 1). to quality and safety improvement efforts and is limited
Individual efforts are often dependent on facilitators and to one level and setting such as simulation-based activi-
individuals’ competencies, who collaborate with their ties at a ward or department with the intent to practice
surroundings to create local buffers such as combining and improve specific skills (in Narrative 1,5). However,
experienced and inexperienced staff to make more robust there is also evidence of intentional educational activi-
team compositions (in Narrative 1.6). So, these anticipa- ties which gather stakeholders such as leaders and staff,
tory and proactive processes are reliant upon collective across levels and across settings such as hospitals, gov-
and collaborative expertise within the healthcare setting, ernment and community care (in Narratives 2,4,8).
again underpinning the importance of these forms of
interdependent working and learning.
Discussion
In this paper we have presented and discussed the find-
ings from a meta synthesis of collaborative processes
Collaborative processes in which learning arise and activities in healthcare and identified how these are
The stakeholders involved are constantly engaged in a aligned with learning in everyday practice as well as in
complex network of collaborative activities. These activi- response to changes at multiple system levels. As shown
ties are divided into i) activities of everyday work, and ii) in Fig. 1, stakeholders in the healthcare system collabo-
Intentional educational activities. rate to respond and adapt to change, maintain processes
and functions, and improve quality and safety. The activi-
Activities of everyday work ties and interactions that constitute these collaborations
Across settings and levels, the stakeholders engage in a are exchange of information, coordination, negotiation,
range of collaborative practices as a result of the activities aligning needs, and developing buffers. The collabora-
of their everyday work. These comprise activities such tive learning processes that arise from these activities
as debriefs, information sharing/exchange, consulta- and interactions are both activities of daily work, such
tions, discussions, prioritizing, anticipation, responding, as discussions, prioritizing and delegation of tasks, and
and clarification of needs. These interactions occur both intentional educational activities such as seminars or
among different practitioners (e.g., doctors, radiologists, simulation activities. In the following section we dis-
specialized nurses, regulators, or leaders), between differ- cuss the findings as part of learning processes in resil-
ent stakeholder groups (e.g., practitioners, patients and ient healthcare in light of resilient healthcare theory and
next of kin), between diverse types of stakeholders from learning theory.
the same group (e.g., managers, patients and next of kin),
and between and within organizations across different
levels of the healthcare system (in Narratives 1–14).
Haraldseid‑Driftland et al. BMC Health Services Research (2022) 22:1091 Page 8 of 12

Fig. 1 Collaborative processes, activities and learning processes in a resilient healthcare organization

Collaborative working requires collaborative learning is how organizational processes can enable team or units
Complex adaptive systems, such as healthcare, do not to successfully collaborate to adapt to their changing
have the opportunity to fully plan every future event in circumstances [54]. Individual action is, therefore, an
advance. They depend on the ability of their healthcare indirect reflection of systems resilience and is thus an
professionals and teams to constantly adjust to emerging important aspect that we need to understand. SH Berg
situations, creating safe processes continuously [1, 52–54]. and K Aase [56] and CJ Foster, KL Plant and NA Stanton
Individuals in the system and their ability to anticipate, [57] propose that resilient characteristics are intercon-
monitor, adapt and respond to potential threats are as such nected both within and across different levels of a system.
a valued asset to secure patient safety [48]. This ability to This interconnection implies that resilient capacities are
adapt is closely linked to the ability to learn, since adapt- dependent on a high level of collaboration within and
ing to a challenge or change is dependent on different across units, teams, contexts, and levels. Strengthen-
kinds of contextual knowledge to handle the event [8, 55]. ing systems resilience, therefore, depends on continu-
As shown in our findings, healthcare professionals often ous organizational based learning efforts that is inclusive
depend on collaborations within and across different sys- of learning at both individual, team and organizational
tem levels to adapt and respond. This is an understand- levels [58]. Improved system resilience through organi-
able outcome of our healthcare systems being designed to zational learning is also dependent on the organizations
provide healthcare as a collaborative effort [16]. The ability ability to integrate changes more systematically into the
to adapt is, therefore, not just dependent on individuals’ everyday work of individuals but also groups and teams
actions, but also on collaborative efforts and the actions of stakeholders. The next level of organizational learn-
of the multiple stakeholders involved in the collaboration. ing is, therefore, to create a shared understanding of how
Efforts to strengthen the ability to adapt should therefore to address a challenge and why. Moreover, from a theo-
be promoted and provided through a group context, where retical perspective, identifying mutual adjustments to
stakeholders who work together also learn together. diverse types of challenges emphasises the interactive
However, according to the definition of resilience, and collaborative process needed to integrate the change
adopted here, the ability to maintain high quality care is into ordinary work practice [58]. Evidence of such mutual
dependent on the ability to adapt and respond at different adjustment and shared understandings are identifiable in
system levels [7]. This means that efforts to strengthen the findings of our synthesis through intentional learning
resilience in healthcare need a systems perspective [7], or educational activities such as simulation and different
and as such is not related to strengthening individual forms of cross-level stakeholder meetings. However, our
resilience. The fundamental issue for systems resilience, findings indicate that we need further investigations into
Haraldseid‑Driftland et al. BMC Health Services Research (2022) 22:1091 Page 9 of 12

how these learning processes at different levels are sup- choices. Enabling such learning processes could be a key
ported as part of enabling resilient performance. to proactive approaches to quality and safety and the
From theoretical lenses, organizational based learn- ability to monitor systems’ performance.
ing efforts, have often not occurred, until changes have Recent research has indicated that the creation of
been institutionalized and integrated in routines, rules reflective spaces, where different stakeholders have the
and procedures [58]. As this study shows, such changes opportunity for collaborative learning through meet-
are dependent on collaborative processes between dif- ing and exchanging experiences within and across levels
ferent stakeholders, who work and learn together, across has the potential to bridge tacit and explicit knowledge,
different levels and contexts to maintain and improve and thereby create awareness [28]. Creating spaces for
healthcare provision. Efforts to strengthen organiza- reflection that can facilitate mindfulness and awareness
tional resilience should, therefore, focus on develop- towards clinical practice, the choices that are made,
ing resilient capacities throughout all system levels and and why, has been suggested as promising in other
learning opportunities should be designed as collabora- contexts [28, 38, 39, 62]. Creating reflexive spaces for
tive efforts as this mimic their everyday collaborative stakeholders across different system contexts and levels
work practice. could therefore potentially create higher awareness and
understanding among different stakeholders related to
Reflection and awareness—a key to successful adaptations how local adjustments could have systemic implications
Findings from this study show that collaborative activi- a in a complex adaptive healthcare system. Our find-
ties often consisted of different forms of trade-offs to get ings support others that learning processes to a higher
appropriate information, coordinate events, negotiate degree are embedded in the healthcare professionals
prioritizations, and align different needs. Similar to other every day work activities [25, 63]. Integrating reflexive
resilience in healthcare studies [59, 60], this study found spaces and awareness of what goes right in healthcare
that the complex demands, competing interests and a provision and why, as a part of healthcare profession-
diversity of stakeholders focusing on different outcomes als everyday work practice could potentially increase
resulted in the need to choose some type of adjustment learning potentials within and across different levels
of practice over another. While such trade-offs might be in the healthcare system, and as a result contribute to
necessary to maintain situational processes and func- strengthen resilient performance.
tions, adaptations and adjustments do not always provide
positive outcomes for service quality and safety [2, 50]. Limitations
In complex adaptive systems [4, 54], all individuals have This meta-synthesis is based on a sample of 14 resilience
a large degree of freedom to act in unpredictable ways. narratives from a Norwegian setting. Including studies
Furthermore, their actions interconnect, due to the high from only one country could have impacted the findings
level of collaborative processes and as individuals’ actions with local variations that are typical for the Norwegian
influence each other’s, they also have consequences for context. While specifics of the Norwegian healthcare
other stakeholders in the system. So, what might appear system in some respects differ from other international
as a rational action for individuals in a situation may have contexts, such as fewer private institutions and a gov-
unforeseen consequences for others and move the sys- ernment funded healthcare system, the collaborative
tem towards the boundaries of safe performance [1, 61]. learning processes which are studied in this paper, and
Actions described in the findings, such as including next how and why different actors in the healthcare system
of kin in care responsibilities, consequently influenced collaborate is believed to be representative of a broader
the broader system by covering up a systemic error such healthcare context, and thereby also useful in an interna-
as lack of staffing resources. This type of adaptation con- tional context. Nevertheless, further studies are encour-
tributes to an increase in overall risk and limits the ability aged to be conducted with narratives based on a larger,
for resilient performance in a long-term perspective [50]. more international sample of research studies. The choice
The complexity of the system, its everchanging cir- of analysing narratives introduces the possibility that
cumstances and the interconnection through collabora- the interpreted material becomes misinterpreted or too
tive efforts, makes it difficult for individuals and teams distant from the intention of the original material. How-
to anticipate how to perform appropriate adaptations. ever, misinterpretation is always an issue in qualitative
However, individuals, teams, and organizations can be research and is therefore a potential bias that needs to
made aware of their role in such complex systems, and be considered and counteracted throughout all qualita-
how local adaptations can have systemic consequences, tive research processes [64, 65]. This study has attempted
and thereby aid decisions during negotiations and trade- to counteract this issue through a rigorous process both
offs through creating awareness of the impacts of specific during the writing of the narratives and the analysis of
Haraldseid‑Driftland et al. BMC Health Services Research (2022) 22:1091 Page 10 of 12

the narratives, where a team of researchers with various Supplementary Information

backgrounds established a clear procedure on how to The online version contains supplementary material available at https://​doi.​
write the narratives and then continued to read, inter- org/​10.​1186/​s12913-​022-​08451-y.
pret and discuss to establish inter-rater reliability at all
Additional file 1: Supplementary file 1. Included projects. Overview
stages of the process [65]. The approach of meta-syn- of details of all the 14 projects included in the narratives, including their
thesis and combining methods for analysing data is also title, years of conduct, the setting in which empirical work occurred and
an important step that allows for multi-level and multi- informants.
setting research that can advance the field of resilience in
healthcare [48, 66] Moreover, it allows for the inclusion Acknowledgements
of a large data set that provides the study with a rich data The authors would like to thank Prof. Karina Aase for her significant role in the
RIH project. Prof. Aase was project manager of the RIH project (2018-2020) and
material in which to ground the results. However, future main applicant of the grant proposal. We also thank Prof. Aase for her con‑
research should seek to include other studies from other tribution to the idea of the narrative inquiry and for contributing to develop
setting to explore the role of collaborative learning in some of the included narratives.

resilience in healthcare. Authors’ contributions

CHD, SB and SW advanced the initial idea for the article. HBL, VG, BF, LS, JGA
and SW developed the narratives that this study is based on. CHD and SB
Conclusion led the analysis of the narratives, while all authors discussed the steps of the
The aim here was to describe collaborative learning pro- analysis and agreed on the results. CHD drafted the manuscript with signifi‑
cant contributions from SW and SB. All authors contributed with significant
cesses in relation to resilient healthcare based on an inves- input to drafts and revisions. All authors have read and approved the final
tigation of narratives from diverse healthcare contexts manuscript.
and levels. The findings show that across levels and con-
Funding
texts healthcare workers collaborate to adapt and respond The study was funded by the Norwegian research council, as a sub study
to changes, to maintain processes and functions, and to under the overall Resilience in healthcare project (RiH) project number
improve quality and safety. The activities and interactions 275367. The authors wish to thank all participants for sharing their knowledge
and experiences.
these collaborations comprise are exchanging information, The Resilience in Healthcare Research Program has received funding from
coordinating, negotiating, and aligning needs and develop- the Research Council of Norway from the FRIPRO TOPPFORSK program, grant
ing buffers. All of which occur through collaborative work- agreement no. 275367. The University of Stavanger, Norway; NTNU Gjørvik,
Norway; and The Norwegian Air Ambulance support the study with in-kind
ing and are generative of learning and changes to practice. funding.
The learning activities embedded in these collaborations are
both activities of daily work, such as discussions, prioritiz- Availability of data and materials
The datasets used and analysed during the current study are available from
ing and delegation of tasks, in addition to intentional learn- the corresponding author on reasonable request.
ing or educational activities such as seminars or simulations.
Based on our findings, we propose resilience in health- Declarations
care is dependent on these collaborations and learning
processes, across different levels and contexts, to adapt Ethics approval and consent to participate
Ethical approval for the study was obtained through the Norwegian Centre
and respond to challenges and changes and maintain for Research Data, ref. nr: 864334. Consent to participate is not applicable for
high quality patient care. This ability to adapt is closely this article.
linked to the ability to learn. The resilience in healthcare
Consent for publication
approach holds a systems perspective. Although indi- Not applicable.
viduals’ actions are important, a systems perspective
demands collaboration and learning within and across all Competing interests
The author SW is a member of the editorial board (Associate Editor and Guest
system levels. Creating space for individual and collec- Editor of this special collection). SW had no role in the peer review or in the
tive appraisals and awareness building could assist indi- handling of this manuscript. The authors declare that they have no competing
vidual, team, and organizational-based learning. Efforts interests.
to strengthen or further enable resilient performance Author details
should consider the importance of the collaborative ele- 1
SHARE ‑ Centre for Resilience in Healthcare, Faculty of Health Sciences, Uni‑
ment and seek to develop framework and learning tools versity of Stavanger, N‑4036 Stavanger, Norway. 2 School of Education and Pro‑
fessional Studies, Griffith University, Mount Gravatt, QLD 4122, Australia.
that can facilitate learning through work and while work-
ing and learning together: that is collaboratively. Received: 17 December 2021 Accepted: 12 August 2022

Abbreviations
SHARE: Centre for Resilience in Healthcare; RiH: Resilience in healthcare.
Haraldseid‑Driftland et al. BMC Health Services Research (2022) 22:1091 Page 11 of 12

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