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Introduction: The COVID-19 pandemic has been one of the most significant challenges faced by healthcare systems in modern times, with homecare services playing a critical role in the delivery of care to patients at home. Providing healthcare in homecare settings is inherently complicated, given the combination of patients’ often complex medical conditions, the use of advanced technologies, and the limited support available from managers and colleagues due to remote working conditions. During the pandemic, homecare staff faced numerous challenges that required continuous adaptation to maintain essential healthcare services. Managers’ capacity to respond to disruptions and support frontline staff was crucial for ensuring safe and effective care. Homecare managers faced a range of organizational challenges that threatened service quality, requiring flexible, innovative, and adaptive strategies. These practices reflect the core characteristics of resilience in healthcare organizations: the capacity to respond to uncertainty, adapt, and maintain effective functioning amid adversity. However, gaps remain in our understanding of the specific strategies managers employ across system levels, how they foster organizational learning, and how they contribute to resilient healthcare delivery within the homecare sector in times of crisis.
Aim: The overarching aim of this thesis was to advance the understanding of managers’ role in fostering resilience within homecare services by exploring the strategies employed at different managerial levels in response to the challenges of the COVID-19 pandemic. This exploration was conducted from the perspectives of both homecare managers and healthcare staff. A secondary aim was to investigate how managers facilitated spaces for reflection and knowledge-sharing, referred to as “reflexive spaces”, and how these spaces contributed to support resilience performance during the pandemic.
Methods: This thesis employed a multiple embedded case study design, comprising three qualitative studies that explored managerial strategies in homecare services during the COVID-19 pandemic, from the perspectives of both managers and frontline staff. The study included four municipalities of various sizes and geographical contexts (urban, rural, centralized, and decentralized). Each case was defined as a municipality’s homecare unit, comprising embedded units at several levels: micro-level healthcare staff, meso-level managers (frontline, middle, and top), and the municipality’s infection control doctor. Data were collected through individual semi-structured interviews with 21 managers and 16 healthcare staff. All data were subjected to thematic analysis.
Results: Paper I (meso-level) explored which strategies managers applied in adapting to challenges while maintaining high-quality and safe homecare services during the COVID-19 pandemic, and how their experiences and strategies were shaped by the local context. The analysis identified four main themes: 1) managerial strategies to mitigate shortages of healthcare staff; 2) contingency planning strategies and infection control; 3) strategies for collaboration, dialogue and coordinated responses across levels; and 4) supportive and present leadership. The local context was important for managers experiences and which strategies they applied in response to the challenges caused by the pandemic.
Paper II (micro-level) explored healthcare staff’s experiences of how their managers adapted and responded to the challenges posed by the pandemic in homecare services. The analysis identified the following three themes: 1) proactive managers’ preparedness and response to challenges despite uncertainty; 2) the importance of targeted and effective information between system levels; and 3) physically present managers made employees feel seen, heard and involved.
Paper III (micro- and meso-level) explored how managers facilitated knowledge-sharing and joint reflections and how these “reflexive spaces” contributed to adapting to the pandemic. The analysis identified two main themes 1) arenas for reflection, communication and dialogue and 2) establishing new solutions through collective reflection facilitated by managers.
The synthesis of findings across the three papers identified six themes that explain homecare managers’ role in resilient healthcare during the COVID-19 pandemic: 1) proactively responding despite uncertainty; 2) driving crisis innovation; 3) being present, available and supportive; 4) adapting to local context; 5) ensuring collaboration and information across levels and boundaries; and 6) enabling collective reflection,
problem-solving and learning.
Conclusion: This thesis uses a resilience perspective to generate valuable insights into Norwegian homecare service managers’ role in handling a pandemic. Managers at all levels of the organization faced continuous and complex Challenges that threatened the delivery of highquality and safe care. In response, they demonstrated adaptability both within and across levels by making sense of evolving situations, monitoring developments, and anticipating potential scenarios. This enabled them to mobilize and innovate using both existing and new resources. At the same time, they evaluated and improved their strategies and enabled learning across levels and boundaries, allowing for restructuring and reorganizing the system to better prepare the system for future responses to challenges. This emphasizes the importance of managers in enabling organizational learning and system-level interaction during a crisis.
Future efforts should aim to support and strengthen local adaptive strategies in response to emerging challenges, with a particular emphasis on cross-level and cross-context learning to drive system-wide improvement.