Scaffolding our systems? Patients and families ‘reaching in’ as a source of healthcare resilience.

Redley and colleagues’ study1 suggests that involving patients in their care can be challenging, even when patients express a preference for involvement. Their paper examines a key opportunity for patient engagement—the ward round—and investigates the links between patients’ expressed preference to be involved and their observed level of involvement during subsequent ward rounds. The authors report little relationship between the two, concluding that involvement is affected by a range of contextual factors. This finding, while disappointing, comes as little surprise to those who have spent any time in the ever-changing clinical environment of an acute hospital ward. What patients want in terms of active involvement, and what they can and do receive, varies in all kinds of ways. The reality of involving patients and families is that both preferences and opportunities for involvement are situated within a complex, dynamic healthcare system. Furthermore, it could be argued that by focusing only on a single opportunity for involvement—in this case shared decision-making within the ward round—we fail to recognise the role of patients and families as active partners across their care experience and the actions and adjustments they routinely make to support the quality and safety of their care. Put simply, these adjustments represent a source of resilience in our healthcare systems. In this editorial, we explore how facilitating these adjustments across the range of care experiences might create better quality and safer care. Healthcare is increasingly recognised as a ‘complex adaptive system’,2–5 within which resilience is seen as: > … the intrinsic ability of a system to adjust its functioning prior to, during or following changes/disturbances in order to sustain required operations under expected or unexpected conditions.6 Thus, resilience is an attribute of a system that allows it to flex and adapt to unpredictable circumstances. Traditionally, such flexing has been …