During sudden onset critical and major incidents affecting NHS hospitals, what decisions are made by hospital tactical commanders, and how are they made? A constructivist grounded theory approach

Dodd, Matthew

Abstract

Aim of the Research:
The research used a constructivist grounded theory approach to work with tactical commanders in hospitals to develop a substantive theory that helps to understand how these commanders sought to manage the immediate organisational response to a sudden onset critical or major incident.

Methodology:
Semi-structured interviews were undertaken with 13 participants who had been tactical commanders during hospital incidents. These interviews were coded and subject to constant comparison to draw out themes and construct a higher-level theory

Findings:
Hospital tactical command needs to be viewed in the context of hospitals as complex adaptive systems. Faced with high levels of uncertainty and a significant potential for jeopardy during critical and major incidents, commanders adopted a role of being the conscience of the organisation and holding responsibility for patient, staff, hospital and public safety. Tactical command undertook three key functions of boundary identification, interface management and consequence mitigation. Their response incorporated the following experiences: Navigating an unfamiliar landscape, (managing a major incident is very different from what tactical commanders are used to within their usual role); Effecting cultural change (the requirement to respond to and implement significant cultural shifts within the environment created by the major incident); Seeking Reassurance (operating on a reassurance-seeking basis initially rather than assurance-seeking model); Absorbing accountability (assuming accountability for the organisation’s response in both passive and proactive ways); Constructing a single version of the ‘truth’ (stepping into a sense-making role for the organisation); Emerging from the pack (taking charge of the organisation to a degree that was beyond ordinary expectations regarding their substantive accountability and role); and Challenging prior assumptions (regarding organisational preparedness and response, and faced with unexpected exacerbating events).

The research considers implications for the training of tactical commanders, as well as approaches to understanding the effectiveness of tactical command during an incident.

Conclusions
This emergent theory of response places tactical commanders within the context of hospitals as complex adaptive systems and highlights the range of demands presented and differential responses required. It offers an insight into the application of the model for major incident planning within the NHS. The current normative decision-making framework for low incidence high impact events in hospitals aspires to a highly structured response but the tactical commanders were frequently experiencing ill-structured and highly dynamic events. Adopting a model of response that is aligned with the actual, rather than mandated behaviours of hospital tactical commanders could support this group of staff dealing with extreme ambiguity and high levels of risk, by emphasising the legitimacy of their instinctual and intellectual responses.

• Thesis Type: Thesis
• Deposit Date: Oct 16, 2024
• Publicly Available Date: Nov 25, 2024
• Award Date: Jul 24, 2024