Building resilience in German primary care practices: a qualitative study

Abstract

Background

In recent years, healthcare has faced many different crises around the world such as HIV-, Ebola- or H1N1-outbrakes, opioid addiction, natural disasters and terrorism attacks). In particular, the current pandemic of Covid-19 has challenged the resilience of health systems. In many healthcare systems, primary care practices play a crucial role in the management of crises as they are often the first point of contact and main health care provider for patients. Therefore, this study explored which situations are perceived as crises by primary care practice teams and potential strategies for crisis management.

Methods

A qualitative observational study was conducted. Data were collected in interviews and focus groups with experts from primary care practices and stakeholders focusing on primary care practices in Germany such as physicians, medical assistants, practice managers, quality managers, hygiene managers and institutions on health system level (politics, research and health insurance). All interviews and focus groups were audio-recorded and transcribed verbatim. A qualitative content analysis was performed using a rapid qualitative analysis approach first, followed by a thematic analysis.

Results

Two focus groups and 26 interviews including 40 participating experts were conducted. Many different situations were perceived as crises, varying from issues in the practice organization to problems on health system level and international disasters. Distinct aspects associated with the perception of a crisis situation by interviewees were the presence of emotional reactions, a need for organizational changes and a lack of necessary resources. A broad spectrum of possible strategies was discussed that could help to cope with or even prevent the emergence of an actual crisis. In particular, strengthening communication within practice teams and resilience among employees was perceived to be fundamental for improving responses to crises or preventing them.

Conclusions

The study provides perspectives of primary health care workers on crises in health, that could inform health policy regarding prevention and management of future crises in primary care facilities.

Background

In recent years, health care faced many crises such as HIV, Ebola, H1N1, opioid addiction, natural disasters and terrorism attacks. Particularly the current pandemic of Covid-19 has challenged the resilience of health systems globally. Furthermore, future crises related to the impacts of climate change, epidemics, wars and pandemics have been predicted [1]. Building resilience to face those potentially upcoming challenges in health care is therefore crucial.

Crises have also been described as “disasters”, “shocks” and ‘’surges’’ [2,3,4]. These terms all refer to a sudden increase in the incidence of health problems, which has major impact on the need for health care. Crises differ from other challenges, such as the ageing population and the increase of multimorbid patients by their attribution to specific events, although a clear differentiation can be difficult. In the literature, there are many different definitions of resilience of health systems. Most of them have in common that they describe it “as the degree of change a system can undergo while maintaining its functionality” [5]. By managing past crises, different strategies have been developed and various articles stating lessons learned have been published [5,6,7,8]. Most contributions on this topic take a health system and population health perspective, while less is known about the experiences and responses of healthcare providers. For instance, the resilience of healthcare workers in the current Covid-19 pandemic seems to be affected dramatically [9, 10]. In Germany, primary care practices are central in the management of the Covid-19 pandemic as they are often first and only point of contact with health care for infectious patients [11].

To prepare for future crises and build resilience in primary care, the project “RESILARE – building resilience of primary care practices by developing and evaluating quality indicators” was initiated. Within this project, quality indicators will be developed that aim to measure crisis resilience of primary care practices in Germany and point out approaches to support practices and their teams in gaining resilience. To support this, a study was conducted that aimed to answer the following research questions:

• Which specific situations are rated as “crises situations” by primary care practices?

• Which aspects need to be fulfilled in order to perceive a challenge as a crisis?

• Which strategies can be identified for managing these different situations successfully?

Methods

Study design

A qualitative observational study was conducted from June 2021 until February 2022. Ethical approval was obtained by the Ethics Committee of the Medical Faculty Heidelberg (S-456/2021). All participants gave their written informed consent prior to the interviews and focus groups. The study was documented in accordance to the Consolidated Criteria for Reporting Qualitative Studies (COREQ) checklist [12].

Study sample

A purposive sample of a maximum of 40 experts was planned. As experts, stakeholders of primary care practices in Germany, such as physicians, medical assistants, practice managers, quality managers, hygiene managers were asked to participate in this study. Furthermore, experts from institutions on health system level, such as policy, research and health insurance focusing on primary care practices, were addressed. All participants needed to be 18 years and older and able to give consent. They were recruited within the personal networks of the institutions involved in the conduction of the RESILARE project such as networks of the project advisory board and via newsletter of the aQua Institute for Applied Quality Improvement and Research in Health Care GmbH. Additional snowball sampling was applied. The sampling strategy aimed to reach a variety in the geographical location of practices within Germany (north/south/west/east and urban/ rural), number of practice staff, different forms of practice organisation (single practices, joint practices, medical care centres, networks), medical disciplines and in the specific profession of the experts.

Staff of primary care practices in Germany were asked personally, by mail or phone to participate in either focus groups or interviews. If participants were affiliated to the same network or institution, they were asked to participate in a focus group. With all other experts, single telephone interviews were conducted.

Within the recruitment process, the thematic focus of the interview was headed with “crisis resilience”. However, some of the participants knew in advance that climate change might be a sub-topic of the interview/ focus group because they were recruited by members of the project advisory board who were engaged with climate change issues in healthcare. In addition, the project website mentions that one of the secondary target criteria of the RESILARE-project is to identify starting points and measures to reduce the ecological footprint of ambulatory medical practices.

Data collection and measures

Data were collected in interviews and focus groups using a self-developed semi-structured interview guide. For focus groups, the guide was slightly adapted to the setting by rephrasing questions to address multiple participants at the same time. The interview guide was also slightly adapted for participants who were not working within the setting of a healthcare practice at the time (researchers or politicians).

In a first step, the development of the semi-structured interview guide was based on a literature research on (organisational) resilience in health care. To search for evidence on resilience, the definition of Blanchet et al. 2017 [13] was used, who defined resilience of health systems “as the capacity of a health system to absorb, adapt and transform when exposed to a shock and still retain control over its structure and functions. Thus, health systems are resilient if they exhibit absorptive, adaptive or transformational capacity in the face of shocks of different intensity”. In a second step, the first draft of the interview guideline was evolved step-by-step by a group of experts (authors as well as further researchers of the University Hospital Heidelberg) with expertise in health services research, qualitative research, work experience in practices, quality management in practices, climate change and health, as well as a researcher who focused on the coping of German general practices with the Covid-19 pandemic. Table 1 gives an overview of subjects and subthemes that were addressed in interviews and focus groups.

Table 1 Overview of interview and focus group guideline topics

Data collection was conducted from July until October 2021, either as telephone interviews or online focus groups using an online meeting program of the University of Heidelberg (heiCONF). Participants of interviews and focus groups were included upon reception according to the entrance of the provided form which confirmed their willingness to participate in an interview or focus group discussion. The interviews were performed by a female researcher and doctoral candidate with approximately four years of experience in qualitative research in the Department of General Practice and Health Services Research at Heidelberg University Hospital (NL) and a female masters-candidate and trainee in the RESILARE-project (VF). Both, NL and VF, have a background in speech and language therapy, interprofessional health care as well as health services research and implementation science, and are both around 30 years of age. Supervision in conduction of the interviews was provided by MW, JS and AW, as well as experienced teachers of the masters-program, with interdisciplinary backgrounds for example in sociology, medicine and medical process management.

Some of the interviewees were recruited throughout the professional networks of NL and JS and were therefore personally known by NL in a professional context. As the development of the interview guideline was done only by NL and experts of the Department of General Practice and Health Services Research at Heidelberg University Hospital, the interview partners did not get any insight into the questions in advance of the interviews. Data collection was part of the very first phase of RESILARE. Project partners participating in an interview or focus group were therefore not yet informed about specific research questions and purposes of the data collection.

All interviews and focus groups were audio-recorded and hand-written notes were taken. The online focus groups were video-recorded as well to ease the transcription process and capture group dynamics (e.g., non-verbal agreement or disagreement such as nodding) properly. No interview or focus group was repeated and no transcript was returned to the participants for correction. All interviews and focus groups were transcribed verbatim. Within the focus groups, non-verbal communication was transcribed as well.

Prior to the qualitative data collection, all participants were handed a short questionnaire referring to sociodemographic data such as sex, age, profession and current working status, geographical location, number of practice staff and specific practice discipline (if working in a practice) as well as their level of education.

Data analysis

For the qualitative content analysis, the pseudonymized data were first processed by randomly comparing them with the audio recordings and checking their accuracy. Next, an initial and pragmatic data analysis was conducted by NL in accordance with the Rapid Qualitative Analysis [14]. The analysis was done immediately after the individual data collection, based on the hand-written notes of the researchers. this facilitated a very quick proceeding without the necessity to wait for finalisation of transcripts. This initial analysis enabled a first understanding of the data and first categories and relevant aspects became visible.

In a second step, an inductive thematic analysis was performed on the full transcripts by NL following Thematic Analysis of Brown and Clarke [15]. The resulting codes were then synchronized with the initial categories which emerged from the rapid analysis.

Several methodological strategies were applied to ensure the trustworthiness of the analysis and findings. These include engaging with other researchers to minimize research bias, thus reducing the risk of losing relevant content. This was realized by accompanying presentations and discussions within the research team periodically during and after the coding process.

For data coding, MAXQDA software Version 20 (Verbi GmbH) was used, IBM SPSS Statistics Version 26 was used for analysis of sociodemographic data.

Results

Two focus groups with 14 participants and 26 individual interviews with a total of 40 experts were conducted between 12^th July 2021 and 14^th October 2021. Because of the additional snowball recruitment, the participation rate cannot be calculated precisely but is rated as high, as all except for two directly contacted experts agreed to participate in the study. The additional snowball sampling provided more medical assistants with interest in participation than could be included in the study. Duration of the interviews varied between 39 and 94 min, with a mean duration of 55 min. Duration of the two focus groups was 80 and 91 min.

The study population included 60% female experts and most participants were between 40–59 years of age (42.5%). Most of the participants were working in a primary care practice, 14 were physicians, 16 were medical assistants of which 69% had an additional training as care assistants, practice managers, quality managers or similar. Few participants were working as researchers or in politics. Further professions included social workers, pharmacists and other health professionals. Table 2 provides an overview on sociodemographic data.

Table 2 Sociodemographic data of the study population

The participants were working in disciplines of practices that are part of ambulatory care, including general practice, internal medicine, neurosurgery, pneumology, dermatology, orthopaedics, otorhinolaryngology and gynaecology. Practice sizes varied between single practices of two employees up to joint practices and practice networks with 40 employees. Participants originated from rural and urban regions all over Germany.

Which situations are perceived as crises by primary care practices?

In total, participants described more than 60 different situations as crises for practices. Those situations can be divided into three domains: a) internal crises in practices, b) crises in health systems and c) overarching crises. Table 3 presents the categories of situations.

Table 3 Situations that are perceived as crises by primary care teams and selected representative citations

Which aspects need to be fulfilled in order to perceive a challenge as a crisis?

Most participants perceived that the rating of a situation as a crisis is very subjective and depends on the characteristics of the individual experiencing the specific situation. However, the following three main aspects could be identified as required for rating a situation as a crisis: a) emotional reaction, b) organizational changes and c) lack of resources.

• a) Emotional reaction: A crisis was described as mental stress that sometimes inhibits a rational reaction. In the eyes of the participants, a crisis implied a risk for a burn-out and personal limits being exceeded. Discussed specific emotional reactions included: fear, stress, desperation, the feeling of losing control, insecurity, helplessness, overload and kind of shock-induced paralysis. In context of the pandemic of Covid-19, some participants described a fear of death. The level of emotional response differed within the participants and the respective crisis situation, but all participants described mental stress regardless of the severity of the crisis situation.

• b) Organizational changes: In all cases, a crisis situation was described by a change of routine and requiring different kinds of reorganization and change. Participants perceived that processes in practices needed to be adapted to the changing environment. Some underlined that a crisis also offers a chance for developing and improving practice processes and explicitly mentioned this as a positive aspect of crises. Processes in practices not only were seen in need to be adapted, but were described as being inhibited by the crisis. It was mentioned that previous routines became disturbed and could not be continued as planned. Some mentioned a certain chaos that occurred. One participant stated that existing vulnerabilities and weaknesses in practices are highlighted throughout a crisis situation.

“When crises come, no matter in what form, weaknesses always reveal themselves everywhere, which were actually already visible for a long time theoretically and (…) were fallow. That actually nothing was ever done against it, and, if then such a crisis comes, like the pandemic for example, then such a thing becomes quite often to the disadvantage, I noticed.” (Int. 15, medical assistant)

• c) Lack of resources: In general, crises were perceived to mean a high “working load exceeding the normal level” (Int. 4, physician), resulting in an overload of available resources such as staff, time, material, knowledge or money. Especially a lack of practice staff was rated as a significant aspect of a crisis. Some participants described that a certain crisis situation might not have been named a crisis if they would have had enough staff to cope with it. A lack of medical supplies such as vaccines, medication or medical devices was described as turning a regular situation into a crisis, because the lack of supplies makes it impossible for the practice staff to respond to the specific situation properly. A crisis situation was also reported to be always linked with a lack of time while requiring a timely reaction.

“Yes, the time pressure is certainly one of the central characteristics of crises, definitely!” (Focus Group 1, Part. 1, physician)

Participants also described crises to appear suddenly or building up slowly but escalating quickly. The crisis situation itself was mostly described to be a longer lasting situation. Besides the necessary timely reaction, a crisis was also described by some participants to be linked with economic losses for the practice, meaning an existential threat in the worst case. Knowledge about the specific situation was named to be another essentially required resource, since a knowledge deficiency was described as directly linked to emotional reactions such as helplessness and insecurity. If participants did not know how to cope with and respond to the occurring challenge, it was perceived as a crisis. Furthermore, a crisis was described as a new and unknown situation for which practice staff was not able to prepare themselves. In connection with this, crises were described to be obscure in their progression and impact and that therefore often there was “no end in sight”.

Strategies to enhance resilience of practices

The awareness of the occurrence of a specific crisis situation and the practices’ willingness to prepare for it, seemed to depend on their individual degree of affection. If only other practices (even in their direct neighbourhood) were affected by a certain situation, some participants described that they felt lucky they were spared and got out of the situation without any consequences. Furthermore, the willingness to learn from past crises varied. Some participants described they developed action plans within past crises to avoid the same unstructured procedures in future occurrences of the same or similar situations and described this to have been helpful during the Covid-19 pandemic. Others expressed their anger as they felt their practice manager refused to learn from past crises such as H1N1. They described that the German health system was in a somewhat luxury situation as there had always been enough resources to cope with crises. In this context it was described that past crises were not “serious and exhausting enough to learn from it” (Int. 12, expert of institution on health system level). The assumption that crisis prevention primarily needs to be an investment requiring money, time and effort and does not bring any immediate effects, was described as discouraging for practice managers to invest in prevention measures. The drawn conclusion was that, if a practice was prepared well for a certain crisis, the specific situation would not be perceived as a crisis when it occurred. Therefore, some participants were concerned that managers might not see a benefit of previous investment in crisis prevention when assuming the situation had not been that bad after all. This concern was explicitly described as being based on personal observations. Most participants showed a high tension for change as they were currently experiencing the Covid-19 pandemic as a crisis. In this context, the project RESILARE was considered an opportunity to increase resilience of practices and that awareness would increase throughout the conduction of the project.

In general, participants expressed a need for concrete and feasible action plans. The following strategies were mentioned either as an experienced coping strategy from past or current crises or as strategies that participants felt should be implemented for future crises in order to successfully deal with these. A number of measures were considered helpful to build up preparedness of practices which was seen as another aspect of resilience in terms of crisis prevention. The resilience of individuals in practices was described as highly relevant and seemed to build a basis for the organizational resilience of the practice. Besides the support of the resilience of every individual, communication and team work were described as central measures to improve resilience of practices. Supporting individual resilience and team work was described as a foundation for a resilient practice and basic values on which in the following, specific procedures and coping strategies might build up on. The identified strategies were subdivided into four domains: a) crisis prevention, b) individual resilience, c) team work, and d) practice procedures / responding to a crisis. As the strategies were consistent, a summary is presented in Table 4.

Table 4 Strategies of primary care teams for management of crises and selected representative citations

Discussion

The interviewed healthcare providers mentioned a wide range of crises, varying from situations in their practice organization and problems in the healthcare system to societal and natural disasters. Crises were seen as being characterized by emotional responses, need for organizational adaptations, and lack of resources. Discussed strategies to manage crises related to crises prevention, individual resilience of healthcare workers, team work, and procedures used in practice. These insights from people with lived experience can be used to inform policies and programs for the prevention and management of health crises at national and international level.

The breadth of the resulting catalog of (potential) crisis situations for primary care practices shows that the demarcation between actual crises, general challenges and other developments in healthcare that might be perceived as crises (e.g. digitization) is not always highly selective. The individual attitude of the respondents and the ability to adapt quickly to unfamiliar situations or short-term changes obviously plays a central role in this classification. This became particularly evident when discussing the topic of climate change, where a wide range of attitudes came to light. While some respondents equated climate change with climate crisis, others did not feel any consequences and therefore did not see any challenges with regard to this topic. This phenomenon also was described by Van Lange and Huckelba (2021), who found that the topic of climate change is much more present when one experiences it oneself or is directly affected [16]. They therefore stated that possible solutions for climate change should also be addressed on a microlevel in order to make it more tangible [16]. Regarding the mentioned crisis situations, it is remarkable that bioterrorism was not mentioned by the interviewees. This topic was discussed especially in the US [17, 18] but does not seem to play a crucial role in the context of German primary care institutions. The same applies to the mentioning of war as a possible crisis. However, it should be noted here that the interviews and focus groups were conducted before the outbreak of the war in Ukraine in February 2022.

When it comes to the mentioned strategies for handling challenges or crises, a lot of emphasis was put on the importance of prevention. Literature shows that a comprehensive and thoughtful prevention and preparation can contribute to averting certain crises for the practice [2, 19]. This is consistent with the findings of this present study as participants concluded that if one prepares specifically, for instance in the framework of a project like RESILARE, then certain situations will no longer be assessed as a crisis in the future. In the long run, this could lead to a relief for the outpatient health care system. Also, in the Covid-19 pandemic, the factor of individual preparedness of primary care practices in terms of availability of medical supplies, was apparent [20]. In line with this, Stengel et al. [11] recommend the development of concrete action plans for German primary care practices in order to be prepared for pandemics. Collins et al. [21] already called for adequate preparation for pandemic situations in their 2008 article. In particular, they emphasized the relevance of expanding human resources to deal with resulting challenges of a pandemic. In contrast to previous work, the interviews conducted here also focused on topics such as team communication and strengthening resilience of individual employees, which seem not to be comprehensively present in medical practices to date. However, from the interviewees’ perspective, empowering individuals and team employed in the practice can help to ultimately strengthen the crisis resilience of the entire organization [22]. Crisis resilience strategies published so far tend to be based on fixed behaviours related to specific situations. However, as the results of this study suggest, efforts should be made to leave room for flexible adjustments and thus be able to respond to different (potential) crisis situations.

In general, it should be noted that the respondents’ views on what constitutes a crisis and what is merely a general change in healthcare are subjective and the boundaries are blurred. Therefore, it is highly relevant that each practice individually considers which of the situations could become a crisis to their own practice and how to prepare for it. This provides a content-related reference to quality management in practices, as it aims to define quality targets, work out optimization approaches and identify concrete measures. In this respect, the approach of the RESILARE project to establish a link to the quality management of the practices and thus to promote a reflection of their own actions and practice organization referring to crises seems to be a promising one. Many aspects listed as possible crisis situations are addressed by quality indicators newly developed in the project to facilitate a stronger awareness of these aspects in the future.

Strengths and limitations

Our study adds to a growing body of research on the concept of resilience and its importance in the context of healthcare. Until now, only a small part of this research has specifically highlighted the relevance of strengthening primary care practices in order to cope with different crises. The results of this study stress how many different dimensions, such as crisis prevention, individual resilience of team members as well as team work, and adaption of practice procedures, need to be addressed in order to enlarge resilience in primary care practice teams. By this it can contribute to strengthening primary care practices for future crises which is particularly important because they often are the first and most important point of contact for citizens needing help in emergency cases.

Despite the study’s focus on general crisis resilience, there is a possibility of sampling bias towards experts with a pronounced interest in the topic area of climate crisis and its impact in the health sector. Nevertheless, when selecting the study participants, maximum care was taken to ensure a balanced composition of the study sample to minimize the probability of the occurrence of a bias regarding the topic “climate change” by accounting for main work areas in the recruitment process. Still, it must be stated that participating experts were potentially better informed about climate change than others. This might also explain the high willingness to participate in the study. On the other hand, it can be noticed that interest in the topic has increased substantially among German ambulatory care providers in recent years.

Another limitation that has to be stated is that data collection took place during the Covid-19 pandemic and therefore the issue of pandemics might have been weighted more heavily than at other times. Nevertheless, the interviews revealed a very broad perspective that brought many different crisis situations to light.

In general, there was a very high need for discussion of the research topic on the part of the participants, particularly among medical assistants. On the one hand, this was reflected by a very high willingness to participate, which even made it necessary to select the participants, as too many came forward. On the other hand, this is also emphasized by the length of the interviews, which often exceeded the targeted 45-min duration.

For the data analysis it has to be stated that coding was executed by one member of the research team without double checking every transcript by another person. Nevertheless, the proceeding of the coding process was discussed conscientiously among the research team.

Conclusion

The study provides insights into views on the topic of crises from the perspective of primary healthcare providers in Germany. In addition to the perception and classification of situations as crises, the study also focused on possible solutions and strategies for crisis management in the primary care sector. In particular, the relevance of strengthening communication within practice teams and resilience among employees was indicated as beneficial for the prevention of crises, or a better response to them. Adequate measures to achieve such strengthening need to be explored.