BackgroundResilience engineering (RE) is an emerging perspective on safety in complex adaptive systems that emphasises how outcomes emerge from the complexity of the clinical environment. Complexity creates the need for flexible adaptation to achieve outcomes. RE focuses on understanding the nature of adaptations, learning from success and increasing adaptive capacity. Although the philosophy is clear, progress in applying the ideas to quality improvement has been slow. The aim of this study is to test the feasibility of translating RE concepts into practical methods to improve quality by designing, implementing and evaluating interventions based on RE theory. The CARE model operationalises the key concepts and their relationships to guide the empirical investigation.MethodsThe settings are the Emergency Department and the Older Person’s Unit in a large London teaching hospital. Phases 1 and 2 of our work, leading to the development of interventions to improve the quality of care, are described in this paper. Ethical approval has been granted for these phases. Phase 1 will use ethnographic methods, including observation of work practices and interviews with staff, to understand adaptations and outcomes. The findings will be used to collaboratively design, with clinical staff in interactive design workshops, interventions to improve the quality of care. The evaluation phase will be designed and submitted for ethical approval when the outcomes of phases 1 and 2 are known.DiscussionStudy outcomes will be knowledge about the feasibility of applying RE to improve quality, the development of RE theory and a validated model of resilience in clinical work which can be used to guide other applications. Tools, methods and practical guidance for practitioners will also be produced, as well as specific knowledge of the potential effectiveness of the implemented interventions in emergency and older people’s care. Further studies to test the application of RE at a larger scale will be required, including studies of other healthcare settings, organisational contexts and different interventions.

Formal escalation actions and their implementation in practice differed and varied in their effectiveness. Monitoring how escalation works in practice is essential in understanding whether and how escalation policies help to manage workload.

There is a pressing need for future workplace health interventions to reduce employee sitting times.

Objective The aim was to develop a method based on resilient healthcare principles to proactively identify system vulnerabilities and quality improvement interventions. Design Ethnographic methods to understand work as it is done in practice using concepts from resilient healthcare, the Concepts for Applying Resilience Engineering model and the four key activities that are proposed to underpin resilient performance—anticipating, monitoring, responding and learning. Setting Accident and Emergency Department (ED) and the Older People’s Unit (OPU) of a large teaching hospital in central London. Participants ED—observations 104 h, and 14 staff interviews. OPU—observations 60 h, and 15 staff interviews. Results Data were analysed to identify targets for quality improvement. In the OPU, discharge was a complex and variable process that was difficult to monitor. A system to integrate information and clearly show progress towards discharge was needed. In the ED, patient flow was identified as a complex high-intensity activity that was not supported by the existing data systems. The need for a system to integrate and display information about both patient and organizational factors was identified. In both settings, adaptive capacity was limited by the absence of systems to monitor the work environment. Conclusions The study showed that using resilient healthcare principles to inform quality improvement was feasible and focused attention on challenges that had not been addressed by traditional quality improvement practices. Monitoring patient and workflow in both the ED and the OPU was identified as a priority for supporting staff to manage the complexity of the work.

This article presents longitudinal data from 1120 participants across 10 worksites enrolled in Walking Works Wonders, a tailored intervention designed to increase physical activity and reduce sedentary behaviour. The intervention was evaluated over 2 years, using a quasi-experimental design comprising 3 conditions: tailored information; standard information and control. This study explored the impact of the intervention on objective measures (BMI, %Fat, waist circumference, blood pressure and heart rate) and self-reported measures of physical activity, sedentary behaviour, physical and psychological health. Interventions tailored to employees' stage of change significantly reduced BMI and waist circumference compared to standard and control conditions. Employees who received either a standard or tailored intervention demonstrated significantly higher work ability, organizational commitment, job motivation, job satisfaction and a reduction in intention to quit the organization. The results suggest that adopting a tailored approach to interventions is particularly effective in terms of improving health in the workplace. Practitioner Summary: This study describes Walking Works Wonders, a tailored intervention, which aims to encourage physical activity in the workplace. The study evaluated Walking Works Wonders over a 2 year period and demonstrated that interventions are more effective in improving health outcomes where the information is tailored to employees' stage of change.

This article presents baseline data from 1120 employees across 10 worksites enrolled in a workplace physical activity intervention. The study provides new data on physical activity, sedentary behaviour, and health and highlights gender, geographical, job type and industrial sector differences. Sitting at work accounted for more than 60% of participants' total daily sitting time on work days. Weekly and monthly hours worked, body mass index (BMI) and waist circumference were significantly higher for workers in the private sector compared to the public sector. Employees in sales and customer services had significantly higher BMI scores and significantly lower scores for workability index (WAI), job satisfaction, organisational commitment and job motivation, compared to other groups. This study provides further evidence that work is a major contributor to sedentary behaviour and supports the pressing need for interventions particularly targeting private sector industries and sales and customer service sectors. Practitioner Summary: Work accounts for more than 60% of the daily sitting time. Private sector employees had higher BMIs than those in the public sector and employees in sales and customer services had higher BMIs and poorer health compared to other occupations, suggesting that these groups should be targeted in workplace interventions.

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Resilient healthcare emphasises the importance of adaptive capacity for the quality of healthcare. It has had extensive theoretical development, but comparatively limited translation for clinicians in practice. This study was the first in the world to present resilient healthcare principles in a serious video game. Serious games are an effective tool for engaging users, sharing ideas and eliciting reflections. The purpose of this study was to communicate principles from resilient healthcare to clinicians through a serious video game, and to evaluate the game's feasibility as a prompt to reflect on practice. The game, Resilience Challenge, is scenario-based and requires players to resolve dilemmas in clinical practice. It was disseminated online, and was played 1,949 times during the four-month study. The game was evaluated using an immediate cross-sectional survey, which included both Likert-style and free text responses (n=141). Participants reported that the game was engaging (93%) and that they would recommend it to others (89%). Fewer participants reported learning about resilient healthcare concepts (64%). Resilience Challenge is a promising way to engage with healthcare professionals and potentially improve safety in healthcare, and warrants further research.