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Special Issue "Resilience and Improvisation at the Frontlines of Healthcare"

A special issue of International Journal of Environmental Research and Public Health (ISSN 1660-4601). This special issue belongs to the section "Health Care Sciences & Services".

Deadline for manuscript submissions: closed (31 March 2021).

Special Issue Editor

Prof. Dr. Pavani Rangachari
E-Mail Website
Guest Editor
Department of Interdisciplinary Health Sciences, College of Allied Health Sciences, Augusta University, Augusta, GA 30912, USA
Interests: health services research; implementation science; organizational change; inter-professional learning; knowledge sharing networks; systems improvement; patient safety; public health systems; mixed-methods research; social network analysis

Special Issue Information

Dear Colleagues,

A key concept in human factors engineering is resilience, which has received increasing attention in the context of healthcare. Resilience focuses on how we can proactively learn from error recovery, rather than reactively searching for causes of error and simplistic remedies. The emphasis of resilience is on preventing errors from being repeated as opposed to an emphasis on human error and error analysis. In other words, resilience shifts the focus from viewing humans (healthcare workers) as a source of error within the healthcare system to one where they can contribute actively toward greater patient safety.

Resilience at the frontlines of healthcare organizations enables the safe delivery of healthcare, despite obstacles. A key source of organizational resilience is improvisation at the frontline, sometimes referred to as ‘workarounds’. Improvisation refers to the ability to develop a solution to an unexpected problem or situation with limited resources or materials at hand. This may involve a clinician contacting a replacement before a shift change to ensure a proper handover or clinicians leveraging the use of telehealth and social media to triage patients based on risk to prevent clinic or ED overflow.

Resilience can be described as a property of individuals and teams within the workplace as well as the whole healthcare organization. When improvisation is left to individual healthcare workers and patient encounters, although the immediate issue may be resolved, the problem is likely to recur. On the other hand, when team and organizational dynamics enable the opportunity to learn from the improvisation of individual healthcare workers and take action to prevent the problem from recurring, it is possible to embed the improvement at an organizational level. Correspondingly, senior leadership commitment to building a culture of safety is a key characteristic of resilient healthcare organizations.

For this IJERPH Special Issue, we welcome submissions on a range of topics relevant to resilience and improvisation at the frontlines of healthcare, including:

  • Resilience and workarounds at the frontlines of healthcare under stressful situations;
  • Improvisational responses of frontline healthcare workers to the COVID-19 pandemic;
  • Psychological and emotional responses of frontline healthcare workers to the COVID-19 pandemic;
  • Impact of the work environment on the mental and emotional health of frontline healthcare workers;
  • Advances in the use of telehealth and other types of information and communication technologies at the frontlines of patient care delivery;
  • Use and influence of social media at the frontlines of healthcare delivery;
  • Role of healthcare leadership in developing a culture of safety in healthcare organizations;
  • Strategies for developing a learning culture for patient safety and systems improvement;
  • Strategies for developing effective interprofessional communication and teamwork in healthcare delivery;
  • Strategies for the successful implementation of evidence-based practices to improve safety and quality at the frontlines of healthcare.

All types of submissions, including original research articles, reviews, communications, and case reports, are welcome for this Special Issue. IJERPH operates a single-blind peer review, meaning that the author does not know the identity of the reviewer but the reviewer knows the identity of the author. Authors can recommend potential reviewers. Journal editors will check to make sure that there are no conflict of interests before contacting those reviewers and will not consider those with competing interests. Reviewers are asked to declare any conflicts of interest. Authors can also enter the names of potential peer reviewers they wish to exclude from consideration in the peer review of their manuscript, during the initial submission process. The editorial team will respect these requests so long as this does not interfere with the objective and thorough assessment of the submission.

I look forward to receiving your submissions for this Special Issue.

Prof. Pavani Rangachari
Guest Editor

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All papers will be peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. International Journal of Environmental Research and Public Health is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2300 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • Resilience
  • Improvisation
  • Workarounds
  • Frontlines of healthcare
  • Telehealth
  • Telemedicine
  • Social media
  • Health information technology
  • Interprofessional communication
  • Leadership in healthcare
  • Safety culture
  • Safety climate
  • Evidence-based practices
  • Healthcare Organizational resilience
  • Quality of care
  • Patient safety

Published Papers (9 papers)

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Research

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Article
We’re Not Gonna Fall: Depressive Complaints, Personal Resilience, Team Social Climate, and Worries about Infections among Hospital Workers during a Pandemic
Int. J. Environ. Res. Public Health 2021, 18(9), 4701; https://doi.org/10.3390/ijerph18094701 - 28 Apr 2021
Viewed by 830
Abstract
Maintaining hospital workers’ psychological health is essential for hospitals’ capacities to sustain organizational functioning during the COVID-19 pandemic. Workers’ personal resilience can be an important factor in preserving psychological health, but how this exactly works in high stakes situations, such as the COVID-19 [...] Read more.
Maintaining hospital workers’ psychological health is essential for hospitals’ capacities to sustain organizational functioning during the COVID-19 pandemic. Workers’ personal resilience can be an important factor in preserving psychological health, but how this exactly works in high stakes situations, such as the COVID-19 pandemic, requires further exploration. Similarly, the role of team social climate as contributor to individual psychological health seems obvious, but how it exactly prevents workers from developing depressive complaints in prolonged crises remains under investigated. The present paper therefore applies conservation of resources theory to study the relationships between resilience, team social climate, and depressive complaints, specifically focusing on worries about infections as an important explanatory mechanism. Based on questionnaire data of 1126 workers from five hospitals in the Netherlands during the second peak of the pandemic, this paper estimates a moderated-mediation model. This model shows that personal resilience negatively relates to depressive complaints (β = −0.99, p < 0.001, 95%CI = −1.45–−0.53), partially as personal resilience is negatively associated with worries about infections (β = −0.42, p < 0.001, 95%CI = −0.50–−0.33) which in turn are positively related to depressive complaints (β = 0.75, p < 0.001, 95% CI = 0.31–1.19). Additionally, team social climate is associated with a lower effect of worries about being infected and infecting others on depressive complaints (β = −0.88, p = 0.03, 95% CI = −1.68–−0.09). These findings suggest that resilience can be an important individual level resource in preventing depressive complaints. Moreover, the findings imply that hospitals have an important responsibility to maintain a good team social climate to shield workers from infection related worries building up to depressive complaints. Full article
(This article belongs to the Special Issue Resilience and Improvisation at the Frontlines of Healthcare)
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Article
Tired, Worried and Burned Out, but Still Resilient: A Cross-Sectional Study of Mental Health Workers in the UK during the COVID-19 Pandemic
Int. J. Environ. Res. Public Health 2021, 18(9), 4457; https://doi.org/10.3390/ijerph18094457 - 22 Apr 2021
Cited by 1 | Viewed by 895
Abstract
The burden of the COVID-19 pandemic on health systems and the physical and mental health of healthcare workers (HCWs) has been substantial. This cross-sectional study aims to assess the effects of COVID-19 on the psychological wellbeing of mental health workers who provide care [...] Read more.
The burden of the COVID-19 pandemic on health systems and the physical and mental health of healthcare workers (HCWs) has been substantial. This cross-sectional study aims to assess the effects of COVID-19 on the psychological wellbeing of mental health workers who provide care to a vulnerable patient population that have been particularly affected during this crisis. A total of 387 HCWs from across a large urban mental health service completed a self-administered questionnaire consisting of socio-demographic, lifestyle and work-based information and validated psychometric scales. Depression and anxiety were measured using the Patient Health Questionnaire (PHQ-9) and the Generalized Anxiety Disorder Scale (GAD-7), respectively; sleep problems with the Athens Insomnia Scale (AIS); burnout with the Maslach Burnout Inventory (MBI); and resilience with the Resilience Scale-14 (RS-14). Multivariable logistic regression analysis was performed to determine potential mediating factors. Prevalence of burnout was notable, with 52% recording moderate/severe in Emotional Exhaustion, 19.5% moderate/severe in Depersonalisation, and 55.5% low/moderate Personal Accomplishment. Over half of all respondents (52%) experienced sleep problems; the presence of depressive symptoms was a significant predictor of insomnia. An increase in potentially harmful lifestyle changes, such as smoking, alcohol consumption and overeating was also observed. However, high Resilience was reported by 70% of the samples and the importance of this is highlighted. Female gender was associated with increased levels of depression and emotional exhaustion while those with a history of mental health conditions were most at risk of affective symptoms, insomnia, and burnout. Overall, our study revealed considerable levels of psychological distress and maladaptive coping strategies but also resilience and satisfaction with organizational support provided. Findings can inform tailored interventions in order to mitigate vulnerability and prevent long-term psychological sequelae. Full article
(This article belongs to the Special Issue Resilience and Improvisation at the Frontlines of Healthcare)
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Article
The Role of Healthcare Professionals’ Passion in Predicting Secondary Traumatic Stress and Posttraumatic Growth in the Face of COVID-19: A Longitudinal Approach
Int. J. Environ. Res. Public Health 2021, 18(9), 4453; https://doi.org/10.3390/ijerph18094453 - 22 Apr 2021
Viewed by 585
Abstract
COVID-19 has increased the likelihood of healthcare professionals suffering from Secondary Traumatic Stress (STS). However, the difficulty of this crisis may lead these professionals to display personal resources, such as harmonious passion, that could be involved in posttraumatic growth. The goal of this [...] Read more.
COVID-19 has increased the likelihood of healthcare professionals suffering from Secondary Traumatic Stress (STS). However, the difficulty of this crisis may lead these professionals to display personal resources, such as harmonious passion, that could be involved in posttraumatic growth. The goal of this study is to examine the STS and posttraumatic growth among healthcare professionals and the demands and resources related to COVID-19. A longitudinal study was carried out in April 2020 (T1) and December 2020 (T2). The participants were 172 health professionals from different health institutions and they reported their workload, fear of contagion, lack of staff and personal protection equipment (PPE), harmonious passion, STS and posttraumatic growth. The results revealed that workload and fear of contagion in T2 were positive predictors for STS, whereas harmonious passion was a negative predictor. Fear of contagion of both times seemed to positively predict posttraumatic growth, as well as harmonious passion. One moderation effect was found concerning the lack of staff/PPE, as posttraumatic growth was higher when the workload was high, especially in those with a high lack of staff/PPE. All in all, these findings pointed out the need for preventative measures to protect these professionals from long-term negative consequences. Full article
(This article belongs to the Special Issue Resilience and Improvisation at the Frontlines of Healthcare)
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Article
Interprofessional and Intraprofessional Communication about Older People’s Medications across Transitions of Care
Int. J. Environ. Res. Public Health 2021, 18(8), 3925; https://doi.org/10.3390/ijerph18083925 - 08 Apr 2021
Viewed by 732
Abstract
Communication breakdowns contribute to medication incidents involving older people across transitions of care. The purpose of this paper is to examine how interprofessional and intraprofessional communication occurs in managing older patients’ medications across transitions of care in acute and geriatric rehabilitation settings. An [...] Read more.
Communication breakdowns contribute to medication incidents involving older people across transitions of care. The purpose of this paper is to examine how interprofessional and intraprofessional communication occurs in managing older patients’ medications across transitions of care in acute and geriatric rehabilitation settings. An ethnographic design was used with semi-structured interviews, observations and focus groups undertaken in an acute tertiary referral hospital and a geriatric rehabilitation facility. Communication to manage medications was influenced by the clinical context comprising the transferring setting (preparing for transfer), receiving setting (setting after transfer) and ‘real-time’ (simultaneous communication). Three themes reflected these clinical contexts: dissemination of medication information, safe continuation of medications and barriers to collaborative communication. In transferring settings, nurses and pharmacists anticipated communication breakdowns and initiated additional communication activities to ensure safe information transfer. In receiving settings, all health professionals contributed to facilitating safe continuation of medications. Although health professionals of different disciplines sometimes communicated with each other, communication mostly occurred between health professionals of the same discipline. Lack of communication with pharmacists occurred despite all health professionals acknowledging their important role. Greater levels of proactive preparation by health professionals prior to transfers would reduce opportunities for errors relating to continuation of medications. Full article
(This article belongs to the Special Issue Resilience and Improvisation at the Frontlines of Healthcare)
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Article
COVID-Well Study: Qualitative Evaluation of Supported Wellbeing Centres and Psychological First Aid for Healthcare Workers during the COVID-19 Pandemic
Int. J. Environ. Res. Public Health 2021, 18(7), 3626; https://doi.org/10.3390/ijerph18073626 - 31 Mar 2021
Viewed by 1050
Abstract
Supported wellbeing centres were set up in UK hospital trusts as an early intervention aimed at mitigating the psychological impact of COVID-19 on healthcare workers. These provided high quality rest spaces with peer-to-peer psychological support provided by National Health Service (NHS) staff volunteers [...] Read more.
Supported wellbeing centres were set up in UK hospital trusts as an early intervention aimed at mitigating the psychological impact of COVID-19 on healthcare workers. These provided high quality rest spaces with peer-to-peer psychological support provided by National Health Service (NHS) staff volunteers called ‘wellbeing buddies’, trained in psychological first aid. The aim of the study was to explore the views of centre visitors and operational staff towards this COVID-19 workforce wellbeing provision. Qualitative semi-structured interviews were undertaken with twenty-four (20F, 4M) employees from an acute hospital trust in the UK. Interviews were digitally recorded and transcribed, data were handled and analysed using thematic analysis. Interviews generated 3 over-arching themes, and 13 sub-themes covering ‘exposure and job roles’, ‘emotional impacts of COVID-19 and ‘the wellbeing centres’. Supported wellbeing centres were viewed as critical for the wellbeing of hospital employees during the first surge of COVID-19 in the UK. Wellbeing initiatives require managerial advocacy and must be inclusive. Job-related barriers to work breaks and accessing staff wellbeing provisions should be addressed. High quality rest spaces and access to peer-to-peer support are seen to benefit individuals, teams, organisations and care quality. Training NHS staff in psychological first aid is a useful approach to supporting the wellbeing of the NHS workforce during and beyond the COVID-19 pandemic. Full article
(This article belongs to the Special Issue Resilience and Improvisation at the Frontlines of Healthcare)
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Article
From Recession to Depression? Prevalence and Correlates of Depression, Anxiety, Traumatic Stress and Burnout in Healthcare Workers during the COVID-19 Pandemic in Greece: A Multi-Center, Cross-Sectional Study
Int. J. Environ. Res. Public Health 2021, 18(5), 2390; https://doi.org/10.3390/ijerph18052390 - 01 Mar 2021
Cited by 4 | Viewed by 1375
Abstract
The COVID-19 pandemic has the potential to adversely affect the mental health of healthcare workers (HCWs). The public healthcare system in Greece was already facing serious challenges at the outset of the outbreak following years of austerity and an escalating refugee crisis. This [...] Read more.
The COVID-19 pandemic has the potential to adversely affect the mental health of healthcare workers (HCWs). The public healthcare system in Greece was already facing serious challenges at the outset of the outbreak following years of austerity and an escalating refugee crisis. This multi-center, cross-sectional study aims to assess the levels and associated risk factors of anxiety, depression, traumatic stress and burnout of frontline staff in Greece. A total of 464 self-selected HCWs in six reference hospitals completed a questionnaire comprising sociodemographic and work-related information and validated psychometric scales. The proportion of HCWs with symptoms of moderate/severe depression, anxiety and traumatic stress were 30%, 25% and 33%, respectively. Burnout levels were particularly high with 65% of respondents scoring moderate/severe in emotional exhaustion, 92% severe in depersonalization and 51% low/moderate in personal accomplishment. Predictive factors of adverse psychological outcomes included fear, perceived stress, risk of infection, lack of protective equipment and low social support. The psychological burden associated with COVID-19 in healthcare professionals in Greece is considerable, with more than half experiencing at least mild mental health difficulties. Findings signal the need for immediate organizational and individually tailored interventions to enhance resilience and support wellbeing under pandemic conditions. Full article
(This article belongs to the Special Issue Resilience and Improvisation at the Frontlines of Healthcare)
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Article
Demographic and Risk Factor Differences between Children with “One-Time” and “Repeat” Visits to the Emergency Department for Asthma
Int. J. Environ. Res. Public Health 2021, 18(2), 486; https://doi.org/10.3390/ijerph18020486 - 09 Jan 2021
Viewed by 647
Abstract
This retrospective study examines demographic and risk factor differences between children who visited the emergency department (ED) for asthma once (“one-time”) and more than once (“repeat”) over an 18-month period at an academic medical center. The purpose is to contribute to the literature [...] Read more.
This retrospective study examines demographic and risk factor differences between children who visited the emergency department (ED) for asthma once (“one-time”) and more than once (“repeat”) over an 18-month period at an academic medical center. The purpose is to contribute to the literature on ED utilization for asthma and provide a foundation for future primary research on self-management effectiveness (SME) of childhood asthma. For the first round of analysis, an 18-month retrospective chart review was conducted on 252 children (0–17 years) who visited the ED for asthma in 2019–2020, to obtain data on demographics, risk factors, and ED visits for each child. Of these, 160 (63%) were “one-time” and 92 (37%) were “repeat” ED patients. Demographic and risk factor differences between “one-time” and “repeat” ED patients were assessed using contingency table and logistic regression analyses. A second round of analysis was conducted on patients in the age-group 8–17 years to match another retrospective asthma study recently completed in the outpatient clinics at the same (study) institution. The first-round analysis indicated that except age, none of the individual demographic or risk factors were statistically significant in predicting of “repeat” ED visits. More unequivocally, the second-round analysis revealed that none of the individual factors examined (including age, race, gender, insurance, and asthma severity, among others) were statistically significant in predicting “repeat” ED visits for childhood asthma. A key implication of the results therefore is that something other than the factors examined is driving “repeat” ED visits in children with asthma. In addition to contributing to the ED utilization literature, the results serve to corroborate findings from the recent outpatient study and bolster the impetus for future primary research on SME of childhood asthma. Full article
(This article belongs to the Special Issue Resilience and Improvisation at the Frontlines of Healthcare)
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Review

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Review
Psychological First Aid Training: A Scoping Review of Its Application, Outcomes and Implementation
Int. J. Environ. Res. Public Health 2021, 18(9), 4594; https://doi.org/10.3390/ijerph18094594 - 26 Apr 2021
Viewed by 629
Abstract
Worldwide commitment to disseminate Psychological First Aid (PFA) training to enable frontline workers to support distressed individuals and/or manage their own self-care is increasing, but the evidence base of PFA training is uncertain. Method: a scoping review was undertaken by searching seven databases [...] Read more.
Worldwide commitment to disseminate Psychological First Aid (PFA) training to enable frontline workers to support distressed individuals and/or manage their own self-care is increasing, but the evidence base of PFA training is uncertain. Method: a scoping review was undertaken by searching seven databases and hand-searching grey literature to maximise coverage of potential studies. Results: Twenty-three studies met the inclusion criteria. Three PFA training models were commonly used in research studies. A broad selection of PFA training outcomes were observed including learning, behavior, satisfaction and practice in crisis mental and behavior health preparedness. Conclusions: Research evidence of reasonable quality demonstrates that PFA training significantly improves knowledge of appropriate psychosocial response and PFA skills in supporting people in acute distress, thereby enhancing self-efficacy and promoting resilience. However, this review highlights inadequate guidance on how PFA training should be applied and adapted, significant shortcomings of reporting PFA training delivery, limited training evaluation and unclear training outcomes. Whilst behavioral, knowledge and system impact of the PFA training are promising, methodologically stronger evaluations which include systematic training adaptation and selection of sensitive outcome measures is needed to strengthen future implementation of PFA training and thereby enhance population preparedness for future emergencies. Full article
(This article belongs to the Special Issue Resilience and Improvisation at the Frontlines of Healthcare)
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Other

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Discussion
Preserving Organizational Resilience, Patient Safety, and Staff Retention during COVID-19 Requires a Holistic Consideration of the Psychological Safety of Healthcare Workers
Int. J. Environ. Res. Public Health 2020, 17(12), 4267; https://doi.org/10.3390/ijerph17124267 - 15 Jun 2020
Cited by 21 | Viewed by 7335
Abstract
During the COVID-19 pandemic, healthcare workers are fighting a lethal virus with acute shortages of Personal Protective Equipment (PPE). These unprecedented circumstances have amplified the sources of emotional distress and worker burnout. However, many healthcare organizations (HCOs) in the United States, have opted [...] Read more.
During the COVID-19 pandemic, healthcare workers are fighting a lethal virus with acute shortages of Personal Protective Equipment (PPE). These unprecedented circumstances have amplified the sources of emotional distress and worker burnout. However, many healthcare organizations (HCOs) in the United States, have opted for a “stoic approach” to healthcare worker support, i.e., no additional support beyond federal and state policy protections for the licensing and liability of healthcare workers. In this scenario, a key public health concern is sustaining an adequate healthcare workforce, both by way of quantity (adequate numbers) and quality (maximizing clinician resilience to provide safe care to large volumes of patients under challenging conditions). Therefore, it is imperative for HCO leaders to recognize that a limited view of worker psychological safety, without due consideration for the broader emotional distress created by the pandemic, could have the effect of restricting organizational resilience and adversely impacting patient safety and staff retention during and beyond the pandemic. This paper uses the organizational resilience framework to discuss the potential impact of a stoic approach to healthcare worker support on patient safety and staff retention in a hospital intensive care unit (ICU) during COVID-19. The discussion in turn, helps to develop recommendations for HCOs to overcome these challenges. Full article
(This article belongs to the Special Issue Resilience and Improvisation at the Frontlines of Healthcare)
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