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Measuring Resilience in Health Care Provider Organizations: Larry A. Mallak
Measuring Resilience in Health Care Provider Organizations: Larry A. Mallak
to defend what he or she has done, and quick- throughout the world provide newscasts with
ly move on to the next situation. Often, work- stories about how a person risked his or her
ers are placed in these situations without life to save another, ran back into a burning
adequate training, preparation, or resources. house to save an elderly person or a child, or
The worker needs to learn how to be resilient, fashioned an escape from enemy territory.
that is, how quickly to design and implement Weick (1993) reported the case of the Mann
positive adaptive behaviors matched to the Gulch disaster. He identified bricolage as one
immediate situation, all the while enduring of four sources of resilience, based on his
minimal psychological stress. These resilient analysis of the case. Bricolage concerns creat-
behaviors help workers meet customer needs ing order out of whatever is available. For
on the spot, capture opportunities that may example, smokejumpers in the Mann Gulch
otherwise be lost, and avert catastrophes by disaster did not always rely on their special-
acting quickly and effectively in crisis situa- ized firefighting knowledge, knowledge that
tions. would help them avoid potentially deadly
Health care workers, in particular, often actions and find their way out of the fire.
find themselves on the front line facing life or Three scales were developed to assist in
death decisions, then moving on to the next assessing the organizational resilience. Coping
case. Human resource managers in health scales have been developed in the literature
care need better tools to understand the and will be incorporated into the research
impact of stress and change on their work when the additional scales have been shown
force so effective interventions can be imple- reliable and valid measures of resilience. The
mented. Some workers thrive in chaotic and scales developed were based on three con-
stressful environments; others burn out after cepts discussed in Weick (1993):
several months or years. What characteristics (1) bricolage;
do the successful health care workers have (2) attitude of wisdom; and
that makes them resilient? Do the ones who (3) virtual role system (VRS).
burn out lack something or can they learn to
be more resilient? In the extreme, resilience is Bricolage
needed to save lives. In more routine environ- Bricolage refers to the practice of creating
ments, resilience is needed to preserve sanity order out of whatever materials were available
and survival. at the time.
This paper embarks on a new research Bricoleurs remain creative under pressure,
precisely because they routinely act in chaotic
stream to begin answering these questions conditions and pull order out of them. Thus,
(see Mallak, 1997 for a full discussion of the when situations unravel, this is simply normal
conceptual background concerning organiza- natural trouble for bricoleurs and they proceed
tional resilience). The concept of resilience with whatever materials are on hand (Weick,
has been studied in early childhood psycholo- 1993, p. 639).
gy but very little has been done for workers in Items in the bricolage scale include the ability
organizations, let alone in health care provider to work under pressure, fight/flight reactions
organizations. Some of the lessons learned by to overwhelming situations, ability to access
these child psychology studies can be applied appropriate resources.
to organizations, but new studies aimed at
learning about organizations should provide Attitude of wisdom
more useful results for those seeking to A story recounted of the Naskapi Indians
become more resilient in their organizations. (Weick, 1993) demonstrates what is meant by
For this paper, I define resilience as the ability the attitude of wisdom. The Naskapi Indians
of an individual or organization to expedi- use caribou bones to locate game. They hold
tiously design and implement positive adap- bones over a fire until the bones crack and
tive behaviors matched to the immediate then hunt in the directions where the cracks
situation, while enduring minimal stress. point. This ritual is effective because the
decision is not influenced by the outcomes of
past hunts, which protects the stock of ani-
Measuring resilience
mals. The final decision is not influenced by
Resilience scale development the inevitable patterns of human choice,
Dramatic episodes of resilient behavior occur which enables hunted animals to become
when faced with a crisis. Natural disasters sensitized to humans and take evasive action.
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Measuring resilience in health care provider organizations Health Manpower Management
Larry A. Mallak Volume 24 · Number 4 · 1998 · 148–152
The attitude of wisdom here is shown by acute care hospitals in Michigan. A total of
ambivalence toward the past. The practice of 128 surveys were returned for a 29 per cent
divination incorporates the attitude of wis- response rate.
dom because past experience is discounted
when a new set of cracks forms a crude map Scale analysis
for the hunt. Past experience is also given The first step of testing the scales was to use
some weight, because a seasoned hunter confirmatory factor analysis. Factor analysis is
“reads” the cracks and injects some of his own a means of describing a characteristic that is
past experience into an interpretation of what not directly observable, sometimes called a
the cracks mean. The reader is crucial. If the latent factor, based on a set of observable
reader’s hunches dominate, randomization is variables. This is accomplished through
lost. If the cracks dominate, then the experi- analysis of the variables where isolation of
ence base is discarded. Items in the wisdom what the variables have in common is used to
scale concern past experience, scepticism, describe the characteristic or latent factor. An
curiosity, and reliance on single or multiple example is wisdom, which cannot be directly
sources of information (Weick, 1993).
observed but may be a combination of factors
Virtual role system such as scepticism and curiosity. The advan-
The virtual role system (VRS) refers to an tage of using the latent factors is that they
advanced form of work team relationships. represent a parsimonious method of describ-
Modeled after Weick’s work in crisis manage- ing the characteristics within the scales and
ment, a VRS provides a work environment can be used for further analysis. The factor
where the team can continue in the absence of analysis was conducted using principal com-
one or more members. This continuity comes ponents analysis where linear combinations of
from each person’s ability to visualize the the observed variable were formed.
entire team functions, not just their particular This was followed by two tests that mea-
role. Much like a holograph, where each sure sample characteristics necessary for
smaller piece contains information to con- factor analysis. The first test, the Kaiser
struct the whole, each person in a virtual role Meyer Olkin’s test, commonly referred to as
system can reconstitute the group in their KMO, was done to determine the sampling
mind and run a credible version of each role adequacy. This test criterion was met using a
in that system. The VRS scale contains items cutoff of 0.60 as suggested by Kaiser (1974).
on how well team members understand their Second, the Bartlett Test of Sphericity was
roles, the roles of others, their ability to take used to determine whether the correlation
on others’ roles, and how an overall vision
matrix is an identity matrix. All the factors
provides role definition.
had a corresponding significance of at least
0.0001 level, thereby rejecting the null
Methods and results hypothesis of an identity matrix. At this point,
the data were determined acceptable for
Instrument development and data
further analysis.
collection
Consideration of how many factors were
Items were written considering the respon-
dent’s experiences and ability to be self-con- represented by the data was determined by a
scious of resilience behaviors and attitudes. cut-off score of 1.00 for the eigenvalue. The
The scales were pretested with a group of 50 number of factors having been determined, a
graduate students enrolled in a masters lower limit of 0.40 was set for factor loadings
degree program at a midwestern US universi- in order to maintain the stringency of the
ty. Based on these pretests, items were analysis. Most of the factor loadings fell in the
changed, added, and deleted to improve the 0.60 through 0.80 range.
understanding of the item and its relationship Finally, the factors were tested for internal
to the underlying construct being measured. consistency using Cronbach’s Alpha reliabili-
The first large-scale testing of these scales ty test. To be consistent with the current
was performed among nursing executives in literature in the field, the minimum cutoff
Michigan hospitals. A survey, consent form, score on the Cronbach’s Alpha was set at 0.6.
and stamped return envelope were sent via Based on these analyses, six factors were
US mail to 445 nursing executives at 168 retained (see Table I):
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Measuring resilience in health care provider organizations Health Manpower Management
Larry A. Mallak Volume 24 · Number 4 · 1998 · 148–152
shared if individuals could make the situation managers in health care settings can begin to
worse by having that information or those use these findings to design interventions
who do not have a “need to know”. targeted at producing a more resilient work
force. Many of the resultant factors have
Role dependence
This factor is a subset of the original virtual cultural implications, thereby requiring
role system scale. Essential to advanced team greater involvement of upper-level adminis-
functioning, i.e. its resilience is the ability to trators in the intervention process. This study
fill in for a missing team member. This demonstrated the importance of using infor-
requires knowledge not only of that team mation effectively, through critical evaluation,
member’s role, but also of all roles and how and creatively seeking solutions. The subse-
those roles interact in a unified whole. quent stages of this research will study the
validity of resultant factors and relationships
Source reliance between resilience measures and outcome
Source reliance showed resilient individuals
variables in the health care industry, such as
rely on multiple sources of information. This
average length of stay, cost per patient day,
allows for the construction of a reality based
and staffing levels. Coping strategies, as inves-
on richer information, thereby reducing the
tigated in the psychology literature, will be
effects of bias if those sources have been
integrated into future studies to add how
chosen carefully and are balanced. Just as a
individuals react behaviorally to different
journalist is expected to have multiple sources
types of organizational stressors. Further
to present alternate viewpoints and get closer
applications of the resilience scales will inves-
to the “truth”, organizations benefit from a
similar approach. tigate their reliability and validity in other
settings, including manufacturing and gov-
Resource access ernment organizations. This research will
The resilient individual not only does all of strive to help the modern-day worker become
the above, he/she has the knowledge needed more effective in an increasingly complex and
to do the job, has access to resources or would stressful work environment.
access them anyway, even if not authorized, to
resolve a situation. This is especially interest-
ing given the hospital setting chosen for this References
study.
Kaiser, H. (1974), “An index of factoral simplicity”, Psycho-
metrica, Vol. 35, pp. 31-6.
Conclusion Mallak, L.A. (1997), “How to build a resilient organiza-
tion”, Proceedings of the Industrial Engineering
These six factors are a start in a research Solutions 1997 Conference, Miami, May, pp. 170-7.
stream targeted at identifying dimensions of Weick, K.E. (1993), “The collapse of sensemaking in
resilient organizations and behaviors of organizations: the Mann Gulch disaster”, Adminis-
resilient individuals. Human resource trative Science Quarterly, Vol. 38, pp. 628-52.
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