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Resilient performance in healthcare during the COVID-19 pandemic (ResCOV): study protocol for a multilevel grounded theory study on adaptations, working conditions, ethics and patient safety
  1. Petronella Bjurling‐Sjöberg1,2,
  2. Camilla Göras3,4,
  3. Malin Lohela-Karlsson1,5,
  4. Lena Nordgren1,2,
  5. Ann-Sofie Källberg4,6,
  6. Markus Castegren2,7,
  7. Emelie Condén Mellgren5,
  8. Mats Holmberg2,8,
  9. Mirjam Ekstedt8,9
  1. 1Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
  2. 2Centre for Clinical Research, Uppsala University, Region Sörmland, Eskilstuna, Sweden
  3. 3Department of Anesthesia and Intensive Care Unit, Falun Hospital, Region Dalarna, Falun, Sweden
  4. 4School of Health and Welfare, Dalarna University, Falun, Sweden
  5. 5Centre for Clinical Research, Uppsala University, Region Västmanland, Västerås, Sweden
  6. 6Department of Emergency Medicine, Falun Hospital, Region Dalarna, Falun, Sweden
  7. 7CLINTEC, Karolinska Institute, Stockholm, Sweden
  8. 8Department of Health and Caring Sciences, Linneuniversitet, Kalmar/Växjö, Sweden
  9. 9LIME, Karolinska Institutet, Stockholm, Sweden
  1. Correspondence to Dr Petronella Bjurling‐Sjöberg; Petronella.bjurling-sjoberg{at}


Introduction Since early 2020, the COVID-19 pandemic has challenged societies and revealed the built-in fragility and dependencies in complex adaptive systems, such as healthcare. The pandemic has placed healthcare providers and systems under unprecedented amounts of strain with potential consequences that have not yet been fully elucidated. This multilevel project aims to explore resilient performance with the purpose of improving the understanding of how healthcare has adapted during the pandemic’s rampage, the processes involved and the consequences on working conditions, ethics and patient safety.

Methods An emerging explorative multilevel design based on grounded theory methodology is applied. Open and theoretical sampling is performed. Empirical data are gathered over time from written narratives and qualitative interviews with staff with different positions in healthcare organisations in two Swedish regions. The participants’ first-person stories are complemented with data from the healthcare organisations’ internal documents and national and international official documents.

Analysis Experiences and expressions of resilient performance at different system levels and times, existing influencing risk and success factors at the microlevels, mesolevels and macrolevels and inter-relationships and consequences in different healthcare contexts, are explored using constant comparative analysis. Finally, the data are complemented with the current literature to develop a substantive theory of resilient performance during the pandemic.

Ethics and dissemination This project is ethically approved and recognises the ongoing strain on the healthcare system when gathering data. The ongoing pandemic provides unique possibilities to study system-wide adaptive capacity across different system levels and times, which can create an important basis for designing interventions focusing on preparedness to manage current and future challenges in healthcare. Feedback is provided to the settings to enable pressing improvements. The findings will also be disseminated through scientific journals and conferences.

  • covid-19
  • ethics (see medical ethics)
  • health & safety
  • qualitative research
  • human resource management
  • quality in health care

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  • Contributors PB-S was responsible for the study design, the protocol draft and the final version. CG contributed to the study design and drafted substantial parts of the manuscript. ML-K, LN and ME provided intellectual input into the study design and contributed to critical review and substantial editing of the draft. A-SK, MC, ECM and MH contributed to critical review and editing of the draft. All authors approved the final version of the manuscript.

  • Funding This work was supported by the Centre of Clinical Research Sörmland, Uppsala University, Sweden (Grant No. DLL-940876), and the Regional Research Council in Mid Sweden (Grant No. RFR-939378). Additionally, Region Västmanland, Region Sörmland, Region Dalarna and Dalarna University, Sweden, support the project with in-kind funding.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.