Organizational resilience in healthcare: A scoping review

Abstract

Goal

Healthcare organizations have always faced challenges, yet the past decade has been particularly difficult due to workforce shortages, the COVID-19 pandemic, and economic demands, all which can impact quality of care. While some healthcare organizations have demonstrated the ability to adapt to such stressors—which has been termed ‘organizational resilience’—others have not. Most of the research on resilience in healthcare has been on individual clinicians; less is known about how extra-individual groups such as teams, units, and systems develop resilience. Understanding what organizational resilience is, how to measure it, and how healthcare organizations can develop it is essential to responding effectively to future acute and chronic stressors in the healthcare industry. The purpose of this scoping review is to synthesize how organizational resilience is defined and measured in the current healthcare literature, to inform future interventions to improve organizational resilience.

Methods

We searched PubMed and Scopus databases for articles mentioning organizational resilience in healthcare. Eligible sources were those published in English through December 2022 in any format, and that described or measured organizational resilience in healthcare. Titles and abstracts were screened and information was extracted from eligible articles.

Principal Findings

We screened 188 articles and included 75 in our review. Across these studies, organizational resilience was described as a healthcare system’s ability to continue functioning and meet its objectives when exposed to stressful stimuli. Reactive and proactive strategies, as well as reflection, were identified as key components of organizational resilience. Four measures of organizational resilience were developed for use in healthcare, but only two have been validated.

Practical Applications

Future studies should focus on validating and comparing existing measures of organizational resilience and using them to investigate how organizational resilience may impact quality of care and clinician well-being, allowing the field to move beyond the focus on individual clinician resilience.

Introduction

While healthcare organizations have always faced challenges, the past few decades have been particularly challenging due to workforce shortages, pandemics, epidemics (e.g., Ebola, COVID-19), cybersecurity attacks, and economic demands. Such challenges and associated stressors have the potential to impact the quality of care. However, while some hospitals weather these stressors well and continue to function effectively, delivering high quality care and supporting the clinicians in their organizations, others do not (Rosenthal BM, 2020); this suggests variation in an organization’s ability to respond to stressors and be resilient, also known as organizational resilience. From an organizational systems perspective, organizational resilience has been defined as the ability of an organization to anticipate, prepare for, respond, and adapt to unexpected disruptions to survive and prosper (Vogus & Sutcliffe, 2007).

Although organizational resilience has been described extensively by Hollenagel (Hollnagel, 2011, 2017, 2019; Hollnagel, Woods, & Leveson, 2006) and was discussed during the Ebola epidemic (Kruk, Myers, Varpilah, & Dahn, 2015), it is only now receiving more attention in healthcare (Barasa, Mbau, & Gilson, 2018; Biddle, Wahedi, & Bozorgmehr, 2020). In the U.S context, most of the emphasis on resilience has been on individual clinicians (Guo et al., 2018; M. Mealer et al., 2017; Meredith Mealer et al., 2012; Rushton, Batcheller, Schroeder, & Donohue, 2015). Interventions that target individual resilience, such as mindfulness or yoga, may be beneficial (Gilmartin et al., 2017), but bolstering individual resilience without addressing organizational factors is insufficient, and may leave clinicians feeling blamed (Panagioti et al., 2017). In contrast, focusing on how an organization can react and respond to stressors (i.e., organizational resilience) might lead to a more robust preparedness and may be more effective in supporting clinicians and patients. For example, in the oil and gas industry and in office-based work, organizational resilience has been linked to improved worker outcomes and safety (Bento, Garotti, & Mercado, 2021; Duchek, 2020; Ferris, Sinclair, & Kline, 2005; Hollnagel, 2019), suggesting it may play an important role in clinician outcomes and healthcare delivery.

Before leveraging or improving organizational resilience to support organizations, clinicians, and patients, a clear understanding of how organizational resilience is defined and measured in healthcare is needed. Thus, the purpose of this scoping review is to synthesize how organizational resilience is defined in the healthcare literature and to examine instruments that have measured organizational resilience in healthcare. This work is essential to ensuring the future sustainability of healthcare systems; it can help inform the development of interventions to address and improve organizational resilience so that healthcare systems can survive a variety of stressors such as disasters, wars, economic crises, and others.

Methods

We conducted a scoping review using a systematic approach (Noble & Smith, 2018) to describe how organizational resilience has been defined and measured in the healthcare literature. We identified studies in English from PubMed and Scopus through December 2022 using a combination of the terms “organizational resilience” or “institutional resilience” and “health care” or “healthcare.” Reference lists were hand-searched. Studies were included if they described or measured organizational resilience in healthcare. Studies that described individual resilience or described organizational resilience only in another setting (e.g., manufacturing), were excluded.

Due to the mix of study designs, we used the Integrated quality Criteria for the Review of Multiple Study designs (ICROMS) to appraise all randomized control trials, controlled before-after, controlled interrupted time series, cohort studies, non-controlled interrupted time series, non-controlled before-after, and qualitative studies retrieved for review (Zingg et al., 2016). The ICROMS tool is a quality appraisal tool to evaluate which studies may merit inclusion in a review based on study design. Given the broad nature of our scoping review and our goal of summarizing how organizational resilience is defined and measured in healthcare, we only used the ICROMS tool to appraise quality and did not exclude articles that were not ICROMS-recommended from our final sample. Instead, we included all articles that met our inclusion and exclusion criteria.

Two authors independently screened articles and applied the exclusion and inclusion criteria (see Table, Supplemental Digital Content 1, search strategy). After title/abstract and full text review, they then used a data extraction tool (see Table, Supplemental Digital Content 2, data extraction tool) to extract and compare how organizational resilience was defined across all included studies. Using these definitions, we then performed a content analysis to characterize organizational resilience strategies (see Table, Supplemental Digital Content 3, organizational resilience definitions). To summarize the measures of organizational resilience in the healthcare literature, we created a data extraction table (see Table 1) to describe each measure, the number of items, validity, reliability, how organizational resilience was defined, factors of organizational resilience, and sample items.

Table 1.

Measures of organizational resilience.

Reference	Description of Measure	No. of items	Validity	Reliability	Organizational Resilience Defined	Factors of Organizational Resilience	Sample items
Mallak, 1998(63)	Three scales: bricolage scale, attitude of wisdom scale, and virtual role system (VRS) scale	24 items		Cronbach’s α >0.60 across all factors	The ability of an individual or organization to expeditiously design and implement positive adaptive behaviors matched to the immediate situation, while enduring minimal stress	(1) Goal-directed solution seeking, (2) avoidance or skepticism (3) critical understanding (4) role dependence (5) source resilience, and (6) access to resource	Try to make sense of the situation when it becomes chaotic (reactive). Have access to resources (proactive). Team’s goals guide individual actions (proactive and reflective).
Carthey et al., 2001(37)	Checklist for Assessing Institutional Resilience (CAIR)	20 items yes (scores 1), maybe (scores 0.5), or no (scores 0)					Clinical supervisors train Junior staff to practice the mental as well as the technical skills necessary to achieve safe performance. Mental skills include anticipating errors and rehearsing appropriate recoveries (proactive). Past events are thoroughly reviewed at high level meetings on a regular basis, not just after some bad event (reflective).
Lee et al., 2013(25)	Measure and benchmark resilience tool (BRT)	53 Items 5-point Likert scale (strongly agree to strongly disagree) as well as open questions and tick boxes	Pilot study used to confirm face validity	Cronbach’s α >0.70 for all except for planning strategies (0.677)	A measure of persistence of systems and their ability to absorb change and disturbance and still maintain the same relationships between populations or state variables	(1) Planning and (2) adaptive capacity	Our organization is able to shift from business-as-usual mode to respond to crises (reactive). Our organization proactively monitors what is happening in its industry to have an early warning of emerging issues (proactive). In our organization we regularly take time from our day-to-day work to reevaluate what it is we are trying to achieve (reflective).
Whitman et al., 2013(59)	BRT-13, shortened Lee et al., 2013	13 items 8-point Likert scale (strongly disagree to strongly agree)	Measured correlations of indicator, factor and overall scale scores generated from different measures and tested reliability of overall scale and constituent factors.	Cronbach’s α BRT-13a  0.84–0.87 BRT-13b  0.85–0.88 BRT-53  0.95	Organizational resilience (OR) is an organization’s ability to plan, respond to and recover from emergencies and crises.	(1) Planning and (2) adaptive capacity	Our organization can make tough decisions quickly (reactive). Our organization maintains sufficient resources to absorb some unexpected change (proactive). We are mindful of how crises could affect us (reflective).

Results

Fig 1 illustrates screening and eligibility criteria and our final sample. Of the 464 articles initially identified, 97 articles published between 1998 and 2023 were included in the final sample. Twenty-seven articles met ICROMS quality criteria for inclusion (26 were qualitative studies, one was a cohort study, and one was a non-controlled before-after design) (see Table, Supplemental Digital Content 4, quality appraisal). Because of the broad scope of our review, we included all studies in our review.

Figure 1.

Eligibility and screening flowchart.

Definition of organizational resilience

Across all 97 articles, organizational resilience was defined as a healthcare system’s ability to continue functioning and meet its objectives when exposed to stressful stimuli (see Table, Supplemental Digital Content 3, organizational resilience definitions). How stressful stimuli were defined differed across studies; some described them as a shock (Ager et al., 2015; Akar, 2020; Alameddine et al., 2019; Blanchet, Nam, Ramalingam, & Pozo-Martin, 2017; Fana & Goudge, 2021; Flaatten, Chew, & Gisvold, 2022; Lilja & Ahmad, 2023; Lyng et al., 2022; Marchal et al., 2023; Montás, Klasa, van Ginneken, & Greer, 2022; Sari et al., 2023; YahiaMarzouk, 2023; Zinn, 2022) or disaster (Blanchet et al., 2017; Fana & Goudge, 2021; Kreh et al., 2021; Mohtady Ali, Ranse, Roiko, & Desha, 2022; Pillay, 2016; Sari et al., 2023; Zinn, 2022), while others described them as an opportunity (Anderson et al., 2016; Back et al., 2017; Berg, Akerjordet, Ekstedt, & Aase, 2018; Elder, McEwen, Flach, & Gallimore, 2008; Fylan et al., 2019; Heath, Sommerfield, & von Ungern-Sternberg, 2020; Mohtady Ali et al., 2022; Patriarca, Di Gravio, Costantino, Falegnami, & Bilotta, 2018; Patterson & Deutsch, 2015; Safi, Thude, Brandt, & Clay-Williams, 2022; Sujan et al., 2022; Tamanna & Sharma, 2020; Witmer & Mellinger, 2016; Zinn, 2022). Additionally, some authors described organizational resilience not only as a system’s ability to continue functioning or sustain operations, but also as entailing a period of growth or improvement (Akar, 2020; Amorøe, Rystedt, Oxelmark, Dieckmann, & Andréll, 2023; Bek Yağmur & Aydıntuğ Myrvang, 2023; Bürgel, Hiebl, & Pielsticker, 2023; Duncan, 2020; Elder et al., 2008; Fleming, Safaeinili, Knox, & Brewster, 2023; Fylan et al., 2019; Gröschke, Hofmann, Müller, & Wolf, 2022; Ignatowicz et al., 2023; Karreinen et al., 2023; Kim, Lee, & Chung, 2023; Lilja & Ahmad, 2023; Marchal et al., 2023; Miyazaki, Sankai, & Omiya, 2023; Mohtady Ali et al., 2022; Patterson & Deutsch, 2015; Ravaghi et al., 2023; Reyes, Bisbey, Day, & Salas, 2021; Sari et al., 2023; Shaw et al., 2022; Tamanna & Sharma, 2020; Wang et al., 2022; Webster, Mahajan, & Weller, 2023; YahiaMarzouk, 2023; Zinn, 2022). While most studies described organizational resilience as a systems phenomenon, 19 studies described it as involving individual resilience (Akar, 2020; Fleming et al., 2023; Hashish & Farghaly, 2021; Heath et al., 2020; Iflaifel, Lim, Ryan, & Crowley, 2020; Jóhannsdóttir, Cook, Kendall, Latapí, & Chambers, 2022; Khalili et al., 2021; Kimberlin, Schwartz, & Austin, 2011; Lagebo, 2019; Marchal et al., 2023; Patterson & Deutsch, 2015; Petersen, Lyng, Ree, & Wiig, 2021; Rangachari & Woods, 2020; Reyes et al., 2021; Riess, 2021; Shaw et al., 2022; Tamanna & Sharma, 2020; Wang et al., 2022; Witmer & Mellinger, 2016). Four articles mentioned time as a key indicator of organizational resilience (Barabadi, Ghiasi, Nouri Qarahasanlou, & Mottahedi, 2020; Flaatten et al., 2022; Gröschke et al., 2022; Hundal et al., 2020; Shaw et al., 2022), such that resilient organizations are those that can return to normal functioning over a short period of time.

Reactive and proactive strategies were key in nearly all definitions. Organizations that responds to events by absorbing, adapting, or transforming practices to continue functioning (Ager et al., 2015; Akar, 2020; Augustynowicz, Opolski, & Waszkiewicz, 2022; Barabadi et al., 2020; Barasa et al., 2018; Bek Yağmur & Aydıntuğ Myrvang, 2023; Blanchet et al., 2017; Bradley & Alamo-Pastrana, 2022; Corbaz-Kurth et al., 2022; Duncan, 2020; Elder et al., 2008; Ellis et al., 2019; Essens, Lepeley, & Beutell, 2023; Fagerdal et al., 2022; Falegnami et al., 2018; Fana & Goudge, 2021; Fleming et al., 2023; Furstenau et al., 2022; Fylan et al., 2019; Gillberg et al., 2023; Haraldseid-Driftland, Dombestein, Le, Billett, & Wiig, 2023; Heath et al., 2020; Iflaifel et al., 2020; Ignatowicz et al., 2023; Jamal et al., 2020; Kaltenbrunner, Stötzer, Grüb, & Martin, 2022; Karreinen et al., 2023; Khalili et al., 2021; Kim et al., 2023; Kisekka, Sharman, Rao, & Upadhyaya, 2015; Kreh et al., 2021; Lagebo, 2019; Lane & McGrady, 2018; Lilja & Ahmad, 2023; Lloyd-Smith, 2020; Lyng et al., 2022; Macrae & Draycott, 2019; Marchal et al., 2023; Miyazaki et al., 2023; Montás et al., 2022; Patterson & Deutsch, 2015; Pennini et al., 2023; Petersen et al., 2021; Pillay, 2016; Qiao et al., 2023; Rangachari & Woods, 2020; Ravaghi et al., 2023; Ross et al., 2022; Safi et al., 2022; Salehi, Moradi, Omidi, & Rahimi, 2023; Salluh et al., 2022; Sari et al., 2023; Sharma & Tamanna, 2019; Shaw et al., 2022; Tamanna & Sharma, 2020; Thomas et al., 2013; van den Berg, Alblas, Le Blanc, & Romme, 2022; Wahl & Durst, 2022; Wang et al., 2022; Webster et al., 2023; Witmer & Mellinger, 2016; YahiaMarzouk, 2023; Zinn, 2022) were described as reactive. Organizations able to anticipate, plan, and prepare prior to challenging events were described as proactive (Akar, 2020; Anderson, Ross, Macrae, & Wiig, 2020; Berg et al., 2018; Deutsch & Patterson, 2019; Duncan, 2020; Ellis et al., 2019; Essens et al., 2023; Falegnami et al., 2018; Furstenau et al., 2022; Fylan et al., 2019; Gherghina, Volintiru, & Sigurjonsson, 2023; Iflaifel et al., 2020; Ignatowicz et al., 2023; Khalili et al., 2021; Kreh et al., 2021; Lane & McGrady, 2018; A. Lee, Vargo, & Seville, 2013; Lilja & Ahmad, 2023; Miyazaki et al., 2023; Mohtady Ali et al., 2022; Patriarca et al., 2018; Patterson & Deutsch, 2015; Pennini et al., 2023; Phipps, Ashcroft, & Parker, 2017; Pillay, 2016; Qiao et al., 2023; Rangachari & Woods, 2020; Salehi et al., 2023; Salluh et al., 2022; Siracusano, Di Lorenzo, Longo, Alcini, & Niolu, 2020; Sujan et al., 2022; van den Berg et al., 2022; Whitman, Kachali, Roger, Vargo, & Seville, 2013; Zinn, 2022). In addition, reflection was a significant element of organizational resilience, noted in approximately half of all included articles (46 of 97) (Abedi, Ogwal, Pintye, Nabirye, & Hagopian, 2019; Ager et al., 2015; Akar, 2020; Anderson et al., 2016; Augustynowicz et al., 2022; Barasa et al., 2018; Berg et al., 2018; Bertoni, Ransolin, Wachs, & Righi, 2021; Bradley & Alamo-Pastrana, 2022; Corbaz-Kurth et al., 2022; Deutsch & Patterson, 2019; Duncan, 2020; Ellis et al., 2019; Falegnami et al., 2018; Flaatten et al., 2022; Fylan et al., 2019; Gherghina et al., 2023; Gröschke et al., 2022; Ignatowicz et al., 2023; Kaltenbrunner et al., 2022; Khalili et al., 2021; Kimberlin et al., 2011; Kreh et al., 2021; Lane & McGrady, 2018; S. Lee, Kim, Arigi, & Kim, 2022; Lyng et al., 2022; Macrae & Draycott, 2019; Mohtady Ali et al., 2022; Patriarca et al., 2018; Patterson & Deutsch, 2015; Phipps et al., 2017; Pillay, 2016; Qiao et al., 2023; Rangachari & Woods, 2020; Reyes et al., 2021; Ross et al., 2022; Salluh et al., 2022; Sharma & Tamanna, 2019; Shaw et al., 2022; Siracusano et al., 2020; Sujan et al., 2022; Tamanna & Sharma, 2020; Wang et al., 2022; Wiig et al., 2020; Witmer & Mellinger, 2016; Zinn, 2022). Thus, an organization’s ability to respond to stressful stimuli reactively and proactively, and to engage in reflection about the stimuli and their response, is critical to the organization’s ability to continue functioning and meet its objectives.

Reactive (absorbing, adapting, and transforming)

A fundamental aspect of organizational resilience is the organization’s ability to respond in such a way that it can survive and even flourish when faced with challenges. Every study except six (Fagerdal et al., 2022; Heath et al., 2020; Jóhannsdóttir et al., 2022; Reyes et al., 2021; Riess, 2021; Safi et al., 2022) included reactive strategies in its definition of organizational resilience (see Table, Supplemental Digital Content 3, organizational resilience definitions). Many described reactive strategies such as absorption, adaptation, and transformation in relation to one another (Barabadi et al., 2020; Barasa et al., 2018; Biddle et al., 2020; Blanchet et al., 2017; Fana & Goudge, 2021; Flaatten et al., 2022; Jamal et al., 2020; Kisekka et al., 2015; Marchal et al., 2023; Wahl & Durst, 2022; Witmer & Mellinger, 2016), with some studies describing these strategies as reflecting the intensity and impact of the challenge (Biddle et al., 2020; Blanchet et al., 2017; Fana & Goudge, 2021; Jamal et al., 2020; Safi et al., 2022). For low-intensity, low-impact challenges, healthcare systems will react through absorptive measures. For example, nurses may take on additional roles when staffing is low and the patient census is high. However, if patient census continues to rise and staffing levels stay the same, the healthcare organization will reach a threshold at which patient safety and care quality are compromised. This is the point where the healthcare organization reaches its absorptive capacity. Absorptive capacity relates to an organization’s ability to continually deliver a consistent level (quantity, quality, and equity) of basic healthcare services and protection to patients while using the same level of resources and capacities, despite the challenges it is enduring. A healthcare system that can no longer deliver safe, high-quality care through absorptive measures will require adaptive strategies.

Adaptation involves reprioritizing work or leveraging outside resources to continue delivering safe care (Blanchet et al., 2017; Corbaz-Kurth et al., 2022; Elder et al., 2008; Fana & Goudge, 2021; Flaatten et al., 2022; Fylan et al., 2019; Iflaifel et al., 2020; Jamal et al., 2020; Kaltenbrunner et al., 2022; Khalili et al., 2021; Macrae & Draycott, 2019; Patterson & Deutsch, 2015; Ross et al., 2022; Salluh et al., 2022; van den Berg et al., 2022; Wiig et al., 2020; Witmer & Mellinger, 2016). For example, adaptation may involve outsourcing services rather than employing clinicians directly (Fana & Goudge, 2021)—such as hiring nurses from a travel agency when staffing is critically low. Adaptation may also involve collaborations with government, local, and international partners, specifically when healthcare organizations are approaching a state of shock and need aid in mobilizing medicine (e.g., vaccines, antibiotics) and sustaining basic health services (Jamal et al., 2020). However, in a state of prolonged crisis, such as a pandemic or economic crisis (e.g., recession), such adaptations may not provide hospitals with the necessary staff. As a healthcare system’s adaptive capacity is reached, the organization’s level of resilience depends upon its transformative capacity.

Transformative capacity refers to the ability to reorganize existing organizational structures and workflows to continue to provide safe, high-quality patient care. Tiered ICU staffing models, an approach recommended by professional societies to address surging patient volume during the COVID-19 pandemic, is one example of a transformative strategy. Some hospitals transformed intensive care unit staffing models (Hernu et al.), investing resources so that an experienced critical care physician could oversee multiple ICU teams comprised of clinicians with and without ICU experience. This approach allowed hospitals to transform their staffing models to ensure that they had clinicians available to care for the growing volume of ICU patients (Halpern & Tan, 2020). Telehealth is another example of a transformative strategy that can allow healthcare organizations to continue to provide care during times of stress. Telehealth services have been used during Hurricanes Harvey, Irma, and Maria to improve access and coordination of primary care, mental healthcare, and home healthcare, as well as allow for patient triage (Der-Martirosian, Chu, & Dobalian, 2020). Transformative capacity allows organizations to meet changing demands and continue to function. When compared to absorbing and adapting, transforming may require a substantial investment of resources and may remain in place for longer, even after the original stressor is removed. While it may not be necessary for organizations to transform all workflows or processes to be resilient, transformative capacity was described as an important element of an organization’s ability to react to stressful stimuli.

Proactive (anticipation, preparation, and planning)

Engaging in proactive strategies can enable healthcare organizations to gain control over challenging situations before they occur. Common proactive strategies include anticipation (Anderson et al., 2020; Deutsch & Patterson, 2019; Ellis et al., 2019; Essens et al., 2023; Falegnami et al., 2018; Fylan et al., 2019; Iflaifel et al., 2020; Ignatowicz et al., 2023; Khalili et al., 2021; Lane & McGrady, 2018; Mohtady Ali et al., 2022; Patriarca et al., 2018; Pennini et al., 2023; Pillay, 2016; Rangachari & Woods, 2020; Salehi et al., 2023; Siracusano et al., 2020; Sujan et al., 2022; van den Berg et al., 2022), planning (Hashish & Farghaly, 2021; Ignatowicz et al., 2023; Lane & McGrady, 2018; Lilja & Ahmad, 2023; Miyazaki et al., 2023; Whitman et al., 2013) and preparing (Akar, 2020; Duncan, 2020; Ellis et al., 2019; Furstenau et al., 2022; Gherghina et al., 2023; Ignatowicz et al., 2023; Kreh et al., 2021; Lilja & Ahmad, 2023; Phipps et al., 2017; Qiao et al., 2023; Salehi et al., 2023; Salluh et al., 2022; Zinn, 2022). Planning and preparing both occur prior to an event yet appear to be distinct as the included studies did not use these terms interchangeably; in these studies, plan or planning was used to refer to a conceptual process or idea (Hashish & Farghaly, 2021; Lane & McGrady, 2018; Whitman et al., 2013) while prepare or preparing was used to describe an active and tangible set of actions (Akar, 2020; Duncan, 2020; Ellis et al., 2019; Furstenau et al., 2022; Gherghina et al., 2023; Kreh et al., 2021; Phipps et al., 2017; Salluh et al., 2022; Zinn, 2022).

An organization’s ability to anticipate challenges depends on whether the organization—and the individuals within it—understand how certain actions or events lead to specific outcomes (Patterson & Deutsch, 2015). Success in planning and preparedness for any challenge is related to the anticipation of the event (i.e., behaving proactively). One example of planning during the COVID-19 pandemic was when organizations calculated the percentage of staff that might be affected; to address potential staffing changes organizations prepared by increasing their travel staff. Planning and preparing for challenges can reduce and, in some cases, prevent, adverse consequences. For instance, strategizing the redeployment of staff from other care settings during peak infection periods (i.e., planning), can inform specific actions that hospitals take to ensure adequate staffing and quality services. These actions might include specialized training to care for specific patient populations for those staff that may be redeployed (i.e., preparing).

Reflection

Reflection has an impact on a system’s ability to respond reactively and proactively (Anderson et al., 2016; Back et al., 2017) and works in concert with proactive and reactive strategies to build organizational resilience. Many articles described organizational resilience as entailing adjustments and growth following stressors (Akar, 2020; Anderson et al., 2016; Back et al., 2017; Berg et al., 2018; Bertoni et al., 2021; Bradley & Alamo-Pastrana, 2022; Gröschke et al., 2022; Ignatowicz et al., 2023; Khalili et al., 2021; A. Lee et al., 2013; Macrae & Draycott, 2019; Patterson & Deutsch, 2015; Pillay, 2016; Qiao et al., 2023; Reyes et al., 2021; Sujan et al., 2022; Wang et al., 2022; Zinn, 2022), implying a period of reflection. Importantly, reflection enables organizations to learn about what went well, what did not, and what could be enhanced to improve overall functioning. Both individual reflection (when individual members of the healthcare organization consider past and current experiences), and organizational reflection (when groups of individuals or administrators examine what went well and what did not for the organization), are needed. Reflection on past experiences can increase knowledge of which reactive strategies—absorbing, adapting, or transforming—will allow organizations to function and continue to provide safe, high-quality patient care.

Organizations that reflect are better equipped to react to crises, anticipate potential challenges and plan and prepare for them. For example, analyzing the health system’s transfer approach during times of stress could lead to different reactive and proactive behaviors in the future (Barabadi et al., 2020). When reflecting on disaster preparedness, a hospital might identify that it lacked a standardized transfer protocol for incoming and outgoing transfers, the organization could address this proactively in the future. First, leadership could create a committee or task force (reactive action) to assemble transfer guidelines during a disaster (proactive action). In this way, reflection can attune organizational leaders to possible changes, enabling proactive response. Individuals may even react differently to a similar scenario in the future (reactive) based on their reflective discussion. For example, reviewing and reflecting on patient transfers that occurred during a hurricane could attune clinicians and healthcare administrators to other concerns (such as equitable distribution of resources), which may lead to additional system changes, leading organizations to be more proactive in the future. In this way, reflection works in concert with proactive and reactive strategies to build organizational resilience.

Measurements of organizational resilience

While several studies explored clinician perceptions of organizational resilience (Alameddine et al., 2019; Back et al., 2017; Fylan et al., 2019; Jamal et al., 2020; Lagebo, 2019; Witmer & Mellinger, 2016), only four studies developed an instrument to measure organizational resilience (Carthey, De Leval, & Reason, 2001; A. Lee et al., 2013; L. A. Mallak, 1998; Whitman et al., 2013). Two of these instruments (A. Lee et al., 2013; Whitman et al., 2013) are long- and short-versions of the same scale (Table 1). All instruments except for one (Carthey et al., 2001) were subjected to reliability testing in the healthcare setting. All studies assess individual perceptions of the organization’s resilience and, specifically, qualities of the organization (Carthey et al., 2001; A. Lee et al., 2013; L. A. Mallak, 1998; Whitman et al., 2013); one also assesses individual perceptions of teams’ resilience within the organization (L. A. Mallak, 1998).

Mallak’s resilience instrument

Mallak’s resilience instrument was intended to be used by individuals to report on their organization’s resilience, but it has instead evolved as the basis for the workplace resilience instrument, which measures individual resilience in the workplace (L. Mallak & Yıldız, 2016; Wright). The three scales of Mallak’s instrument (bricolage, attitude of wisdom, and virtual role system) assess reactive, proactive, and reflection strategies (L. A. Mallak, 1998). To the best of our knowledge, apart from its initial development, Mallak’s instrument has not been used to measure organizational resilience in healthcare since its initial development.

Bricolage refers to the practice of creating order out of a diverse range of available things. Items in the bricolage scale include the ability to access appropriate resources, the ability to work under pressure, and fight/flight reactions to overwhelming situations.

For example, to assess an individual’s ability to engage in reactive strategies, clinicians are asked whether they try to make sense of a situation when it becomes chaotic or whether they back off from a problem when they are overwhelmed.

Attitude of wisdom is a blend of confidence and caution, uncertainty and curiosity, and disregards precedent (Weick, 1993). Items in the wisdom scale involve skepticism, curiosity, and experience, and rely on single or multiple sources of information. To assess the ability to act proactively, clinicians are asked about organizational resources and whether they have access to them.

Virtual role system (VRS) denotes an advanced form of work team relationships. The VRS scale includes items about how well members of a team understand their role, the roles of others, their ability to take on others’ roles, and how role definition is provided by the teams overall. For example, to assess reflective strategies, clinicians are asked whether their team’s goals guide individual actions.

Checklist for Assessing Institutional Resilience (CAIR)

The checklist for assessing institutional resilience (CAIR) (Carthey et al., 2001) can be used by any healthcare worker to assess their perceptions of their organization’s resilience, with a broad focus on reflective and proactive strategies. To assess clinicians’ perceptions of the organization’s reflective strategies, CAIR asks whether past events are thoroughly reviewed at high-level meetings on a regular basis and not merely after a bad event occurs. Proactive strategies are assessed through questions such as whether clinical supervisors train junior staff to practice the mental and technical skills necessary to achieve safe performance. No studies have validated or used CAIR in the healthcare setting.

Benchmark Resilience Tool-53 (BRT-53) and Benchmark Resilience Tool-13 (BRT-13)

The Benchmark Resilience Tool measures organizational resilience from the perspective of all employees (i.e., staff, supervisors, middle and senior management) (A. Lee et al., 2013). BRT-53 contains 53 items concerning groups of individuals (e.g., management or staff) rather than a specific employee or manager. The questionnaire specifically asks respondents to think about their entire organization, not just their department or unit, when answering the questions. For example, one item asks whether “managers actively listen for problems in [their] organization because it helps them to prepare a better response.” Few studies in healthcare have used BRT-53, possibly due to its length (Lane & McGrady, 2018; Whitman et al., 2013). Whitman et al developed and validated (in Spanish) two short-forms of BRT-53—BRT-13a and BRT-13b that have been used in several studies (Gonçalves, Navarro, & Sala, 2019; Gonçalves, Sala, & Navarro, 2021; Shaw et al., 2022; Whitman et al., 2013). Table 1 reports the reliability and validity of BRT-53, BRT-13a, and BRT-13b.

All BRT tools assess reactive and proactive strategies and reflection. In assessing reactive strategies, each tool asks employees whether their organization can make tough decisions quickly; in assessing proactive strategies each tool asks employees whether their organization maintains sufficient resources to absorb some unexpected change. For example, employees are asked whether their organizational leaders are mindful of how crises could affect them. BRT assess reflection by asking employees whether in their organization they regularly take time from their work to reevaluate what it is they are trying to achieve.

Discussion

This scoping review summarizes how organizational resilience is defined and measured in the healthcare literature. We identified 75 studies that discussed organizational resilience in healthcare and only 4 that measured it. Organizations were described as resilient if they were able to meet objectives and continue functioning in the face of expected or unexpected challenges or stressors. We identified reactive, proactive, and reflective strategies as key components of organizational resilience.

Reflection was often described as a way to enhance reactive and proactive strategies. While reflectivity often appeared more subtly, consideration of past experiences is crucial to guide organizational decision-making processes during periods of stress that may have implications for patient safety (Anderson et al., 2020; Back et al., 2017). For instance, over the course of the COVID-19 pandemic, various healthcare organizations made the decision to stop all elective surgeries as staffing was critically low and hospitals anticipated nearing full capacity (Kerlin et al., 2021). Healthcare systems were proactive in halting all surgery. Later, healthcare systems were reactive when they reinstated surgery after beds and staff became more available. With every wave of COVID, healthcare systems reevaluated or reflected on the best action regarding elective surgery. Thus, the strategies used by healthcare organizations—reactive, proactive, and reflective—impact their ability to deliver care.

Only four instruments measure organizational resilience in healthcare (Carthey et al., 2001; A. Lee et al., 2013; L. A. Mallak, 1998; Whitman et al., 2013) and only three are validated (A. Lee et al., 2013; L. A. Mallak, 1998; Whitman et al., 2013). These instruments assess perceptions of individuals within the organization and qualities of the organization (Carthey et al., 2001; A. Lee et al., 2013; Whitman et al., 2013) or both (L. A. Mallak, 1998) which suggest different uses, interpretations and implications. One of these instruments is long (BRT-53 is 53 items); survey length has been associated with lower response rates (Burkhart et al., 2021) thus impacting the potential utility of the BRT-53.

Our findings expand the current knowledge about organizational resilience in healthcare. Two reviews have previously been conducted to examine organizational resilience in healthcare (Forsgren, Tediosi, Blanchet, & Saulnier, 2022; Ignatowicz et al., 2023). Both reviews covered shorter periods of time [2000 – 2021 (Forsgren et al., 2022) and 2013 – 2021 (Ignatowicz et al., 2023)] and included fewer studies (n=35 and n=22 respectively). The larger number studies in our review (n=75) reflects the increased interest in organizational resilience in healthcare in the last few years. Our findings also expand on these reviews in several concrete ways. First, neither of the prior reviews aimed to synthesize the definitions and descriptions of organizational resilience in healthcare, thereby missing an opportunity to clarify how organizational resilience is conceptualized in the healthcare literature. Second, the most recent review (Ignatowicz et al.) aimed to describe the approaches, methods, and indicators of organizational resilience, but did not describe the reliability or validity of any instruments as we do here. Third, our review offers measurements of organizational resilience that align with how it has been conceptualized in the literature. While the previous review describes instruments that have been used to measure organizational resilience, many focus on only one phase: before, during, or after an event. Our review describes instruments that support the idea that organizational resilience is a broad concept that covers all phases of an event—before, during and after. Since the way we operationalize a concept should reflect how it’s been conceptualized (Fawcett, 2013; Ryan, Weiss, & Papanek), our review helps future researchers by guiding them to choose the most appropriate tool for their research with information about psychometric properties of the instruments, potentially allowing for more robust research.

Of note, none of these reviews, including ours, examined how organizational resilience impacted outcomes (clinician, patient, organizational) and many of the articles were deemed low quality in our review and in one other (Ignatowicz et al., 2023). To move the field forward, more rigorous studies with robust designs are needed, including more measures of organizational resilience administered to larger populations, and testing the relationships between organizational resilience and outcomes.

This scoping review is limited by the scientific literature on which it draws. We identified reactive, proactive, and reflective strategies as key elements of a resilient organization, but our methods cannot determine whether all of these behaviors must be present for an organization to be resilient. Additional work to refine organizational resilience measures is needed. We conducted a quality appraisal using the ICROMS tool, however, many studies did not meet the mandatory criteria for quality appraisal due to their study design, indicating the need for more rigorous research in this area.

Conclusion

This scoping review characterized organizational resilience as an organization’s ability to continue functioning and meet objectives in the face of stressors. Only four studies measured organizational resilience in healthcare. Future research should focus on measuring organizational resilience in healthcare, determining how to improve it, and testing its association to patient, clinician, and organizational outcomes. Investing in such research is an important first step in enhancing healthcare systems’ ability to withstand, survive, and thrive during and after times of stress.