Haraldseid-Driftland et al. BMC Health Services Research (2023) 23:646 BMC Health Services Research
https://doi.org/10.1186/s12913-023-09653-8
RESEARCH Open Access
Learning does not just happen: establishing
learning principles for tools to translate
resilience into practice, based on a
participatory approach
Cecilie Haraldseid-Driftland1*, Hilda Bø Lyng1, Veslemøy Guise1, Hilde Valen Waehle1,2, Lene Schibevaag1, Eline Ree1,
Birte Fagerdal1, Ruth Baxter3, Louise A. Ellis4, Jeffrey Braithwaite4 and Siri Wiig1
Abstract
Background Theories of learning are of clear importance to resilience in healthcare since the ability to successfully
adapt and improve patient care is closely linked to the ability to understand what happens and why. Learning from
both positive and negative events is crucial. While several tools and approaches for learning from adverse events
have been developed, tools for learning from successful events are scarce. Theoretical anchoring, understanding of
learning mechanisms, and establishing foundational principles for learning in resilience are pivotal strategies when
designing interventions to develop or strengthen resilient performance. The resilient healthcare literature has called
for resilience interventions, and new tools to translate resilience into practice have emerged but without necessarily
stipulating foundational learning principles. Unless learning principles are anchored in the literature and based on
research evidence, successful innovation in the field is unlikely to occur. The aim of this paper is to explore: What are
key learning principles for developing learning tools to help translate resilience into practice?
Methods This paper reports on a two-phased mixed methods study which took place over a 3-year period. A range
of data collection and development activities were conducted including a participatory approach which involved
iterative workshops with multiple stakeholders in the Norwegian healthcare system.
Results In total, eight learning principles were generated which can be used to help develop learning tools to
translate resilience into practice. The principles are grounded in stakeholder needs and experiences and in the
literature. The principles are divided into three groups: collaborative, practical, and content elements.
Conclusions The establishment of eight learning principles that aim to help develop tools to translate resilience
into practice. In turn, this may support the adoption of collaborative learning approaches and the establishment
of reflexive spaces which acknowledge system complexity across contexts. They demonstrate easy usability and
relevance to practice.
Keywords Resilience in healthcare, Learning, Tools, Healthcare systems
*Correspondence:
Cecilie Haraldseid-Driftland
Full list of author information is available at the end of the article
© The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use,
sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and
the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this
article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included
in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The
Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available
in this article, unless otherwise stated in a credit line to the data.
, Haraldseid-Driftland et al. BMC Health Services Research (2023) 23:646 Page 2 of 10
Introduction enables us to develop understanding over time, and to
Learning is fundamental to quality and safety improve- deeply appreciate what happens and why [25, 26].
ment efforts in healthcare and has been an integral part Based on the premise that resilience in healthcare is
of researchers’ and policy makers’ agendas for decades. a systems perspective, the learning component within
The traditional logic, both within healthcare, workplaces, resilience refers to organizational learning. This occurs
and education is that learning from adverse events helps when an organization adapts its enterprise by assimi-
improve structures and systems, and avoids future reoc- lating new knowledge, while simultaneously exploiting
currences, thereby ensuring safer and better outcomes existing knowledge to change and improve their systems,
[1–5]. Within healthcare, this traditional approach - routines, rules and procedures [27]. Given the complex-
focusing on adverse events and ‘find and fix’ solutions - ity of healthcare, resilient performance depends on high
is known as ‘Safety-I’ [6]. However, recent studies show levels of collaboration and interconnection across dif-
that despite a range of efforts over the past two decades, ferent system levels (individuals, teams and organiza-
the rate of healthcare related adverse events holds steady tions), and between different stakeholders (including
at between 5 and 10% for hospitalized patients [7–9] and healthcare professionals, patents, and families) [28–30].
has even been reported to be as high as 24% [10]. This The learning element within the resilient healthcare lit-
consistency of these figures over time could imply that erature therefore builds on the importance of collabora-
traditional ‘Safety-I’ methods, such as root cause analy- tive learning - that is learning through work and learning
sis [11] and checklists, are inadequate for maintain- together [31, 32]. Learning in professional environments
ing high quality and safe care [12]. Research within the works best when it occurs continuously and is a collec-
educational sector has also pointed out the difficulties of tive enterprise – when healthcare professionals, patients
learning from error, due to the multi-facetted and com- and families, leaders, and policy makers exchange infor-
plex contexts within which errors occur, which could mation, share knowledge, offer support to each other,
even imply that this approach is counter-productive [13, and coordinate, negotiate and align efforts to deliver care
14]. Research within the healthcare setting has therefore safely [30]. However, beyond these general statements,
called for a radical change in the approach to under- we lack detailed empirical knowledge about how learning
standing and improving the quality and safety of patient processes for translating resilience to practice occur, how
care. This new theoretical approach, known as Resilient learning principles may support resilience activities, and
Healthcare or Safety-II, takes into account the complex- more specifically how such theoretical positioning can
ity of care process and tries to understand and learn from be translated from theory into practice to improve qual-
what predict positive outcomes in addition to studying ity and safety of care [6, 12, 30, 33]. In short, we need a
errors [12, 15]. more detailed picture of learning processes for resilience
In recent years, interest in resilient healthcare, and in healthcare in situ.
in particular, ‘Safety-II’, has increased. The focus here Optimally, complex interventions need an underpin-
is on everyday work and performance variability. This ning program theory which describes the mechanisms
approach asks: how are patients kept safe in complex, and contexts that are hypothesized to produce the
challenging, pressurized environments, through normal desired outcomes [34]. To scale up efforts to strengthen
working conditions and practices? Understanding how resilient healthcare, exploration of the collaborative
safe care is created, and how things go right so often, is learning mechanisms that underpin the adaptations,
seen as a key source of learning [12, 16–21]. Resilient trade-offs, and improvisations that occur when people
healthcare research explores how healthcare organiza- respond to disruptions is needed [6, 19, 30]. We propose
tions, their staff, patients, and informal carers anticipate, that theoretical anchoring, understanding of learning
monitor, respond and learn when facing disruptions mechanisms, and establishing foundational principles
and/or possibilities for innovation [16, 18, 22, 23]. In for learning in resilience are key requirements when
this research field, resilience is defined as the capacity to designing interventions aimed at strengthening resil-
adapt to challenges and changes at different system lev- ient performance. Experts in resilient healthcare argue
els in order to maintain high quality care [6]. Resilient that learning from both positive and negative events is
healthcare offers a systems perspective on how individu- important, and while many tools and approaches for
als, teams, and organizations successfully adapt to their learning from adverse events have been developed, tools
changing circumstances [24]. This systems approach is for learning from successful events are limited [35]. The
important since it shifts the responsibility for provid- resilient healthcare literature has called for resilience
ing high quality patient care from individuals alone and interventions [20, 36], and new tools to translate resil-
instead puts the focus on the system’s ability to enable ience into practice have started to emerge e.g. [37–40].
resilient performance among the actors in the system. In this context, a learning tool can be understood as an
Learning is central to developing resilient systems– it artefact that people collectively interact with to support
https://doi.org/10.1186/s12913-023-09653-8
RESEARCH Open Access
Learning does not just happen: establishing
learning principles for tools to translate
resilience into practice, based on a
participatory approach
Cecilie Haraldseid-Driftland1*, Hilda Bø Lyng1, Veslemøy Guise1, Hilde Valen Waehle1,2, Lene Schibevaag1, Eline Ree1,
Birte Fagerdal1, Ruth Baxter3, Louise A. Ellis4, Jeffrey Braithwaite4 and Siri Wiig1
Abstract
Background Theories of learning are of clear importance to resilience in healthcare since the ability to successfully
adapt and improve patient care is closely linked to the ability to understand what happens and why. Learning from
both positive and negative events is crucial. While several tools and approaches for learning from adverse events
have been developed, tools for learning from successful events are scarce. Theoretical anchoring, understanding of
learning mechanisms, and establishing foundational principles for learning in resilience are pivotal strategies when
designing interventions to develop or strengthen resilient performance. The resilient healthcare literature has called
for resilience interventions, and new tools to translate resilience into practice have emerged but without necessarily
stipulating foundational learning principles. Unless learning principles are anchored in the literature and based on
research evidence, successful innovation in the field is unlikely to occur. The aim of this paper is to explore: What are
key learning principles for developing learning tools to help translate resilience into practice?
Methods This paper reports on a two-phased mixed methods study which took place over a 3-year period. A range
of data collection and development activities were conducted including a participatory approach which involved
iterative workshops with multiple stakeholders in the Norwegian healthcare system.
Results In total, eight learning principles were generated which can be used to help develop learning tools to
translate resilience into practice. The principles are grounded in stakeholder needs and experiences and in the
literature. The principles are divided into three groups: collaborative, practical, and content elements.
Conclusions The establishment of eight learning principles that aim to help develop tools to translate resilience
into practice. In turn, this may support the adoption of collaborative learning approaches and the establishment
of reflexive spaces which acknowledge system complexity across contexts. They demonstrate easy usability and
relevance to practice.
Keywords Resilience in healthcare, Learning, Tools, Healthcare systems
*Correspondence:
Cecilie Haraldseid-Driftland
Full list of author information is available at the end of the article
© The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use,
sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and
the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this
article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included
in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The
Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available
in this article, unless otherwise stated in a credit line to the data.
, Haraldseid-Driftland et al. BMC Health Services Research (2023) 23:646 Page 2 of 10
Introduction enables us to develop understanding over time, and to
Learning is fundamental to quality and safety improve- deeply appreciate what happens and why [25, 26].
ment efforts in healthcare and has been an integral part Based on the premise that resilience in healthcare is
of researchers’ and policy makers’ agendas for decades. a systems perspective, the learning component within
The traditional logic, both within healthcare, workplaces, resilience refers to organizational learning. This occurs
and education is that learning from adverse events helps when an organization adapts its enterprise by assimi-
improve structures and systems, and avoids future reoc- lating new knowledge, while simultaneously exploiting
currences, thereby ensuring safer and better outcomes existing knowledge to change and improve their systems,
[1–5]. Within healthcare, this traditional approach - routines, rules and procedures [27]. Given the complex-
focusing on adverse events and ‘find and fix’ solutions - ity of healthcare, resilient performance depends on high
is known as ‘Safety-I’ [6]. However, recent studies show levels of collaboration and interconnection across dif-
that despite a range of efforts over the past two decades, ferent system levels (individuals, teams and organiza-
the rate of healthcare related adverse events holds steady tions), and between different stakeholders (including
at between 5 and 10% for hospitalized patients [7–9] and healthcare professionals, patents, and families) [28–30].
has even been reported to be as high as 24% [10]. This The learning element within the resilient healthcare lit-
consistency of these figures over time could imply that erature therefore builds on the importance of collabora-
traditional ‘Safety-I’ methods, such as root cause analy- tive learning - that is learning through work and learning
sis [11] and checklists, are inadequate for maintain- together [31, 32]. Learning in professional environments
ing high quality and safe care [12]. Research within the works best when it occurs continuously and is a collec-
educational sector has also pointed out the difficulties of tive enterprise – when healthcare professionals, patients
learning from error, due to the multi-facetted and com- and families, leaders, and policy makers exchange infor-
plex contexts within which errors occur, which could mation, share knowledge, offer support to each other,
even imply that this approach is counter-productive [13, and coordinate, negotiate and align efforts to deliver care
14]. Research within the healthcare setting has therefore safely [30]. However, beyond these general statements,
called for a radical change in the approach to under- we lack detailed empirical knowledge about how learning
standing and improving the quality and safety of patient processes for translating resilience to practice occur, how
care. This new theoretical approach, known as Resilient learning principles may support resilience activities, and
Healthcare or Safety-II, takes into account the complex- more specifically how such theoretical positioning can
ity of care process and tries to understand and learn from be translated from theory into practice to improve qual-
what predict positive outcomes in addition to studying ity and safety of care [6, 12, 30, 33]. In short, we need a
errors [12, 15]. more detailed picture of learning processes for resilience
In recent years, interest in resilient healthcare, and in healthcare in situ.
in particular, ‘Safety-II’, has increased. The focus here Optimally, complex interventions need an underpin-
is on everyday work and performance variability. This ning program theory which describes the mechanisms
approach asks: how are patients kept safe in complex, and contexts that are hypothesized to produce the
challenging, pressurized environments, through normal desired outcomes [34]. To scale up efforts to strengthen
working conditions and practices? Understanding how resilient healthcare, exploration of the collaborative
safe care is created, and how things go right so often, is learning mechanisms that underpin the adaptations,
seen as a key source of learning [12, 16–21]. Resilient trade-offs, and improvisations that occur when people
healthcare research explores how healthcare organiza- respond to disruptions is needed [6, 19, 30]. We propose
tions, their staff, patients, and informal carers anticipate, that theoretical anchoring, understanding of learning
monitor, respond and learn when facing disruptions mechanisms, and establishing foundational principles
and/or possibilities for innovation [16, 18, 22, 23]. In for learning in resilience are key requirements when
this research field, resilience is defined as the capacity to designing interventions aimed at strengthening resil-
adapt to challenges and changes at different system lev- ient performance. Experts in resilient healthcare argue
els in order to maintain high quality care [6]. Resilient that learning from both positive and negative events is
healthcare offers a systems perspective on how individu- important, and while many tools and approaches for
als, teams, and organizations successfully adapt to their learning from adverse events have been developed, tools
changing circumstances [24]. This systems approach is for learning from successful events are limited [35]. The
important since it shifts the responsibility for provid- resilient healthcare literature has called for resilience
ing high quality patient care from individuals alone and interventions [20, 36], and new tools to translate resil-
instead puts the focus on the system’s ability to enable ience into practice have started to emerge e.g. [37–40].
resilient performance among the actors in the system. In this context, a learning tool can be understood as an
Learning is central to developing resilient systems– it artefact that people collectively interact with to support
