Background
Healthcare is facing turbulent times due to the increasingly complex needs of patients, driven by higher survival rates for severe illnesses, an aging population, and the associated financial constraints combined with staff shortages [1, 2]. To deal with these macro-level changes and address the evolving needs of their patients, healthcare professionals need to cultivate innovation to adapt their work routines [3]. For example, frequent intra- and interdisciplinary collaboration within and across healthcare organizational boundaries is needed to organize care for patients with complex multimorbidity [1]. On the organizational and even the ward level changes are required to solve the lack of coherent care pathways, the unavailability of equipment or staff shortages. Additionally, on both ward and professionals’ level continuous alterations to daily practices are needed for when a patient becomes unexpectedly ill, for instance. These intertwining changes on different levels that influence daily practices derive from the complexity of the healthcare system [4]. A complex system is characterized by continuous non-linear transformation of interacting components [4]. Complex systems feature continuous and discontinuous changes in practices, with occasionally unexpected results on both the process and outcome level [1]. These changes in practices, processes and systems require the resilience of healthcare staff. Resilience is understood as people’s the capacity to adapt to challenges and changes at different system levels, to maintain high quality care [5]. This can be divided in situated (short term solutions) and structural (long term solutions) resilience [4].
Research has shown that it is not easy for individual healthcare professionals to make adjustments in complex systems because the corporate culture and structures in most organizations are fixed by rules and regulations [6]. To provide optimal patient care amidst constantly changing circumstances, all healthcare professionals are called upon to exercise personal leadership [1, 7‐9]. Resilient leadership on a daily basis is especially crucial for nurses, who spend most of their time at the patient’s bedside [10, 11]. In this paper we explore the resilient behavior of nurses in daily practice and focus on their leadership style to adapt to and cope with complex systems.
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To provide good quality of care (i.e., safe personalized care) in a system with changing processes and work routines, healthcare professionals must be aware of the changing aspects that require resilience [1]. This is especially relevant for nurses who have a significant role in adaptations to the complex changing system that surrounds patient processes in hospitals. Nurses are and must consider themselves an important link between healthcare disciplines. They play a crucial role in aligning processes within and across the boundaries of organizations [11, 12]. Clearly, nurses are key players to keep things on track in this complex system and an influential factor for change [12]. Research shows that the decisions nurses make can set off a chain reaction which is more far-reaching than the nurses often realize [13]. By being resilient to changes in patient care and work routines, nurses implicitly show leadership that influences the complex system. Studying nurses’ leadership in response to non-linear change will help us better understand the behavior of the complex adaptive system. This is described in literature as a dynamic and self-organizing system composed of numerous interconnected components or agents that interact [14].
Numerous nursing leadership models and theories have evolved in recent years. Traditional leadership research emphasizes transformational and transactional leadership as supportive for nurses aiming to alter daily practices [15]. This approach assumes that a single leader influences or directs others. However, Raelin [9] argues that leadership is not merely a situation where one person sends and the other receives. Leadership arises when one or more people lead others who are already moving in a different direction when the situation calls for it [9]. This contrasts with traditional leadership research, which seldom takes context into account [16]. Raelin [9, 16] calls this notion Leadership as Practice (LAP), a collective action-reaction process that is embedded in a complex adaptive system and in close collaboration with other people (i.e., patients, management, other staff). LAP focuses less on formal roles and positions and more on the ability of individuals to move things forward [11]. LAP is not about what one nurse thinks or does, but more about what nurses achieve together [9].
LAP theory is well explained in the literature [9, 16]. However, not much is known about how LAP manifests itself in nurses’ daily work [11] as most articles discuss LAP in its theoretically envisioned form. This resembles what is known as ‘Work as Imagined’ in the Safety-II approach: a theoretical notion of daily practice [17]. Research describing how LAP manifest in practice, or ‘Work as Done’ [17], is still sparse [11, 18]. To gain more insight into the exhibition of leadership in a complex working environment, empirical research on ‘Work as Done’ practices is needed [11, 16]. According to de Kok et al. [11], studying this kind of leadership would be done best when researchers immerse themselves in the nurses’ daily work environment as adjustments to the structures, rules and regulations of an organization are often made ‘under the radar’ [11, 19]. Non-participatory observations would obtain insights into the resilient leadership behavior of nurses adapting to complex changes in daily practices. Non-participatory observations would reveal the nurses’ considerations, beliefs, and interactions — their subjective notions — in a continuously changing context that demands action or change, and thus makes their adaptations to work practices visible [11, 16]. Our research question was: How do nurses show leadership to respond to changes in the complex work environment that demands resilience in daily practices?
Methods
Design
We conducted an empirical qualitative study to gain insight into how nurses exhibit leadership in daily practices and show the resilience needed to respond and adjust to their complex working environment [20]. We combined non-participant observations with monodisciplinary (nurses) and multidisciplinary (healthcare professionals) group interviews. We followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist [21] to enhance the quality of the design and reporting (Supplementary file 1).
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This study was part of a larger study named ‘Met Verve!’ which investigates how nurses implement quality and safety management in their daily practice. This larger study adopts an appreciative approach, examining nursing wards where quality and safety improvement is already effective. By identifying what works and why in these wards, other nursing wards can be supported in enhancing quality and ensuring patient safety [22].
Study setting and recruitment
The main population consisted of nurses working on a specialized internal medicine ward of a Dutch university medical center. The entire nursing team consisted of 42 nurses, both men and women, aged between 21 and 64 years, and with a range of work experience from 0 to 23 years. A physician assistant, manager, team leader, and nurse specialist also participated. The hospital was conveniently selected for its academic expertise and perspective. The internal medicine ward was selected as it was one of the best performing wards, based on business intelligence data from routinely collected nursing sensitive indicators (e.g., pressure ulcers, malnutrition, pain). Analysis of the data indicated that this department excelled particularly in pain management. Therefore, the primary focus during observations and interviews was on pain management, with additional emphasis on the roles of leadership and resilience.
One researcher (EL) contacted the management team of this ward by email, explaining the study aim and research methodology. After granting permission for the study, the ward manager, two nurses, a quality officer, a physician assistant, and two researchers formed a local research team under the supervision of the principal researcher. This local team supported the researchers and provided contextual information about the ward.
The study began with non-participatory observations of daily practices on the ward. Based on the shifts during which observations were made, a total of 28 nurses were observed. Next, five nurses took part in one monodisciplinary group interview, and six participants took part in one multidisciplinary group interview. Table 1 describes the participants’ characteristics. Nurses were recruited for the monodisciplinary interview by an email sent to the entire nursing team of this ward, which explained the purpose and procedures for data collection and storage. No exclusion criteria were set up front. Snowball sampling was used to recruit information-rich participants for the multidisciplinary group interview [20].
Table 1
Characteristics of interview participants
Number | Nurse-only group (N=5) | Multidisciplinary group (N=6) | |
|---|---|---|---|
Age | 20–30 | 1 | 1 |
31–40 | 1 | 1 | |
41–50 | 0 | 2 | |
51–60 | 1 | 1 | |
> 60 | 2 | 1 | |
aExperience | < 1 | 1 | 1 |
1–10 | 1 | 4 | |
11–20 | 1 | 0 | |
> 20 | 2 | 1 | |
Profession | Nurse | 5 | 2 |
Clinical Nurse Specialist | 0 | 1 | |
Team leader | 0 | 1 | |
Manager | 0 | 1 | |
Physician | 0 | 1 |
Data collection
Non-participatory observations (n = 60 h) were conducted in February and March 2022. The observations were imposed on randomly selected day shifts (n = 3) and evening shifts (n = 2) (7:30–16:00 A.M. and 16:00–22:00 A.M.). Different shifts were selected for shadowing nurses at work to observe the presence of leadership across all nursing shifts. It was anticipated that the absence of management during evening shifts might result in distinct challenges compared to day shifts. The observers were paired for the day shifts, as these are busier than evening shifts. One observer shadowed nurses on the inpatient ward, while the other observed in the day treatment area. During the day shifts, the observers held an evaluation session to discuss their observations and to guard against ‘going native’, defined as a situation where an observer becomes so immersed in the environment that their objectivity is compromised [23]. The observers used a predefined topic guide that addressed resilience and leadership (Supplementary file 2) as well as behavior, setting, social interactions, body language, moods, and non-verbal communication. They wrote an almost continuous set of field notes during the shift, and asked questions for clarification or to reveal purpose. The observers also kept a log of events. Thick descriptions were written shortly afterwards based on the event log and field notes [24]. Data collection continued until data saturation was reached.
Based on the analysis of the thick descriptions the interview guide for these group interviews was developed in April 2022 (Supplementary file 3). To obtain a deeper understanding of the observations, a semi-structured group interview with nurses was conducted in May 2022 (duration: 95 min). Subsequently, in June 2022, a multidisciplinary group interview (duration: 110 min) was conducted to gather the perspectives of the various disciplines that work with the nurses in the department on a daily basis, and to understand how several topics are manifested in practice. The interviews were conducted at a place in the hospital convenient for the participants. Demographic data, including age, gender, and years of work experience were collected at the start (Table 1) [21, 25]. All interviews were audio recorded and transcribed verbatim.
Data analysis
The rich, dense, and comprehensive data set acquired from the non-participatory observations and interviews was analyzed using Braun and Clarke’s [26] six-step approach to thematic analysis. This cyclic inductive process involved two researchers independently coding all data to identify common overarching themes, ideas, and patterns. First, they familiarized themselves with the observation data by reading the thick descriptions, field notes and other notations, such as answers to informal questions and the event log. Second, they independently generated codes, using descriptive labels highlighting data aspects from three thick descriptions and discussed these up to consensus. This coding tree was used to re-analyze all the data. Third, the researchers independently grouped the codes into potential themes. Together with another researcher they critically evaluated the emerging themes refining definitions and ensuring data alignment. In the fifth and sixth step, the three researchers defined and named the themes to encapsulate deeper insights. Finally, they integrated these themes in a coherent narrative refined by data comparison to yield comprehensive insights [26].
Subsequently, inductive content analysis was used to interpret and identify coding, subcategories, and main categories of the group interviews [27]. Two researchers independently read and re-read the interview transcriptions to make sense of and identify codes. Next, another researcher joined to discuss the codes in an iterative way, up to consensus was reached. Afterwards, similar codes were grouped into subcategories, generic categories, and main categories. See Table 2 for an overview.
Table 2
Definition of main themes
•Proactive patient-centered care: related to subthemes such as taking initiative, taking control, ensuring continuity of care, advocating for the patient •Investigative problem solving: associated with subthemes such as asking follow-up questions, adopting a critical attitude, justifying actions, consulting with colleagues •Reflective learning: this indicates reflective learning behavior on daily tasks, self-reflection, and work routines. Subthemes related to this are collaboration, honesty, transparency, showing vulnerability •Profession-based approaches: related to subthemes such as educating each other, performing preparatory work, exploring possibilities, adapting flexibility |
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Ethical considerations
This study was conducted according to the principles of the Declaration of Helsinki (version October 2013), the Dutch Code of Conduct for Research Integrity (2018) and the Medical Research Involving Human Subjects Act (WMO). The study was part of a larger study named ‘Met Verve!’ approved by the Erasmus Research Ethics Committee (reference number: ETH2122-0079).
Participants were informed verbally and in writing about the study purpose, research methodology and data storage procedures. One of the first authors was available to answer their questions.
Informed consent was obtained from all participants involved in this study. Prior to the observations, the researchers asked nurses if they agreed to being shadowed and obtained their verbal informed consent. Prior to the interviews, informed consent was obtained regarding voluntary participation and agreement to record the interviews. The researcher named all aspects of the informed consent form to which the participant answered with a clear ‘yes’ or ‘no’. This consent procedure was recorded, transcribed, and stored separately from the interview. The participants were assured that data would be processed confidentially and that they could withdraw from the study at any time.
Results
The analysis of both observational and interview data revealed four leadership behaviors showing how nurses adapt to work environment changes that require resilience. Data saturation was achieved, and no differences were found across shifts. The four leadership behaviors were: 1) proactive patient-centered care, 2) investigative problem solving, 3) reflective learning and 4) profession-based approaches.
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Proactive patient-centered care
Nurses acquire a comprehensive understanding of the patients’ condition (physically, emotionally, socially) that enables them to be resilient in the face of (potential) issues and to prevent complications during hospitalization. Nurses dedicate a significant effort to identifying and assessing the patients’ condition. Rather than conducting a one-time assessment at the beginning of admission (anamneses) or the start of a shift, they continuously strive to obtain a holistic overview of the patient’s condition, including the reason(s) for admission along with the patient’s medical history and home context. This produces a thorough assessment of (potential) problems and the formulation of actions to address or prevent them. Building on this foundation, nurses convincingly propose well-defined plans to other healthcare professionals and/or management, fearlessly advocating for the patient’s best interests. These actions could relate to operation management workflows, as demonstrated in the first observation below, but also to treatment and nursing practices as evidenced by the second excerpt of an observation of OR5 displayed after the next section:
“Nurse X [ward nurse] does the handover and tells something about the patient in room 12. Pain medication has been increased and is under control since 12:00 pm. Please ask patient again at 4:20 pm [for her pain score] and evaluate with the doctor to see if medication needs to be adjusted. The evening shift nurse nods and understands what to do.” (OR5, 9-3-2022)
This excerpt illustrates how nurses’ proactive behavior prevents pain management issues arising in the next shift by considering doctors’ routines in their assessment. The specific mention of 4:20 pm highlights the importance of timely collaboration because ward doctors finish their shift at 5:00 pm. By promptly asking for pain scores, nurses ensure there is ample time to consult the attending ward doctor so that treatment can be adjusted if needed.
“After the patient has answered the nurses’ observations and suggestions, the physician assistant (PA) says that she will ask her supervisor [doctor] to increase both long-acting and short-acting pain medication. The nurse says this is necessary as the current medication is not sufficient in the long term. She strongly advocates not to wait for approval, but to increase the pain medication right now. The PA nods, indicating that this might be a good thing to do.” (OR5, 9-3-2022)
This excerpt illustrates nurses taking on responsibilities beyond their professional domain, to ensure optimal care in the best interest of the patient. They guided the PA by sharing observations, proposing alterations to the standardized medication protocol, and advocating for immediate action. Their proactiveness prevented unbearable pain for the patient, displaying situated resilience in the collaboration with other healthcare professionals. Additionally, nurses actively seek structural solutions to recurring problems, displaying structural resilient behavior. For instance, nurses encountered challenges in monitoring patient-requested pain medication via a Patient-Controlled Analgesia pump, due to its inability to reset the medication count daily. This resulted in uncertainty about the frequency of additional pain medication administered in the past 24 h. Zeroing the medication count required a specific code owned only by the specialist pain team. This lack of information hindered the development of a more effective pain management strategy. One nurse described how she managed this situation:
“So, then I passed that on to X [specialist pain team nurse]. I said: “I think this is not workable for us, we have to do something about it.” Next, we had a consultation with the whole pain team together with management about what we [ward nurses] come across and need. And a few months later we got that code [so that] we nurses could do it. Now we start zeroing early in the morning.” (Nurses group interview, P4)
This example displays nurses’ proactive behavior in identifying and addressing a recurring issue in daily practice and their subsequent pursuit of a sustainable solution, displaying their structural resilience. This solution not only improved the understanding of a patients need for additional pain medication via the pump but also facilitated the evaluation of pain management policies. The nurses effectively communicated the problem not only to the pain specialists’ team, but also to ward management and this led to changes in policy. Their leadership ensured the implementation of a suitable solution into daily routines.
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By being attuned to others, nurses show proactive resilient behavior:
“I observed nurses communicating extensively about the work, making them a well-oiled machine running a seamlessly coordinated system where tasks can easily be taken over at any time. This enables immediate assistance for patients when needed, such as fixing drips or preparing patients for discharge by removing intravenous catheters. The nurses seem unaware of how efficient their system is. They naturally assist colleagues as soon as they complete their own tasks, demonstrating a remarkable ability to anticipate when their help is required. Interestingly, they seem to have a kind of radar that lets them know when they are needed.” (OR2, 4-3-2022)
All observations in this section depict nurses’ proactive behavior in daily practice, fostering both situated and structural resilience. Furthermore, social resilience is evident as nurses influence and collaborate with others to modify work routines for short and long-term benefits. Nurses’ leadership is necessitated by their ongoing monitoring of patient conditions and thereby solving and preventing problems, along with contextualizing solutions to alter work routines and organizational policies.
Investigative problem solving
Nurses frequently exhibited an investigative attitude and behavior when facing unexpected situations, altered work routines, or problems in navigating complex work routines and/or organizational policies. We observed their active pursuit to the gained knowledge needed to address the daily workplace challenges that demanded leadership and resilience. The following quote exemplifies how nurses strive to unravel the patient’s thoughts, aiming to provide patient-centered care while also gathering knowledge to avert unexpected complications:
“They pay attention to patients and ask questions about fear and related matters. They use every hook in a patient’s story to ask further questions about worries and/or anxiety.” (OR2, 4-3-2022)
Investigative behavior is done both individually and collaboratively with other nurses. We observed them collectively discussing and critically analyzing noteworthy events, as the following quote describes:
“Looking at a patient’s medication list, nurse X sees that she should give a particular medicine at this point of time, but she knows from previous experience that she never gives it at this time. ‘Looks strange to me,’ she mumbles. Nurse Y agrees and asks nurse X to check the chemotherapy guide. Studying the guide together they conclude that this time of administration is not in there. Nurse Y says that nurse X can also ask the patient if he ever takes this medicine at this time. [...] I get the impression that the patient’s experience also plays a role in the final decision not to give the medication.” (OR9, 21-3-2022).
This example shows nurses critically analyzing an unusual situation and examining a guide to jointly determine the most suitable reaction. Their investigative attitude is a fusion of resilience and leadership in coping with an unusual situation. By actively seeking knowledge to anticipate challenges arising from unexpected circumstances, they utilize collective insights to make informed decisions, which may include deviating from medication orders.
Reflective learning
Nurses demonstrated a reflective attitude and behavior in three key areas: 1) daily tasks, to make them easier to do and enhance efficiency or effectiveness; 2) self-reflection on personal behavior, to foster team cohesion; and 3) work routines, to cultivate a positive work environment. We observed collective discussion and critical reflection occurring daily on the nursing ward. They highlight the nurses’ commitment to mutual learning, highlighting various forms of resilience. These reflections underscored a culture of respect among the nurses and their willingness to embrace individual vulnerability for the sake of learning and improvement. Our observations suggest nurses felt safe discussing matters among themselves. The following excerpt comes from one nurse who courageously opened up to the team:
“The nurse team leader asks nurse A, who cared for this patient, to tell colleagues what happened. Nurse A explains the [life-threatening] situation and says she did not feel competent enough to help the patient properly, so she was a bit hesitant. Nurse B, who had more experience, took over and gave nurse A several other tasks to do. Nurse A says that she feels guilty because this patient was her responsibility. But she didn’t dare admit that she didn’t know what to do and wanted someone else to take over [the care for the patient]. The team leader notes that all nurses on duty are responsible for the well-being of patients and the standard of care the ward provides. She tells the nurses, ‘Just speak up next time you feel at a loss in a situation. Your colleagues will understand and can help and support you.’ The evaluation goes smoothly. The nurses are quiet but have an open, listening attitude. The team leader shows the understanding that provides a safe climate. Nurse A says this situation made big impression on her, but now she feels reassured.” (OR1, 24-2-2022)
In this excerpt, the nurse team leader encouraged the nurses to engage in a critical discussion of individual actions in a specific situation that led to friction among colleagues. However, we observed more situations when nurses, without management present, held both positive and negative reflection-based discussions, not just among themselves but also with other healthcare staff. These discussions reflected on individual actions, risks to patient safety and/or ineffective working practices. We observed several instances of nurses inspiring one another to improve care processes and/or their behavior. These team-wide reflections, characterized by open communication and self-awareness, proved not only to benefit individual nurses but also to serve as collective learning opportunities. They reflected on ethical and cultural considerations, which culminated in a consensus on what should or could be done differently in their pursuit of the best quality of care. This form of leadership supports resilience as it allows nurses to learn how to manage future situations, preventing them from experience the same challenges as their colleagues.
Reflection was not limited to healthcare staff but extended to interactions with patients. Nurses cultivated an environment that encouraged patients to actively engage in their treatment, thereby promoting the preservation of their autonomy, as the next quote:
“[...] I’ll tell the patient to call if the pain medication isn’t working well enough after 45 minutes. […] Or, if I think the patient is a bit mistrustful, I’ll drop by to ask how things are going and inquire about the pain.” (Nurses group interview, P4)
This quote demonstrates the nurses’ ability to prevent a breach of pain by assessing the patient’s ability to self-manage, thus promoting patient autonomy alongside maintaining their leadership role. By creating opportunities for mutual reflection on the patient’s pain treatment, nurses can gauge whether the patient is seizing autonomy. The nurses’ efforts to empower patients in their treatment process requires resilience from patients too.
Profession-based approaches
Beyond the learning insights derived from reflection, collaborative conversations also fostered the exchange of knowledge and skills of the nurses on the team, enhancing both their resilience to deal with future situations and their leadership abilities. This commitment to delivering high care quality is further exemplified by the following:
“When I had just graduated, I came across a terminal patient in severe pain and my instinct was to rush for pills. However, at one point I didn’t know what to do, and then a colleague good at complementary care came and sat [with the patient]. She took the patient’s hand, and pain was gone. […] It was an eye-opener for me, made me realize that I needed a different approach.” (Multidisciplinary group interview, P8)
This quote shows how nurses leverage each other’s knowledge and experience, demonstrating leadership by integrating non-pharmacological interventions into their work routines. Despite the lack of guidelines on this, their nursing professionalism compelled them to deal suitably with the patient’s request for help. This shows form of resilience on the content of the nursing profession.
Moreover, we observed how nurses educated and informed patients about the why, what, and how of diagnostic tests and treatments, as a way to share knowledge about their profession. The following shows that nurses took the role a patient could play very seriously:
“Nurse X [informs the patient that] there is a chance of an allergic reaction when the therapy first starts, so nurse X must stay with the patient for the first 10 minutes and be prepared for this [allergic reaction]. Nurse X goes on to say that she has already taken precautions because she’s got the emergency kit ready. She also spoke to the patient and her husband about the risk of an allergic reaction and the precautions she should take in order to be able to act immediately if necessary.” (OR7, 14-3-2022)
Nurses need to educate and inform patients to involve them in their treatment and safeguard them in potentially risky situations. This also gives them the opportunity to build informed-patient resilience, a process based on the shared information on nursing in which the patient acts resiliently. However, involving the patient in the care process also implies that the nurse may occasionally be asked to deviate from the intended path, in order to meet the patient’s needs and wishes. The following shows a nurse dealing with the wishes of one patient, yet maintaining a professional attitude by guaranteeing the safety of other patients:
“Because of COVID (coronavirus disease), visitors are not allowed to enter the four-person treatment room. I get that. Then a patient and her partner arrive for the final treatment. The partner tells me that he was at the patient’s first treatment, and he should be at this final one too to finish the therapy. The nurse explains the COVID guidelines again, but the patient insists on completing it with her partner. Then the nurse deviates from hospital policy and finds a single room so that the partner can stay with her and there is no [danger of] contact with other patients.” (OR4, 9-3-2022)
The profession-based resilience of nurses is based on the combined exchange of knowledge and skills. First, this involves integrating knowledge, experience and skills derived either from their discipline or from patients to enhance care quality. However, this requires leadership, individuals to take on the responsibility to gather and synthesize this ‘collective wisdom’ to promote resilience not only in the present circumstances, but also in future situations. Second, nurses share their professional knowledge with patients to foster patients’ resilience, which may prompt additional resilient behavior.
Discussion
We studied how nurses exhibit leadership in their dynamic work environment that demands resilience. Building on the concept of LAP, we examined how leadership emerges through collective actions and interactions within the context of "work as done”. We identified four distinct behaviors that effectively navigate the evolving complexities of their daily practices: proactive, investigative, reflective, and profession-based leadership behaviors. These behaviors all share one overarching theme: the collaborative nature of nursing work [12]. Collaboration comes in various essential forms: among nurses, between nurses and patients, with other healthcare staff, and with management. Our empirical findings indicate that collaboration is vital not only to ensure high-quality care [1], but also for the resilience of nurses acting in complex work environments [5]. This collaborative imperative manifest itself in multiple facets: 1) the synergistic effort to change practices and policies, 2) knowledge exchange to generate new insights and, 3) in interprofessional discussions to reflect on situations, processes, and policies. While the importance of collaboration in the nursing profession is not a new finding [11, 12], its relevance to nurses exhibiting resilient behavior and leading adjustments to daily practices, work routines and organizational policies is a novel insight. This finding aligns with LAP theory, highlighting the role of professionals in demonstrating leadership in routine daily practices [9, 11]. Prior research has found that collaboration is a complex, multifaceted process demanding knowledge sharing, respect, and dialogue in both mono- and multidisciplinary contexts [28]. The study by Chaffee & McNeill [29] shows that friction can easily arise, often stemming from the interconnectedness of work routines, where one individual’s action influences the actions of all other elements in a system. The complex systems approach elucidates this interconnectedness and how resilience behavior can mitigate personal and organizational frictions. Rectifying equilibrium after friction in a complex adaptive system presents opportunities for collective growth, termed “co-evolution” by Chaffee & McNeill [29]. Shared reflection to address and prevent friction are indicative of the resilience demonstrated by the nurses observed in this study too. In the long run, the willingness to expose vulnerabilities and foster a psychologically safe atmosphere [30] are essential for sustaining resilient behavior. Moreover, this psychological safety not only leads to resilient behavior but also to better quality of care [31].
Nurses’ proactive attitudes are exemplified by their comprehensive patient assessments, their fearless advocating for the patient’s best interests and their taking the initiative to cooperate with diverse healthcare professionals to solve or prevent problems. Collaborating in synergistic, finely tuned teamwork is a way to enhance seamless transitions in task delegation and immediate responsiveness. It demonstrates both individual leadership and the ability to respond resiliently to the complexities of unexpected change in the work environment. An attentive nurse notices a problem and either starts discussing the problem with colleagues or proposes a solution to management and/or other healthcare staff. LAP is clearly reflected here as the nurse notices something and, in collaboration with other healthcare providers, initiates a movement to address it [9, 11]. This proactive attitude aligns with the findings of Doessing [32], wherein nurses not only acknowledge the care continuum challenges upfront (“they are on top of things” according to Doessing [32]), but also are motivated to proactively engage in ‘creating’ responsive solutions. Our study showed that nurses can solve problems resiliently in both situated (short term) and systemic (long term) ways. Moreover, an effective communication style is essential to foster reflection, knowledge gathering and exchange, all of which nurses use to act resiliently. The LAP literature [9, 11] often mentions nurses taking the lead in honest and open communication. Resilience literature also sees communication as a key competence in resilient professionals [33]. Although resilience was observed during moments of structural problem-solving, it often appeared as ad hoc problem-solving. This is more related to the situated resilience described by Anderson et al. [4] and Vanbelleghem et al. [34]. Furthermore, the role of a supportive manager or a vigilant nurse is regarded as a prerequisite for structural resilience [11].
Noteworthy is the remarkable adaptability of nurses to accommodate patient preferences that derives from their proactive, investigative, reflective, and profession-based leadership. In their aim to provide high-quality person-centered care, they occasionally needed to deviate from established care patterns, guidelines, and policies. Also, nurses educated patients, involved them in decision-making and gave them a specific task to act resiliently. Nurses exhibiting attentiveness to patients’ desires and needs are inclined to engage in patient collaboration (informal coordination) and are willing to deviate from structured pathways (formal coordination) [32].
Our study also illustrated the crucial role of profession-based knowledge combined with the ability to access and share relevant information (documents, other staff) for an effective resilient response. This was especially pertinent when abnormal or unexpected circumstances necessitated adjustments to accommodate individual patient preferences or prevent (patient) safety risks. Fitzgerald [35] also emphasizes the importance of domain-specific knowledge as this empowers nurses to navigate the changing work environment. Additionally, nurses demonstrated an investigative leadership style by critically assessing situations (conditions, workflow), gathering knowledge (written, verbally), and proposing solutions to solve or prevent problems to colleagues, other healthcare staff, and management. This resulted in informed decisions based on individual or collaborative reflections, leading to modifications in the current situation, and in some cases the work routines or policies to mitigate potential harm (e.g., as seen in the pain pump example), which resembles with Wiig et al. [5] concept of resilience. The literature on complex adaptive systems emphasizes that nursing care cannot be summarized in linear relationships or predetermined guidelines [29, 33, 36]. Given the capricious and unpredictable nature of healthcare, the role of nurses assumes as “glue” to keep things “on track” [12]. The four adaptive attitudes identified in this study serve as practical demonstrations of this “glue”. It underscores the essential nature of interconnections and interactions among diverse care systems.
Limitations
This study has several inherent limitations that should be acknowledged. Firstly, as the scope is confined to a single nursing department in one academic medical center, the generalizability of the findings to other nursing settings, such as acute care units, or other contexts such as general hospitals or nursing homes is limited. Secondly, there is the potential influence of repeated observations of the same staff within a short time frame. Duplication in the observed cohort may have influenced the information richness of our observations. However, we had an optimal diversification of the observed nursing staff. Third, data collection encompassed observations from both day and evening shifts until data saturation was achieved. The analysis did not reveal significant differences in leadership behaviors between shift types, so no distinctions were made. However, including night and weekend shifts might have uncovered differences.
Implications
Due to the unpredictable nature of healthcare, the role of nurses as care and work practice coordinator is perceived as essential. Nurses are acting as a cohesive agent bridging various demands of the healthcare system. The four identified leadership behaviors demonstrate how this resilience cohesion manifests in daily practices. This research makes an important contribution to understanding the LAP theory as it showed different resilient leadership behaviors nurses exhibit to deal with unexpected changes, coined in Safety II as ‘Work as Done’ [17]. The findings can be utilized to assess its application within one's practice and explore ways to enhance nurses' role as a stronger unifying force within healthcare systems that demand resilience. This research could benefit nurses, healthcare managers and policymakers who are interested in (enhancing) resilient nursing practices and nurse leadership in daily practice.
Conclusion
Responding to the changing, complex work environment that necessitates adaptive and resilient behavior, nurses exhibit four distinct types of leadership to ensure optimal care. First, nurses demonstrate a proactive attitude by possessing in-depth patient understanding, taking protective action, and engaging in effective collaboration with healthcare professionals. The nurses’ investigative approach displays their pursuit of knowledge, critical analysis, and solutions for bottlenecks that contribute to high-quality care. Reflective leadership in daily practices foster collective learning by encouraging open discussions, enhancing patient safety, and enabling adaptation in future situations. Finally, a profession-based attitude embraces knowledge sharing, multidisciplinary collaboration, and patient engagement, exemplifying leadership and adaptability. Collectively, these four behaviors illustrate how nurses lead by example,—resembling LAP insights—fostering resilience to adapt to changes in their work routines, work environment, and sometimes organization policies in close collaboration with other nurses, healthcare staff, management, and patients.
Acknowledgements
The authors wish to thank all respondents and co-researchers involved in this study and in particular Conny van Velden, Marielle van Mersbergen, Ina Braam and Naomi Stol. Furthermore, we extend our gratitude to the dedicated members of the local observer team: Marieke Robbers, Claudia van Bochove-Bijl and Louise van Esch.
Declarations
Ethics approval and consent to participate
Ethical approval was obtained by the Erasmus Research Ethics Committee, Rotterdam, the Netherlands (ETH2122-0079). The researcher obtained informed consent from all participants involved in this study. The participants were assured that data would be processed confidentially and that they could withdraw from the study at any time.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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