Coordinative strategies for sustaining resilience and safe care practices: an exploratory observational study of first line management in a neonatal intensive care setting

  • Karl Hybinette Karolinska Institutet, Sweden


The Neonatal Intensive Care Unit is a dynamic, resource-constrained clinical practice with unpredictable workload. Systemic brittleness will only be evident in retrospect, which poses challenges for learning about which managerial strategies that are successful and how. First line managers have a central role in managing the complexities of everyday clinical work, but their role in maintaining resilience is only partially understood.

Aim: To explore how managers´ make coordinative work actionable and to identify relevant aspects of system´s characteristics influencing managerial adaptations.

Methods: Explorative observational study, using shadowing and observation of coordination actions. First line managers were shadowed through full work shifts for 50 hours. Inductive-deductive content analysis with constant comparison was used and interpreted through the perspective of resilience engineering theory.

Results: The strategies for enabling coordinative work employed by a team of first line managers was associated with and varied in concert with the availability of systemic degrees of freedom. Clinical coordination has primarily allostatic and problem-solving features. The managers work was focused on maintaining stability of the unit in escalating problematic situations, mainly by facilitating teamwork through goalsetting, problem-solving, and circumventing the technical systems’ limitations in creating situational awareness.

Conclusions: Resilience is the ability of managers to find, create and make use of systemic degrees of freedom (SDOF) by adapting their strategies for enabling coordinative work. This imply that resilience is possible to engineer by preparing the system by design of SDOF or signals for where they may be found and training of managers.