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Rosenbäck and Eriksson BMC Health Services Research (2024) 24:759
https://doi.org/10.1186/s12913-024-11201-x BMC Health Services Research
*Correspondence:
Ritva Rosenbäck
ritva.rosenback@hv.se
Full list of author information is available at the end of the article
Abstract
Introduction This paper presents a structured review of the use of crisis management, specically examining the
frameworks of surge capacity, resilience, and dynamic capabilities in healthcare organizations. Thereafter, a novel
deductive method based on the framework of dynamic capabilities is developed and applied to investigate crisis
management in two hospital cases during the COVID-19 pandemic.
Background The COVID-19 pandemic distinguishes itself from many other disasters due to its global spread,
uncertainty, and prolonged duration. While crisis management in healthcare has often been explained using the
surge capacity framework, the need for adaptability in an unfamiliar setting and dierent information ow makes the
dynamic capabilities framework more useful.
Methods The dynamic capabilities framework’s microfoundations as categories is utilized in this paper for a
deductive analysis of crisis management during the COVID-19 pandemic in a multiple case study involving two
Swedish public hospitals. A novel method, incorporating both dynamic and static capabilities across multiple
organizational levels, is developed and explored.
Results The case study results reveal the utilization of all dynamic capabilities with an increased emphasis at
lower organizational levels and a higher prevalence of static capabilities at the regional level. In Case A, lower-
level managers perceived the hospital manager as brave, supporting sensing, seizing, and transformation at the
department level. However, due to information gaps, sensing did not reach regional crisis management, reducing
their power. In Case B, with contingency plans not initiated, the hospital faced a lack of management and formed a
department manager group for patient care. Seizing was robust at the department level, but regional levels struggled
with decisions on crisis versus normal management. The novel method eectively visualizes dierences between
organizational levels and cases, shedding light on the extent of cooperation or lack thereof within the organization.
Conclusion The researchers conclude that crisis management in a pandemic, benets from distributed
management, attributed to higher dynamic capabilities at lower organizational levels. A pandemic contingency plan
should dier from a plan for accidents, supporting the development of routines for the new situation and continuous
improvement. The Dynamic Capabilities framework proved successful for exploration in this context.
COVID-19 healthcare success or failure?
Crisis management explained by dynamic
capabilities
RitvaRosenbäck1* and Kristina M.Eriksson1
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Page 2 of 22
Rosenbäck and Eriksson BMC Health Services Research (2024) 24:759
Introduction
e COVID-19 pandemic is a disaster [1]. However, it dif-
fers from many other disasters by the worldwide spread,
the uncertainty about the patient treatment, especially in
the beginning, and the long duration. e healthcare cri-
sis management challenges in a long duration pandemic
are dierent from management in short duration disaster
like an earthquake or a major accident. e management
in shorter crises or disasters is described in the research
of surge capacity (SuC) [2, 3], but the COVID-19 pan-
demic revealed that successful management in a pan-
demic, needs to be dierent [4]. Further, pandemics dier
from other long-duration disasters like war or severe air
pollution, due to the uncertainty of the type of health-
care and knowledge needed. Merely, the infected patients
appear at the hospital, thus the rst to receive informa-
tion about both the number of patients and their needs
are the professionals at the hospitals [4]. Usually the ow
of information comes from a rescue leader through the
regional management that prioritizes and distributes the
patients to the hospitals [5]. e hospital management
needs to use the in-house knowledge and improve the
mobility at the hospital [6]. us, the management’s need
in a pandemic is less hierarchical and more learning and
innovative [4, 7, 8].
SuC expresses the demand of unusually high capacity
caused by crisis and disasters [2, 3]. e concept of SuC
seems to be the base for the worldwide used NATO stan-
dard for crisis management, with a hierarchic structure
and strong rules of communication [5]. Resilience (R)
is the most used management framework in healthcare
organizations, dened as the capacity to absorb shocks
while maintaining function, focusing on two categories
i.e., robustness and rapidity [7, 9]. e strategic “inside-
out” Resource-based view, focus on how the resources
on hand could be used to the market “inside-out” and
have developed during time to the organization’s ability
to renew competences to adjust to changes in the sur-
roundings, and include understanding of the require-
ments from the market or environment (“outside-in”)
[10]. e dierent ow of information and the constant
need for learning and development in an unknown and
continuously changing environment could make the hier-
archic system of SuC too static and less successful. ere-
fore, in a disaster such as the COVID-19 pandemic other
approaches to crisis management need to be considered.
e Dynamic Capability (DC) framework was designed
to explain how organizations achieve and sustain com-
petitive advantages by adjusting resources and adapting
to changing environments. Originating from a resource-
based view, Dynamic Capabilities (DCs) emphasize an
organization’s ability to adapt resources to new condi-
tions. From this perspective the DC framework has
been limited applied in healthcare management research
before the COVID-19 pandemic [11–13]. However, the
possibilities of DCs in the context of the public sector
have gained research interest, e.g., Furnival et al. [12]
suggest further research into using the microfoundations
and Pablo et al. [13] ask for more research on how man-
agers or organizations can enable DC in the public sector.
e application of the DC framework in health care orga-
nizations are thus gaining research interest and to under-
stand the applicability of DCs in health care, especially in
relation to unpredictable and long duration disasters, fur-
ther research into the eld is called for. Contributions to
the eld, demonstrating results from in-dept studies with
hospital management expertise at dierent management
levels may be especially valuable for building knowl-
edge toward meeting future long-duration disasters and
crises with similar characteristics. is study adopts
and develops the DC framework to investigate eective
resource utilization and how the DC framework could
be more usable, especially in long-duration pandemics.
is prompts the research question: How can the DC
framework explain the disaster management in health-
care organizations during the COVID-19 pandemic?
e research presented develops the concept of the DC
framework, which is applied to a multiple qualitative case
study to understand the management changes during the
COVID-19 pandemic.
e paper starts with an overview of applied crisis
management theories, thereafter the results from a struc-
tured review of the use of SuC, R and DC in healthcare
research, especially focusing of disasters and pandemics,
is presented. e methodology of a qualitative multiple
case study and the two cases are outlined and thereafter
the ndings are reported. e discussion and conclusion
wrap up the paper.
Crisis management in literature
SuC expresses the demand of unusually high capacity
caused by crisis and disasters [2, 3]. SuC have been stud-
ied over the last decade, mostly in healthcare organiza-
tions, but can be generalized to other systems involving
complex activities [9]. e management part of SuC is
carefully stated with solid rules concerning how and to
whom to communicate and incorporates a hierarchy of
decisions [5].
R was originally used to describe ecological systems’
ability to resist disturbances [9]. e theories of R have
been developed in crisis management science with the
aim of improving performance of systems during crisis. R
Keywords Dynamic capabilities, Healthcare, COVID-19 pandemic, Static capabilities, Crisis management
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Page 3 of 22
Rosenbäck and Eriksson BMC Health Services Research (2024) 24:759
should include all resources that need to be safeguarded
from expected or unexpected disturbances and can be
described both as being robust during change, but also
as the ability to absorb uncertainty [9]. Kruk, et al. [14]
describe the need during the outbreak of a disease or
other disasters resulting in a surge demand for health-
care. e conclusion is that a resilient health system
needs to be aware, diverse, self-regulating, integrated,
and adaptive [14]. During the COVID-19 pandemic,
R could be described by three required preconditions;
global solidarity, legal framework, and workforce policies
[15], which are aligned with the research of Kruk et al.
[14] and errien et al. [9]. McDaniels et al. [7] recom-
mend using R instead of SuC in healthcare organizations,
due to the described less static management.
DCs focuses both on the perspective of how the mar-
ket (outside) inuences the organization (inside) and
the perspective that the organization needs to adapt to
the chosen market [16], but also to the inside-out per-
spective which values the organization’s knowledge and
resources in the choice of strategy and marketplace [10,
17]. Teece, et al. [18], considered founders of the DC
framework, describe the resource based view as static,
when organizations in the short term are stuck with
existing knowledge and structure. DCs are a special class
of capabilities that describe change and innovation essen-
tial when organizations need to sustain performance in
a changing environment [19]. e aspect of cyclicity and
moving through the DC phases in several iterations may
be necessary for organizations to be able to continuously
develop [12] and reach a higher level of understanding of
their specic organizations planning characteristics, such
as shown by Eriksson, et al. [20]. Pablo et al. [13] describe
this iteration to learn and transform as experimenting.
Further, the importance of taking a holistic view of the
organization is stressed as a prerequisite when moving
towards the capability of transformation [20]. Developed
DCs are dicult for competitors to replicate and will
give a competitive advantage and innovative response in
a rapidly changing market when time to market is criti-
cal [18]. Both inside-out and outside-in strategy capa-
bilities need to be dynamic and constantly renewed [21].
For moderately dynamic markets it is possible with tradi-
tional routines to build on predictable and analytical pro-
cesses and build DC from existing knowledge. However,
for high-velocity markets, with unpredictable outcomes,
DCs need to develop to be simpler, more experimental,
and iteratively relying on situation specic knowledge
within simple rules and are often described vaguely as
“routines to learn routines” [11]. Capabilities that are
not supporting changes is by a few scholars called static
capabilities (SC), e.g., Dawson [22] is using SC for explor-
ing knowledge management and Mortensen et al. [23]
are using it to explore barriers for futures literacy. e
DCs have advanced in dierent areas and hereafter the
development over the last ten years in healthcare disaster
management are focused and described.
Crisis management in healthcare literature
e COVID-19 made the healthcare business volatile and
has caused an exponential increase in frequency of use
of concepts of crisis management i.e., SuC, R, and DCs.
A structured search in Scopus, searching “all elds” with
the keywords “Healthcare” and “Disaster” (doted lines) or
“Pandemic” (full lines) and “Surge Capacity”, “Resilience”
Fig. 1 Use of the crisis management concepts SuC, R and DCs
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Page 4 of 22
Rosenbäck and Eriksson BMC Health Services Research (2024) 24:759
or “Dynamic Capability” between 2010 and 2022, deliv-
ers a result of the amount of research papers applying the
concepts, see Fig. 1. Research studies investigating the
use of R is more than ten times higher than SuC and DCs
(left scale) and shall therefore be read at the right scale in
Fig.1. SuC and R seem to have been used in healthcare
crisis management research at least from the beginning
of 2010th decade both for pandemics and disasters. e
interest of R seems to rise in use especially in combina-
tion with disasters and the interest of DC started later,
but the use in research increased after 2014. At the start
of the COVID-19 pandemic in 2020 the research into all
three concepts increased largely and DCs is the concept
with the highest increase in publications between 2019
and 2022 (> 400 times) after which it exceeded the use of
SuC. SuC declined between 2021 and 2022. us, explor-
ing the DC concept in healthcare was found interesting.
e search in Scopus was limited from all elds to;
article title, abstract and the keywords was reduced to
“healthcare” and “Dynamic capabilities” resulting in 88
papers (reduced from 5134 results). Further papers in
the areas of computer science, focusing on simulations
and analytics, were omitted, resulting in 54 papers. e
abstracts of those 54 papers were read and 24 papers of
the highest relevance were kept. All 24 papers were read
in full, and the eight most interesting papers were studied
in more detail in this research. In addition, ve research
papers, found outside of the Scopus search through
snowball technique, were included because of additional
interesting and highly relevant research. us, in total 13
papers, outlined in Table1, about DC in healthcare cri-
sis management were studied in detail and used in the
research presented in this paper.
Dynamic capabilities framework in healthcare
e DCs framework is usually divided into sensing, seiz-
ing and transformation [24]. However, other scholars
express it dierently as i.e., detection, understanding and
reconguration [25] or i.e., dynamic managerial capa-
bilities and dynamic organizational capabilities, where
the latter is divided as described above, but the former
divides into managerial cognition, managerial human
capital, and managerial social capital [26]. Moreover,
Sheng [27] divides the capabilities into three groups
for the inside-out view. First the “system capabilities”
with the content of written regulations, guidelines, and
instructions. Secondly the “socialization capabilities” can
be explained as the organizations shared ideology and
basic values and inuences how the members of the orga-
nization treat each other in a crisis. e third is expressed
as “coordinating capabilities” and inuences the number
of fruitful contacts in the organization. For the outside-in
Table 1 Papers found about DC in healthcare crisis management and used in this paper
Scholars Title Journal
From
Scopus
Evans, J. M., Brown, A. and
Baker, G. R [19].
Organizational knowledge and capabilities in healthcare: Deconstructing
and integrating diverse perspectives
SAGE open medicine, 2017.
Furnival, J., Boaden, R. and
Walshe, K [12].
A dynamic capabilities view of improvement capability” Journal of Health Organiza-
tion and Management, 2019.
Linden, A. I., Bitencourt, C. and
Muller Neto, H. F [31].
Contribution of knowing in practice to dynamic capabilities The Learning
Organization,2019.
Ljungquist, U [29]. Unbalanced dynamic capabilities as obstacles of organisational eciency:
Implementation issues in innovative technology adoption
Innovation,2014.
Loureiro, R., Ferreira, J. J. and
Simoes, J [25].
Understanding healthcare sector organizations from a dynamic capabili-
ties perspective
European Journal of Innova-
tion Management,2023.
Ohrling, M., Solberg Carlsson,
K. and Brommels, M [8].
No man is an island: management of the emergency response to the
SARS-CoV-2 (COVID-19) outbreak in a large public decentralised service
delivery organisation
BMC Health Services
Research,2022.
Pablo, A. L., Reay, T., Dewald, J.
R. and Casebeer, A. L [13].
Identifying, enabling and managing dynamic capabilities in the public
sector
Journal of management
studies,2017.
Sirmon, D. G., Hitt, M. A. and
Ireland, R. D [31].
Managing rm resources in dynamic environments to create value: Look-
ing inside the black box
Academy of management
review, 2007.
Snowball Sheng, M. L [27]. A dynamic capabilities-based framework or organizational sensemaking
through combinative capabilities towards exploratory and exploitative
product innovation in turbulent environments
Industrial Marketing Man-
agement, 2017.
Karali, E., Angeli, F., Sidhu, J. S.
and Volberda, H. [26[
Understanding healthcare innovation through a dynamic capabilities’ lens Healthcare entrepreneurship,
2018.
Sundararaman, T., Muraleed-
haran, V.R. and Ranjan, A [15].
Pandemic resilience and health systems preparedness: lessons from
COVID-19 for the twenty-rst century
Journal of Social and Eco-
nomical Development, 2021.
Chokshi, A. and Katz, H [30]. Emerging Lessons From COVID-19 Response in New York City The Journal of the American
Medical Association, 2023
Boin, A., Hart, P., Stern, E., and
Sundelius, B [32].
The Politics of Crisis Management: Public Leadership under Pressure Cambridge University Press,
Cambridge, 2016
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Page 5 of 22
Rosenbäck and Eriksson BMC Health Services Research (2024) 24:759
view Sheng [27] describes “organizational sensemak-
ing”, as a continuous process of how the organization is
seeking information of the environment and how this is
formed to common goals for the organization. Moreover,
in a framework for decision-making in crisis in major
projects, sensing is explored as an important framework
category [28] In the developed method in this paper
Teece’s [24] the microfoundations are used as framework
categories i.e., sensing, seizing and transformation.
Sensing includes the identication of all kinds of risks
and opportunities, e.g., technical advancements, sup-
pliers’ possibilities to deliver and regulations, preferably
before they arrive [12, 29]. Research concerning sens-
ing often refers to analytical and forecasting [30], and
the need for real time data [8]. e capability of sensing
focuses on service users, stakeholders, and suppliers [12]
or on specic important factors e.g., problems detection,
lack of coherence of safe routines or risk for high demand
or exhaustion [31]. Ohrling et al. [8] describe the impor-
tance of rapidly understanding the unexpected during the
COVID-19 pandemic and nding resources to increase
the ability to analyze the situation and add that knowl-
edge and experience to the emergency management
team. Further, the communication to spread an always
changing target and new information to the emergency
management team and to everyone, to create a common
understanding [8] could also be included in the DC of
sensing. To make the sensing appear, meetings need to
be highly frequent both in the organization and between
organizations. However, it could be important to limit
information due to a high and intense ow from dierent
resources that may lead to misunderstandings [8].
Seizing can be seen as the enablers to make dynamic
capabilities work and can both be already existent in the
organization or newly developed. e DC of seizing pro-
vides a link between environmental change and internal
adaptability [13] or it could be routines and processes for
change [29]. A beforehand made contingency plan can be
a part of the seizing; thus, these are often built on SuC
and are therefore rather static and work against DC [32].
Seizing could also include culture and management capa-
bilities in the managers’ choice of the competing priori-
ties [12]. Routines could be how planning, evaluating and
decision making should be done, how ideas are received
and accredited and how leadership and teamwork are
functioning in the organization [31]. Decentralization
and a culture of rapidly responding from the informa-
tion towards actions and more practically, routines and
processes that enable higher frequency meetings, faster
coordination, added experts and teamwork can be seen
as parts of the DC of seizing [8].
e transformation includes implementing new pro-
cesses and policies, for example, decentralization, co-spe-
cialization, or governance, and measuring improvement
activities and reviewing plans and strategies [12, 29]. .
Moreover, some researchers refer to learning to respond
to changes [31]. e transformation during a pandemic
needs to be continuous with adjustments and rearrange-
ments, due to changing information and environment
and the activities need to be tightly followed and con-
tinuously evaluated to build exibility [8]. e sensing,
seizing and transformation as described here is hereafter
used in this research.
e synchronization of microfoundations is neces-
sary to make the DC perform [33]. An organization
without seizing will become cosmetic and bureaucratic,
and therefore ineective to take decisions and fulll the
customer needs due to shortage of inter-relationships
between the microfoundations. Further, a shortage of
transformation will ensure customers and stakeholders
that the service will be provided, but it never happens.
Without sensing, the organization will appear arrogant
and unwilling to seek ideas and knowledge from the out-
side, thus just focusing on internal plans and strategies
[12]. Whereas, a strong sensing capability could lead to
high expectations of seizing and transformation, caus-
ing a capability gap, which could be recognized by a lack
of top management [18, 29]. Moreover, they also mean
that a strong sense and a strong transformation at local
organizational level implies local unit-focused initiatives,
thus, may suboptimize the local unit and not benet the
whole organization. If sensing and seizing capabilities
are high, it leads to high barriers between local units,
but could also lead to barriers between local units and
the top management [29]. At the daily level, especially in
healthcare, the transforming capability is strongest, and
the sta will try their best to help the patients. However,
a focus on operational tasks may lead to organizations
with diculties in verifying their capacity for change and
responding quickly to changes in the surroundings [34].
Furnival et al. [12] suggest that organizations in a disas-
ter are dierent, thus sensing will be more important to
be able to rebuild organizational condence and capabil-
ity of movement. However, in non-crisis organizations,
seizing may be of higher importance, where commitment
and culture should help ensure continuous development.
Methodology for the case study and case description
e methodology applied in the research presented
is multiple case study. e case study methodology
includes the collection of internal hospital documenta-
tion, documentation from externa public sources and
qualitative data collection through interviews. e case
studies are considered suitable when capturing dierent
and elusive aspect and perspectives from real context
[35, 36]. us, the method was chosen to capture and
develop an encompassing view of capabilities for disas-
ter management during the COVID-19 pandemic. e
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Rosenbäck and Eriksson BMC Health Services Research (2024) 24:759
selection of case hospitals was meticulous. Several hos-
pitals were considered before nalizing the choices [36,
37]. Key diversity factors included hospital size, infec-
tion pressure, pandemic timing, collaboration ability,
and management stability. e rst case, a medium-sized
hospital, faced high and early infection pressure, could
transfer patients, and had a stable organization. e sec-
ond case was chosen for its contrasting attributes: larger
size, lower and later infection pressure, responsibility to
assist other hospitals, and a recent management change.
To understand the selected cases, internal documents
regarding mission and organization both before and
during the Covid-19 pandemic were studied. Further,
documents from external public sources were gathered
and studied, e.g., newspaper articles and information
from national press conferences during the pandemic
to increase the knowledge about the pandemic situation
and the cases.
e multiple and qualitative case study was built on
semi-structured interviews with managers that were con-
ducted about a year after the start of the COVID-19 pan-
demic. e choice of semi-structured interviews as data
collection method were considered valuable for the mul-
tiple qualitative case study, to gain focused data and the
managers personal view of the management [36]. Case
studies produce context-dependent knowledge, and the
data could be used to understand the complex issues of
the aspects of the managers dynamic management dur-
ing the pandemic [38]. e narratives from managers of
dierent levels were used to identify their opinion of the
organization’s management practice.
Case descriptions
e rst investigated case (A) is a middle-sized hospi-
tal with about 1300 employees, located in a large Swed-
ish region, with several hospitals. e case hospital is an
emergency hospital, but without an infection department
and with few intensive care unit (ICU) beds. e increase
of the COVID-19 infection rate in the catchment area
was rapid in the beginning of the pandemic and some-
times the percentage of hospitalized citizens was the
highest in the country [39]. e hospital was about to
implement a new NATO standard with instructions for
starting a regional command center (RCC) at the regional
headquarters and local command centers (LCC), with
static rules for how to communicate and make decisions
[5] and concluded the implementation during the begin-
ning of the pandemic.
e second case hospital (B) was chosen to be dier-
ent, as sought to be advantageous for designing a multi-
ple case study [36]. Case hospital B is the central hospital
in a less populated region (compared to Case hospital
A). is region also includes two local hospitals. Case B
has about 5000 employees and have an infection depart-
ment and the most ICU beds in the region. Just before
the COVID-19 pandemic the healthcare director was
replaced and the region was reorganized and a regional
organization was implemented with some of the depart-
ment’s management centralized to the main hospital, for
example the departments of infection and the depart-
ments of ICU. e contingency plan was not updated to
the new organization.
Interviews
e interview sessions started in March 2021, one year
after the onset of the pandemic, and were completed
within a month for Case A and another month for Case
B. At Case A, a total of twelve interviews from three
organizational levels i.e., hospital manager group (3),
department manager group ( 5) and unit manager group
(4), were conducted. e presentation of the interviewees
is found in Table2 including the time of the interview. At
case B, with a total of eight interviews were performed
the hospital management were merged to a regional
healthcare management group with the responsibility
of the departments, directly reporting to the director
of healthcare and hospital managers were not existing.
Important functions were found at the regional level and
therefore the three levels of management studied became
Table 2 Interviewees in management groups and the length of
interviews
Manage-
ment
group
Case A Length
[h:
min]
Hospital
managers
(3)
Hospital manager (CEO) 1:15
Chief physician 1 1:09
Chief physician 2 0:55
Depart-
ment man-
agers (5)
Department manager of surgery 0:59
Department manager of medicine and
geriatrics
0:52
Department manager of intensive care and
surgery services
1:37
Department manager of inpatient care 1:02
Department manager ED 1:12
Unit man-
agers (4)
2 Unit manager of ED 1:05
Unit manager of inpatient geriatric 0:39
Unit manager of inpatient care 0:55
Unit manager of Surgery/ICU 1:07
Case B
Regional
managers
(3)
Chief of Sta of RCC 1:03
Chief Hygiene Physician 1:17
Chief Medical Ocer with Preparedness
Responsibility
1:10
Health care
managers
(2)
Regional healthcare director 0:55
Chief of Sta of LCC 1:06
Depart-
ment man-
agers (3)
Department manager of internal medicine 0:56
Department manager of infection 1:08
Department manager of ED 1:21
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Rosenbäck and Eriksson BMC Health Services Research (2024) 24:759
i.e., regional manager group (RM, 3), regional healthcare
manager group (2) and department manager group (3)
and in total eight interviews were conducted. e presen-
tation of the interviewees is found in Table2 including
the time of the interview.
e interviews were semi-structured, which means the
interviewees were allowed to talk freely, and the inter-
viewer avoided aecting the interviewees [37]. e same
researcher moderated all interviews and used a semi
structured interview guide as been described in earlier
research [6], with topics of the feeling of the size of the
disaster, the contingency plan, how they built capac-
ity for the COVID-19 patients, management during the
pandemic and the information ow, as support. Another
researcher actively observed the interviews and used the
interview guide to follow the completeness of the collec-
tion of information and sometimes added a few ques-
tions for completion. All interviews were conducted via
video conferencing with both sound and video recording.
e interviewees were later provided with feedback in
the form of a lecture and a written report, to make sure
the information gathered was correctly understood [40].
e recordings were verbatim transcribed and NVIVO14
was used to structure the data. ereafter, the data were
exported to Excel and further analyzed.
Methodology analytical development
e DC and SC frameworks were applied and further
developed in this study to explore and analyze the man-
agement during the pandemic in the cases. To align the
data in relation to the DC and SC frameworks it was suit-
able to perform the analyses deductively. erefore, the
data were deductively analyzed by selecting excerpts,
from the interviews, that aligned with the dierent DC
framework categories (microfoundations)i.e., sensing,
seizing and transformation, and SC framework catego-
ries (microfoundations), i.e., non-sensing, non-seizing,
and non-transformation following other scholars’ de-
nitions and proposals in their research. Moreover, to be
able to receive deeper knowledge about the organization
and the dierent management groups’ viewpoint of the
organization’s performance at dierent organizational
levels, the data was divided into organizational levels, i.e.,
department, hospital, regional and national level in case
A. In case B one additional level of regional healthcare
was used necessary by the special organization, where
the regional healthcare organization worked besides the
RCC stated in the contingency plan. e hospital level
contained a spontaneously developed group of depart-
ment managers during the rst wave of the COVID-
19 pandemic. However, during later waves a LCC was
started as stated in the contingency plan and emerged
with the department managergroup at the hospital level.
Table3 shows the 42 dierent categories in the deductive
analyze.
e interviewee’s excerpts were analyzed several times
both from the transcription of the interviews and later
from the framework categories. is procedure was con-
ducted to enhance the rigor of the research [41]. To be
able to analyze and present the ndings both qualitatively
and quantitatively, the excerpts from each interviewee
were only coded once to one framework categories.
e deductive analysis of the excerpts in the interviews
to the framework categories of DCs and SCs at dier-
ent organization levels was suitable and the researchers
found the method satisfactory. e imposed quantitative
analysis is done according to the visualizations in Table4.
Findings: multiple case study
A qualitative analysis was conducted to clarify special
phenomenon in each of the cases. Moreover, the data
was quantitatively analyzed according to the developed
method described above. e framework categories and
examples of excerpt of each case, group of managers,
organizational level are structural gathered in Tables5,
6, 7, 8, 9 and 10 and are referred to in the text to prove
dierent phenomenon in the organization. e use of
the group of managers instead of a single title for every
excerpt gives an improved overview of the management
opinions at dierent organizational levels. Moreover it
ensures keeping the anonymity of the hospital and their
employees. e excerpts about the national level were
fewer and were therefore excluded from the table. How-
ever, DC at a national level mostly referred to the national
organizations of ICU and infection physicians, who made
large eorts to gather important medical information and
treatment of the COVID-19 patients and to spread the
knowledge to other physicians through webinars once a
week as the chief medical ocer at case A expressed:
“e Swedish Association of Infectious Disease
Physicians has taken on a great deal of responsibil-
ity and has held regular webinars with knowledge
Table 3 The framework categories coupled to organizational
levels of the cases
Case Organizational level Framework category
A Department level (DepLev)
Hospital level (HospLev)
Regional level (RegLev)
Sensing (Sens)
Seizing (Seiz)
Transformation (Trans)
Non-Sensing (NonSens)
Non-Seizing (NonSeiz)
Non-Transformation
(NonTrans)
B Department level
Hospital level
Regional healthcare level
(RegHealthLev)
Regional level
Sensing
Seizing
Transformation
Non-Sensing
Non-Seizing
Non-Transformation
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Rosenbäck and Eriksson BMC Health Services Research (2024) 24:759
updates with leading researchers and clinicians in
this eld.” (Chief medical ocer, case A).
Some DC was about the prognoses from the National
Board of Social Aairs and Health and the public health
authority that was helpful especially towards the end of
the pandemic for example:
“During the late spring (2020) and just before the
summer, more scenarios are brought up that were
sort of adapted based on dierent regions that you
could then work with” (e chief of sta at regional
level, case B).
us, the SC excerpts describe lack of information and
the continuously changing information from Swedish
authorities for example:
“Quite shaky at rst. Slightly dierent message. Mes-
sage not coming … We felt it was messy”. (e chief of
sta at regional level, case B).
Figure 2 visualizes the excerpts of each of the units
and department managers of case A and there were
about double as many as the excerpts of the hospital
management. At case B the healthcare management
had a slightly smaller number of excerpts. is needs to
be remembered during the semi-quantitative analysis.
Moreover, Fig. 2 envisions that the managers nd the
organizations to be more dynamic than static. e hospi-
tal manager and unit managers in case A and the health-
care managers in case B have proportionally fewer SC
excerpts.
Figure3 visualizes the number of excerpts per organi-
zation level to show their dynamically respectively stati-
cally behavior during the pandemic. e department
level in case A received the highest number of dynamic
excerpts followed by the hospital level, however, the hos-
pital level has a higher proportion of SC. e highest
proportion of static behavior, showing nearly the same
number of excerpts as DC, are found at the regional level.
e examples of criticism was that they lately understood
the severeness of the COVID-19 pandemic (Table6, Reg-
Lev: NonSensa), pushed to work use the NATO standard
even if it was not implemented (Table7, RegLev: Non-
Seiza) and kept the structure of crisis management even
when the disasterwere prolonged. However, further into
the COVID-19 pandemic RCC lost power towards the
normal group of hospitals directors, which made the hos-
pital managers more positive towards the regional level.
(Table7, RegLev: Trans). Examples of criticism from the
department managers towards the regional level appears
later in the COVID-19 pandemic when the politicians
changed focus and made the cooperation over the region
work less eective (Table6, RegLev: NonSeizb). e poli-
ticians also caused dissatisfaction among the profession-
als by building an ICU at a fair hall outside the hospitals
which was never used.
In case B the highest numbers of dynamic excerpts
were at the hospital level and at the regional level, but
the proportion of SC at the regional level was higher. e
healthcare level had the highest proportion of SC with
slightly the same number as the DC correlative to the
situation at the regional level at case A. e healthcare
level got criticised both from the department and the
regional managers, for example one regional manager’s
questioned the active decision at the healthcare level to
have their own regional crisis management beside the
RCC and that they did not start an LCC at the case hos-
pital (Table10, RegHealthLev: NonSeiza; Table8, RegHe-
althLev: NonSeiza). Further, the regional management
had a high proportion of SC especially from the health-
care level, because of the regional levels strong statement
of a contingency plan that maybe was not appropriate in
a pandemic (Table9, RegLev: NonSeiza). e regional
healthcare level pushed for management more as usual
as in line with the hospital managers at case A (Table9,
RegHealthLev: Seiza). us, the department manag-
ers started an local manager group at the hospital for
Table 4 Imposed quantitative analysis of deductively coded
excerpts
Visualization Shown Phenomenon Figure in
ndings
Number of
DC and SC
excerpts/group of
managers
The proportion of excerpts per manage-
ment group to analyze the amount of
bias in the data. The visualization also
shows the opinion of the management
groups if they found the total organiza-
tion to be dynamic or static by the
proportion of SC to DC.
2
Number of
excerpts/organi-
zation level
The managers’ opinions about what
organization level in the organization
was the most dynamic or static. Also,
here the proportion of SC to DC is
showing the levels that was success-
ful respectively failed in their disaster
management.
3
Number of inter-
viewees excerpts
for each group of
managers/organi-
zational level
A more detailed picture of each man-
agement group’s opinion about the
dynamic of each level of the organiza-
tion. The results could visualize good co-
operations, but also conicts between
the organizational levels.
4
Number and type
of excerpts/orga-
nization level
The managers opinion about the
number of each DS or SC is most at
each organization level. Answers the
questions; What level in the organiza-
tion appropriate sensed the disaster?
Who structured the work and used the
competence and plans in a dynamic
way? Who transformed most in the
organization?
5, 6
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Rosenbäck and Eriksson BMC Health Services Research (2024) 24:759
practical decisions and needs without any mandate and
ocial agreement (Table8, RegHealthLev: NonSeizb).
When looking closer of how dierent management
groups assesses each organization level (Fig.4) the cases
dier even more. In Case A the managers consider their
level with positive eyes as well as the level nearest above,
for example when the department manager group praised
the hospital manager for his braveness (Table6, HospLev:
Seiza) or when the department manager group talked
about their thoughts of getting the employees to act with
the managers spirit (Table6, DepLev: Seiza). However,
the most SC also appeared for the level directly above, for
example, that the department level underestimated the
COVID-19 changings (Table5, DepLev: NonSens) and
the lack of tools for keeping employees at the working
place in a stressing environment (Table6, HospLev: Non-
Seiza). However, the unit managers evaluates the second
nearest hospital level dynamic and comment on the short
distance to the hospital director, known by everyone
(Table5, HospLev: Seiz).
All manager groupsof Case B seem to be self-critical
and considered their own level as being somewhat static,
for example the department managers reection that the
idea to start a new department was not the best choice
(Table8, DepLev: NonTrans) or the regional managers
reection of their poor management when the healthcare
LCC was not started in the beginning of the pandemic
(Table 10, RegLev: NonSeiz). e regional manager
group seem to be self-condent about their own level
(Table10, RegLev: Seiz), but the number of excerpts from
the regional managers reected that the healthcare level
has higher proportion of SC than DC caused by the spe-
cial crisis management group at healthcare regional level
as described before. e healthcare manager group have
a high number of dynamic excerpts towards the hospital
level, who they found transformed by building additional
beds at ICU (Table9, HospLev: Trans), but do not have
many comments about the department level. e propor-
tion of SC is high from the healthcare managers towards
the regional level arguing that a pandemic need to be
managed by normal healthcare management (Table 9,
RegLev: Nonseizb). Caused by interviewing the regional
management of case B, the excerpts about the national
level are present in higher numbers – both positive and
negative.
At hospital A the sensing and transformation occurred
more frequently at lower organization levels (Fig. 5)
with a descending occurrence at higher levels. At the
Table 5 Case A - unit managers
Framework
categories
No. of
excerpts
Example of excerpts across framework categories
DepLev Sens 52 During wave two [of the pandemic] another patient clientele came to us. Then the elderly was very sick.
Seiz 54 We introduced morning, lunch, and afternoon meetings, because there was also a need from the sta - and
we introduced that too - where we had the opportunity to meet and get information out.
Trans 70 So now we have some places in ward 23 for high ow.
NonSens 5 I believe, we patted ourselves on the back, thinking we can take this and it’s so simple and then something
happened that we hadn’t imagined - so everyone was a bit shocked at the beginning - what happened here?
NonSeiz 5 There were some pressured groups were already there - intensive care unit sta and surgery sta didn’t really
get along - and there were a lot of old schisms.
NonTrans a 11 No one really got an introduction, but you had to learn that kind of work shift.
NonTransb steal stu
HospLev Sens 10 So, we still had to bear in mind that it could have been much worse.
Seiz 29 We are quite close in our [management] lines up [in the hierarchy], it’s me and then I have my business
manager, then there’s the CEO. Like the CEO, you know - it’s not anonymous when you are in a small hospital
[as in this case].
Trans 21 The supply then has – after all, they come up every day and rell.
NonSens 1 uncertain about materials and all – but it’s a dierent story – a new disease – no one knew anything about
anything.
NonSeiz 7 …had diculty with care places at the hospital and many patients remained in the emergency department.
The situation we entered the pandemic with was worrying.
NonTrans 3 But the second wave we got no external resources at all.
RegLev Sens 0
Seiz 2 It has been quite fast to get those decisions through.
Trans 6 Covid ambulance redirection it was yes.
NonSens 0
NonSeiz 2 In wave two [of the pandemic], politics wanted to take over and try to get some of this back then and like
controlling everything - then suddenly it became much slower - it was slower to get care places in wave two
than during wave one.
NonTrans 0
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Rosenbäck and Eriksson BMC Health Services Research (2024) 24:759
Themes No. of
excerpts
Example of excerpts across themes
DepLev Sens a 42 It was quite - it was really this sense of uncertainty (it) was enormous - a lot of anxiety in the air - especially
for the doctors. So, this was you know with protective equipment and that some doctors didn’t even want
to go to the patient - it was very, very chaotic.
Sens b This is not a crisis this is a pandemic. It is not a crisis event. It’s not a point it’s a line.
Seiz a 58 Acting in the boss’s spirit, but it gives them freedom and their own power in carrying out their job.
Seiz b Yes, it has gone extremely quickly in acute somatics because we have single rooms there, so we never end
up in those situations. We talk all the time in cohorts and then each single room is a cohort, which means
you can change from one minute to another.
Trans a 50 But, on the other hand, we have said that you call out for help if you forgot something when you go into
the room and investigate so that you don’t bring too much in because everything must be washed - so it
has denitely changed a lot of things.
Trans b Here we went from 160 to 320 people [sta] in three weeks and you can just imagine the group dynam-
ics—and a four 100% increase in intensive care unit production here—and the intensive care unit that the
hospital had back then when this started.
NonSens 0
Nonseiz 1 It wasn’t clear to us what operational targets we have and what we must work towards, so I’ve had quite
a long journey just to understand who is responsible for targets. Well, it is actually the managers who are
responsible for the targets and then they must try to get all their employees to understand these targets.
So obviously it’s challenging for us.
NonTrans 0
HospLev Sens 18 And the unpleasant thing is that when I talk about this, I get goosebumps all the way down to my knees.
I remember so well when this came out and we started discussing it and we slowly started—it probably
took a day or two for me to really take it in.
Seiza 44 With a brave manager at the hospital, and a bit of luck with timing with the right person in the right place,
we were able to get momentum going and get going.
Seizb So actually, I would like to say that in terms of places and such we have somehow taken a position almost
daily on the situation of how we can balance the ow in the best way and take care of the patients. And
then we worked with our strategic meetings where we made decisions. There have been decision forums
every day when we have been in reinforcement mode and since then, our management team has been in
hospital crise mode three times a week.
Trans 21 Hospital management meeting we have on Teams, but I think there should be both opportunities. It helps -
it does. It is not at all so stupid to be able to have digital [meetings].
NonSens 1 It should have been over before the summer - oh dear - how hard could it be? Who knew. Oh. Uh-oh. So
many times, I’ve been wrong in what I’ve believed about this – yes, we’ve learned here that we can’t predict
the future - it always turns out in some new way.
NonSeiz a 21 But I must have tools that keep the sta on the line and continue to perform. We don’t have such tools in
healthcare - because we have never rigged for it.
NonSeiz b And then there has been a lot - a lot like contractual issues around how to do - how to move sta - you
must change schedules and sort of dialogue with the unions around this and there have been compensa-
tion issues linked to this because it hasn’t - that has not been so popular to switch - switch and help in
other areas of activity.
NonTrans 5 Perhaps I thought that they were almost overstaed - there were, as it were, too many people, especially in
anaesthesia, my opinion is that it turned out that way.
Table 6 Case A - Department managers
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Rosenbäck and Eriksson BMC Health Services Research (2024) 24:759
department level in case A they listened to the interna-
tional network and because of their closeness to the pro-
duction they saw the changing number of patients and
clearly sensed the level of worry and stress on the orga-
nization (Table6, DepLev: Sensa). Further, they early on
realized that a long duration pandemic made the situation
dierent from other disasters (Table6, DepLev: Sensb).
e proportion of transformation was high and for exam-
ple they managed an increase in employment at the ICU
from 160 to 320 (Table 6, DepLev: Transb). Moreover,
they changed working procedures, for example agreeing
on an allowance to shout out into the corridor when you
needed something to avoid taking the Personal Protec-
tion Equipment (PPE) o and on again (Table6, DepLev:
Transa). Examples of non-transforming capabilities were
overusing PPE, the infection spread between employees,
the shortage of employees at the critical units and the
shortage of training before work a shift at a new position
(Table5, DepLev: NonTrans; HospLev: NonTrans).
At the hospital level they sensed the employees’ anxiety
and worries about the risk of infection for themselves and
relatives and the knowledge shortage when moving to
other tasks and transformed by arranging psychological
help for the employees (Table7, HospLev: Transa). More-
over, they helped with recruitment, moved employees to
the units needed, built education and hygiene rounds,
and started and stopped planned surgery several times
(Table7, HospLev: Transb). e meetings became digi-
tal and the number of employees in the coee rooms at
once was reduced and they reconstructed several depart-
ments. e non-transformation was rather high at the
hospital level, possibly a sign that transformation was too
late or not large enough (Table7, HospLev: NonTrans).
e seizing was found equally at department and hos-
pital level. Hospital, department, and unit levels of case
A increased the frequency of meetings to daily or even
more. (Table5, DepLev: Seiz). e unit managers used
the existing dynamic quality of the organization includ-
ing single rooms at the wards (Table6, DepLev: Seizb),
the united management of all wards and the knowledge-
able management of ICU to take necessary decisions
and execute them. e cooperation between the hospital
departments increased and there was a focus on health-
care and all other questions were not prioritized (Table7,
HospLev: Transc). e non-seizing was the most occur-
ring static behaviour, and it increased in occurrence with
higher organization level. us, the structure for moving
employees to even out the pressure, for example agree-
ments of compensation and individual education, were
not in place and were not working properly (Table 6,
HospLev: NonSeizb). Moreover, department managers
responsible for the reduced planned healthcare were not
allowed to use their free time to develop their organiza-
tion and they also commented that the focus of stang at
ICU was too high and that the decisions about the start
of surgery in between the waves came to late (Table6,
HospLev: NonTrans). e non-seizing towards the
regional level was higher than the seizing. e criticism
was that there was too little capacity at ICU in the region,
neither agreements for cooperation between the public
hospitals nor between the private and public hospitals
were in place (Table 6, RegLev: NonSeiza). Moreover,
Themes No. of
excerpts
Example of excerpts across themes
RegLev Sens 2 No, that came from statistics - there were statistics from the region - to all hospitals - to intensive care units.
Seiz 7 In the third wave they have agreed more on how we should scale up and balance the care between our
dierent emergency hospitals - so that we help each other and get a reasonable load on all hospitals as
well - so it has become that we have gone in rhythm with the other hospitals and when it has been neces-
sary, we have also had to step up.
Trans 2 And it would never have worked if we had tried to bring it along or in some other way - but that was where
operational managers and intensive care managers collaborated almost on a daily level - several times a
week. And this potential that exists in Swedish healthcare and in the region, not least with cooperation
between the hospitals instead of them competing as if it were a market.
NonSens a 4 Reality and the hospitals solved the problem - and they came later and said that you have done this, do
that. And it was like - they came again and again and looked at how it turned out and blessed it afterwards.
NonSens b Here you have a curve that just rises and rises and rises and it becomes a completely dierent dynamic
and this continued for weeks, months, six months - and the whole healthcare system will be involved.
Everywhere, right up to the health centres and the nursing homes and the emergency departments of the
emergency hospitals and the intensive care, and it was like a total heart attack of information.
NonSeiz a 19 And the incentive for why it has not been done and has not been given to us by the sta who have worked
as nurse anaesthetist and anaesthetist in the private sector who have rolled on and run ASA1 and ASA2
hips and knees in parallel to keep their production.
NonSeiz b In wave two and three, dierent degrees of political dynamics and divide and rule entered the whole thing,
and we have had varying results and have managed signicantly fewer patients.
NonTrans 4 …which is not so well we may have to wait and see what the region says and such - no answers came from
the region - they are busy thinking about a lot of other things - or just drowned in questions and meetings.
Table 6 (continued)
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Rosenbäck and Eriksson BMC Health Services Research (2024) 24:759
the contingency plans structured methods of commu-
nication, built for short term disasters, caused a lot of
questions, especially during the rst wave and no one
listened to the managers respond about what happened
at the hospital (Table7, RegLev: NonSeizb). e excerpts
of seizing described the appreciation when the produc-
tion group later became more powerful. Moreover, the
ICU managers met over the region at a regional level and
made decisions (Table6, RegLev: Trans).
e DC and SC excerpts pattern/organization level
in case B were dierent compared to case A (Fig. 6).
Instead of the highest number of excerpts about trans-
formation near the production, the transformation in
case B seems to have been high at department, hospital,
and regional level and lower at the healthcare level. e
number of excepts about sensing was surprisingly highest
at the regional level, which possibly is due to the highly
experienced and knowledgeable regional chief hygienist
physician’s high and his trust and a good international
Table 7 Case A - Hospital managers
Framework
categories
No. of
excerpts
Example of excerpts across framework categories
DepLev Sens 2 So, it was a lot about going back to the facts – getting help from experts.
Seiz 1 They just had it completely clear - suggestions on how to respond and they know their business - like run-
ning water and on their ve ngers in the smallest detail, and then the internal medicine they follow then.
Trans 6 Change the way they receive patients several times.
NonSens 0
NonSeiz 2 Many who come from other cultures who actually also have a little diculty with the language and where
we have had a dominance of those groups, there it has been the most dicult. They have been the most
afraid.
NonTrans 0
HospLev Sens 30 You can say when the rst wave rolled in, it was a bit of a shock experience, I think it was an acute crisis in
some way that then became protracted and it left a lot to be desired, you could say, and then…
Seiz 45 Well, you could say that for this type of crisis, we probably weren’t prepared, but we had enough tools to
start it all up, then we’ve developed agile in this, you can still say we started.
Trans a 33 So that we were very early in setting up for it and with the fact that all elective care was basically shut down,
then we freed up resources for paramedics, counsellors, psychologists, physiotherapists for that matter as
well. And some went and helped and looked after the patients and some looked after the sta so to speak –
so that’s how it is. That’s how it still is.
Trans b We rebuilt the hospital in large parts. We cancelled elective care, and we scaled up the care places [in wards].
Trans c But it is probably also the case that a lot of other things are set aside. So that you can - you dedicate - you
put a lot of focus on this.
NonSens 0
NonSeiz 6 It is very heavy for other care units; we have a very small intensive care capacity.
NonTrans 2 It’s very interesting and see, like the rst wave, how we sit close together, no one is wearing protective
equipment and work like that. With the pandemic.
RegLev Sens 4 There you estimate dierent scenarios, so to speak, and decide that, ok, what kind of capacity are we going
to achieve.
Seiz 23 In that way, but now we sort of make decisions about our volumes, how we sort of coordinate ourselves,
ambulance redirections, we work a lot with load balancing. As a logistician, this is how we manage ows in
the region. We’ve never worked like this before, so it’s completely unique from a regional perspective.
Trans 4 Since the second wave and the third wave, now there we don’t get any directives from RCC, so that’s what
happens, there is no ordering from that direction, but all decisions are made in the production coordination
group.
NonSens 0
NonSeiz a 16 We had introduced a new model without actually having introduced it properly, but it was introduced in
connection with… and then in the second wave there was a discussion about whether we can really work
in this, which is intended for major accidents and chemical accidents and as well as special events for a short
time.
NonSeiz b After all, they have the ultimate responsibility for their hospitals, and I think they realized they didn’t really
have the opportunity to inuence that they needed to be able to lead the business. And that it was some-
times too slow.
NonTrans 2 In fact, this is how it would have been a meeting - there is a forum with an abbreviation called… The
disaster and preparedness committee or something like that would have been yesterday. But it is postponed
because we are in the middle of the third wave. So that if it had been, I would have been able to answer the
question. But I think they will update this plan.
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Rosenbäck and Eriksson BMC Health Services Research (2024) 24:759
Table 8 Case B - Department managers
Framework
categories
No. of
excerpts
Example of excerpts across framework categories
DepLev Sens 8 We who are in the front line, it was very tangible for us.
Seiz 17 We’re pretty good at ad hoc solutions too. It is one of healthcare’s stronger areas of competence,
naturally the origin of the fact that we have a certain unpredictability in the organization and for
every single patient.
Trans 30 But he got his… the covid wall that is talked about, he had to build up and such. And since then,
we have rebuilt a lot more, it was only the rst wall that was built, then even more has been built
to deal with the infection.
NonSens 2 And we … this fear around the disease has subsided in a dierent way, because we know more.
It was something that took on quite large proportions, and rightly so, initially, because we knew
so little about it.
NonSeiz 3 But what we saw from the reassigned sta that we got was that it’s not… it’s not easy for an
employee who works in a nursing department to start working in an emergency department.
There were a lot of people who almost turned away at the door, like “By God, I can’t work here, it’s
too messy and it’s too ad hoc”.
NonTrans 8 …not so functional to open a completely new care unit from scratch.
HospLev Sens 6 A target image exists. That target picture can change. And it has been very clear during this part
since local crisis management came in.
Seiz 39 But it was early. It was before there was local special healthcare management, because before
that there was something called a coordination group or something like that.
Trans 22 We have almost only digital meetings, and we have limited the number of seats in the sta room
and people keep to themselves. Yes.
NonSens 4 Perhaps it is also dicult to get a little attention from the organizations where the pandemic had
not yet reached.
NonSeiz 3 But we were a group with a small mandate, so we only had mandate over our own, which made
it dicult to navigate.
NonTrans 2 And that created a bit of internal conict, because our sta came and transported low-risk pa-
tients with high-risk protective equipment, which was of course… pedagogical, it became crazy.
RegHealthLev Sens 0
Seiz 5 The health care regional management information, as it is now called, and it is every other week
for the entire county’s business managers. It is something that has developed, because from the
beginning there were no meetings like that, and we didn’t have any before the pandemic. There
we probably had too many … for the hospitals and something like that.
Trans 2 Yes, then there was a decision to redeploy personnel.
NonSens 0
NonSeiz a 15 Who manages the hospital?
NonSeiz b We worked like some kind of guerilla warfare… It was incredibly unpleasant. It was very boring.
We got a lot of criticism for it from above and were told not to speak loudly and everything.
Terrible. Yes, it was.
NonTrans 1 So that an infection 2 [unit] was set up there. It was used, as I said, not fully… certainly not fully.
RegLev Sens 5 I would say that this research group at the university was healthcare hygiene. And it is not
because it would be the organization care hygiene, but it is because care hygiene has a care
hygiene senior doctor who is partly a driven researcher and partly has contacts with this research
group. It was like personal contacts in combinations with…
Seiz 6 And there is also a pandemic plan, but it is clear that they have learned so much that the new
plans will be much, much better of course.
Trans 7 …in the same vein, I pressed that we need to have more emergency departments. So then there
were premises adjacent to the emergency department that have been planned for quite some
time to expand. So, I was released that money, 8.4million [SEK], to complete an additional clini-
cal part to conduct emergency medical care.
NonSens 0
NonSeiz 10 Yes, there was an emergency preparedness plan. No, it was not used. And we have long pointed
out that it does not make sense against a pandemic. We have pandemics. Not really pandemics,
but we have the u every year. We have long pointed out how poorly prepared we are for the u.
NonTrans 0
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Rosenbäck and Eriksson BMC Health Services Research (2024) 24:759
Framework
categories
No. of
excerpts
Example of excerpts across framework categories
DepLev Sens 0
Seiz 1 So, it has gradually emerged empirically.
Trans 5 Established a neonatal intensive care unit at home as well. Thus, even premature children, if
they feel safe, should be sent home with parents, with support so that they can be sent home
much earlier.
NonSens 0
NonSeiz 0
NonTrans 0
HospLev Sens 9 Because there has periodically been signicantly less pressure [incoming patients] in the emer-
gency department, and we have gures for that.
Seiz 14 I’m thinking of health care hygiene, which was very good at informing at department head
meetings, on the intranet, showing … Because it was changing all the time with mouth guards
and FFP3 and everything they were called, and what’s current. So information and information
and information.
Trans 26 When we opened to twelve places from… or on the intensive care unit 2, so it was a decision
that I made in the management together with the intensive care, because we saw that there
was danger on the way.
NonSens 0
NonSeiz 1 Without the same principle… That is to say that the healthcare must, regardless of whether it is
war, reinforcement mode then, carry out the same activities with the same management…
And then it became very dicult at times… We are line managers as well, so is this a regional
sta issue or is it regular business?
NonTrans 1 Yes, before the preparation for the second and third wave, it was then established that it does
not work so well…
RegHealthLev Sens 7 Oh, my God, 130 treated in the hospital at the same time, of which 50 in the intensive care
unit. I think that’s what we said. And then we said that we must do this. So, we were mentally
prepared for it, but concretely.
Seiz a 18 To deal with a pandemic, that is to run healthcare. It is not this kind of crisis management
organization at all. But so, it was us then in what is… Yes, that is, my management group, that is,
we who are responsible for healthcare. So, we were the ones who decided that we must… This
is what we must do.
Seiz b And very quickly we started having information meetings … Once a week we have had opera-
tional safety meetings with information then from infection control and health care hygiene
where they have given a lot of information about everything.
Trans 12 So, they didn’t build it right away, but the department existed. It was empty. It would be fur-
nished, and all the materials and all that.
NonSens 2 “It might not even come here.” That was the attitude they had.
NonSeiz 5 During the pandemic, we had the rst turn, from about week ten [of the year] onwards, a
healthcare management with also the director of healthcare as management. And then all of
us area managers were involved in something that was probably not actually in the plans, but it
came so quickly that we had to act in a dierent way because we had no current plans for how
we were going to… So, the whole healthcare ended up in a separate group of sta.
NonTrans 7 The messiest thing about it was the stang of it, because we had to get sta from other parts
to be able to sta these infection units. It was a bit messy, I can say.
Table 9 Case B - Regional health care managers
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Rosenbäck and Eriksson BMC Health Services Research (2024) 24:759
network (Table 8, RegLev: Sens). Moreover, the chief
hygiene physician contributed to merely transforming
the organization by decisions to decrease the infection
between employees and at elderly homes (Table10, Reg-
Lev: Trans), which also caused the high number of trans-
formation excerpts at the regional level. e number of
excerpts for non-seizing is high both at the healthcare
level and the regional level due to the earlier mentioned
argumentation unclearness of documentation about
where decisions were made (Table 10, RegHealthLev:
NonSeizb) and this meant a focus of seizing at hospital
level. e non-transformation was rather high both at the
healthcare level and at the regional level.
Discussion
e discussion is divided into discussion about the devel-
oped research method and discussion about the result of
the multiple qualitative case study.
Research method
e research presented developed the use of DC in a
qualitative deductive analysis of interviews and is novel
especially in healthcare organizations. e data were
analyzed with framework categories (microfoundations)
of DC i.e., sensing, seizing and transformation following
other scholars’ approach, e.g., Teece et al. [18]. , . In addi-
tion to this proven application of DC the interviewees’
excerpts, which narrate a static behavior, were coded as
framework categories (microfoundations) of SC i.e., non-
sensing, non-seizing, and non-transformation to increase
the visibility of malfunctions in the disaster management
analysis [22, 23]. e coding of both DC and SC con-
tributes to a more encompassing analysis of the organi-
zations’ development during the COVID-19 pandemic.
e introduction of SC shows important insight also into
occurrences that may reverse the movement towards
transformation of the organization. Further, the cod-
ing was divided by management group and organization
levels, which revealed a visualization of the dynamics
in between the management levels which had not been
found in earlier research. e excerpts were only coded
once and therefore the qualitative analysis could partly be
quantitative even if some excerpts might contain several
items. e method was used to analyze multiple cases
and successfully revealed dierences between the organi-
zations when using this developed technique of analysis.
Multiple case study
e professionals working in production in both cases
clearly sensed the situation when the COVID-19 patients
arrived and the organization rapidly transformed to save
lives, in line with research by Teece [34] and Ohrling et
al. [8]. e early sensing at department level in case A,
due to an international network made the organization
transform even before the rst patient arrived. ese
occurrences of sensing made the response to changes
in demand possible even with high focus on operational
tasks, despite such situations can be proved to be non-
resilient [12, 34].
Framework
categories
No. of
excerpts
Example of excerpts across framework categories
RegLev Sens 6 We have received the forecast. We are still receiving forecasts for various incidents depending
on the spread of infection, the state of infection. And so we know that [inaudible] from the
moment of infection until you get sick and a certain proportion then needs hospital care and a
certain [proportion] needs intensive care. So there are pretty good models to get a rough idea
of what it will look like a few weeks ahead even.
Seiz 13 And I feel that it works, because we x it without arguing about what the crisis management
organization should look like, so we x care in any case. A bit like that.
Trans 14 But it is clear that very quickly a lot of care hygiene went into it and had a very important role in
everything from testing and use of protective equipment and so on. We had excellent coopera-
tion with infection control and care hygiene.
NonSens 1 So, during the spring when everything started, we knew very little about everything. The
disease, where it would go and so on, and so on.
NonSeiz a 11 But these regular disaster and crisis management organizations, they are not adapted to deal
with pandemics.
NonSeiz b I think that then it would look the same as usual, and that is the principle of similarity we should
use, I think. That if we manage healthcare in this way and manage, and this management struc-
ture we have. Then it is the one that should be there. But it may need to be reinforced.
NonSeiz c It was probably because we didn’t have an up-to-date disaster or pandemic plan. Then we also
changed the organization in 2019. Transitioned from an old management model to a new one,
and then we didn’t have time … We hadn’t had time to nd a new plan for it.
NonTrans 3 And certainly, there has been frustration towards us management that we have not made clear
enough decisions and we have not communicated them, and so on. So there has been some
irritation and frustration as well. It has been.
Table 9 (continued)
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Rosenbäck and Eriksson BMC Health Services Research (2024) 24:759
Table 10 Case B - Regional managers
Framework
categories
No. of
excerpts
Example of excerpts across framework categories
DepLev Sens 0
Seiz 4 If you activate the right people, there are very, very good opportunities to increase resources, for
example, in intensive care. I mean, all the colleagues we have there, it is their whole profession to be
able to adapt capacity according to the requirements.
Trans 9 And on the spot spread out those who know intensive care, and bring in a little more people, but
that you still had to keep your place, so to speak.
NonSens 0
NonSeiz 0
NonTrans 0
HospLev Sens 0
Seiz 7 And those assessments are made by local special healthcare management at each hospital. So,
when you see that it is at a steady level with covid patients, and maybe starting to reduce it. Yes, but
then you can scale up a bit. So.
Trans 3 In the rst wave, a couple of doctors from the intensive care unit are sent down to [another hospital]
to study these patients, to try to understand: “What do you actually do with them?”
NonSens 0
NonSeiz 2 And then every business manager is left on their own.
NonTrans 2 Excess capacity as far as intensive care places were concerned.
RegHealthLev Sens 0
Seiz 4 So, I talked about working under uncertainty and how to deal with it. So, we put a lot of energy into
what you said as well, that “Ok, now it’s like this. There is a lot that is unknown here, but we still must
function. But we must be prepared to change. Today this applies. But these are uncertain facts. And
everyone must be prepared for them to change by tomorrow.”
Trans 4 Well, my employees have been there (at the hospital).
NonSens 0
NonSeiz a 11 At that time, we had not established local crisis management in [name of city], because… well, for
various reasons, there was not such a… lack of knowledge in this matter of what is called crisis man-
agement, or special healthcare management, that you have not really understood the point of it.
NonSeiz b And that then led to confusion, diculties in the ow of information. Local level didn’t really under-
stand where the decisions are made. So, it became very unclear. And it’s about the fact that far too
many people didn’t understand how this was supposed to work.
NonTrans 4 …but I still can’t interpret it as anything other than an active decision.
RegLev Sens 35 So, when I say that we create a common situational picture, then we try to capture as many aspects
as possible, in terms of sta loss, patient inow, occupancy rate. So, what you need to capture, but
also [need to] forecasts from infection control, forecasts from healthcare hygiene, forecasts from
logistics.
Seiz 48 The area of crisis preparedness is very much regulated by law, which is the task of various authorities
to prepare for crises. And it is based on risk and vulnerability analysis and will land in a crisis and
disaster medicine plan that we will have with a crisis management organization, with dierent roles
that are determined that will be trained and practiced. That is the basic idea.
Trans 29 I understood that they could set up lab analysis capabilities. So, we requested that from them back
in March, or something like that, I think. Yes. And that meant that they… And they’re a bit quick-
footed too, here locally. It didn’t take a lot… weren’t forced by a lot of agreements, but they started
and planned their… And then we were able to direct it to be used out in the municipalities and in
primary care to a much greater extent, I think, than anyone elsewhere.
NonSens 5 There was very little information that went to regional special healthcare management.
NonSeiz 22 If you talk from a crisis and disaster medicine perspective, it is not ok that such a large actor as a
region does not have the ability to ensure that you follow your plans and that you have trained and
practiced personnel. So that was a big shortcoming that we saw early on.
NonTrans 9 The concern is that when you join a crisis management organization, you take o your old hat and
put on a new hat and step into a dierent role. And that role is clearly described how it should
act. And if everyone had done that, then I think there would have been greater clarity in the entire
organization.
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Rosenbäck and Eriksson BMC Health Services Research (2024) 24:759
Fig. 3 Number of excerpts/organization level
Fig. 2 Number of excerpts/group of managers
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Rosenbäck and Eriksson BMC Health Services Research (2024) 24:759
Fig. 5 Excerpt/organization level, case A
Fig. 4 Number of interviewees excerpts for each group of managers/organizational level
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Rosenbäck and Eriksson BMC Health Services Research (2024) 24:759
All DCs were, according to the managers narratives,
present at the department level in case A and the occur-
rence of high seizing impeded the suboptimizing of the
local unit over the whole organization that could occur
with strong sensing and transformation [18, 29]. More-
over, seizing, which Furnival et al. [12] mean is advan-
tageous when working with continuous development,
might be a sign of a higher need of continuous develop-
ment in a long-lasting pandemic than in a short crisis.
e highest occurrence of sense in case A was found at
the department level and led to high expectations of seiz-
ing and transformation, which according to our research
was not delivered from the regional or national level,
which is aligned with situations described by other schol-
ars [8, 18, 29]. In fact, the quota between the number of
interviewees’ excerpts/framework categories of seizing
and non-seizing decreases with higher organization level
in case A, which suggests that the top management was
less dynamic. e low sense at the regional level made
the mistrust high, possibly because that they appeared
arrogant and unwilling to change, in line with the study
of Furnival et al. [12]. When the RCC was overtaken by
the hospital managers, this production group made the
organization more dynamic, and the sense of the situa-
tion was more easily transferred to the regional level.
Later, when the politicians started to interfere with the
organizations, the cooperation between the hospitals
decreased, which resulted in suboptimization of the local
units in the organization, which decreased the overall
organizational eciency, as also expressed by Ljungquist
[29].
However, the situation in case B, where the non-ocial
department management group originated in the absence
of a strong hospital manager or a working LCC, became
dierent. e department management group sensed the
situation and transformed accordingly, which according
to Ljungquist [29] and Teece et al. [19] research could
cause suboptimization of the regional cooperation as well
as high barriers between the department managers and
the regional healthcare management. However, because
the sense was high at the regional level the barriers
between the department manager’s group and regional
management were not seen. e chief hygiene physician
at regional level early sensed the situation, by his inter-
national network and reacted fast, transformed, and
successfully reduced the infection rate also outside the
hospital. His placement at the top of the organization, far
away from the production, was of a less hindrance due to
his and his team members’ high frequency and trustful
contacts with the organization’s lower management lev-
els. e lower occurrence of sensing in case B, except for
the regional level, is probably the cause of the decreased
condence between the organization levels, which is in
line with Furnival et al. [12]. Moreover, Ljungquist [29]
and Teece et al. [18] discuss that a higher occurrence
of seize could mean higher barriers and mistrust both
Fig. 6 Excerpts/organization level Case B
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Rosenbäck and Eriksson BMC Health Services Research (2024) 24:759
between local units and the units and top management,
which is also recognized in case B. e low sense at
healthcare level made the mistrust even higher possibly
due to the appearance of arrogancy and unwillingness to
change [12].
When the knowledge increased, and the COVID-
19 infections changed, the transformation continued
in cycles, as Eriksson et al. [20] highlighted in their
research, for example when the surgery started stopped
and restarted several times in case A. Another cyclic
change occurred in case B when the launching of a new
infection department failed due to problems with sta-
ing. is proved an important learning point for the next
step of transformation when instead an old inpatient unit
was transferred, which follows the experimentation work
described by Pablo et al. [13].
e information ow during the COVID-19 pandemic
was enormous especially in case A with the higher and
earlier breakout and the recommendations often changed
and made the information channels break down. Using
integrated information from dierent sources from dif-
ferent management levels like Ohrling et al. [8] suggest
could probably also in our case reduce the amount of
information and reduce misunderstandings.
e contingency plans, which the regional crisis
management at both cases insisted on following were
designed to manage a short-term crisis and seemed to be
built according to a static and hierarchical SuC. However,
this and other studies reveal a need for more distributed
management in a long-term disasters [4, 7, 8]. Reality
often diers from beforehand plans and if the plans are
followed too strictly the organization will be static and
not able to follow the dynamic changes [32]. e regional
level’s insisting on sticking to the contingency plan
excluded them from supporting the pandemic. Moreover,
in case B the contingency plan caused a lot of argumen-
tations about the plan instead of looking at the reality
and developing a sound cooperation between the levels
in the extended work caused by the pandemic. However,
the regional healthcare level in case B insisted on keep-
ing normal management routines, but because of the low
sensing at regional healthcare level in case B this did not
function. Whereas in Case A this approach worked well.
e focus on following the plan in Case B possibly made
the management levels less sensitive to the situation [12].
e suggestion from Eisenhardt et al. [11] to have “rou-
tines to learn routines” could build a more successful
disaster management in a next pandemic.
Concluding discussion multiple case study
Case A had at department and hospital level well devel-
oped and synchronized DCs and managed the high
pressure of the COVID-19 pandemic successfully, as
foreseen by other scholars [12, 33]. e managers in case
A described that they and their employees became more
self-condent and took decisions independently, which
is in line with the reasoning by Ohrling et al. [8] about
decision space as a success factor during the COVID-19
pandemic. e cooperation and trust at department and
hospital levels increased during the pandemic, which is
in line with research by Ohrling et al. [8] and Pablo et al.
[13]. Higher management levels lacked developed DCs,
which grew mistrust between the hospitals in the region
and the regional management.
However, in case B the seizing and non-seizing were
the strongest capabilities, which could be the sign of a
concentration and discussion of routines in the over-
all organization rather than supporting a transforming
at department level to save lives. e seen self-criticism
in case B could be a sign that the management was mal-
functioning, and they were looking for what was wrong
at their position. To conclude, Case B coped well with the
pandemic, however, they might have had problems suc-
ceeding if encountering the higher infection rate, such as
in case A.
Conclusion/relevance/contribution
e method, using a deductive analysis of analyzing with
DC and SC, dierent management groups and organiza-
tion levels, has successfully been used when explaining
the crisis management in healthcare organizations dur-
ing a long-term disaster as a pandemic. is novel way of
analyzing data facilitated a structured and detailed expla-
nation of organizational behavior and has not been found
in earlier research.
e case hospitals studied showed major dierences,
when evaluated with the promising DC-method; In case
A the hospital manager was considered by the lower-
level managers to be brave and strong and supported the
professions sensing, seizing and transformation at the
department level. Due to the information developed at
profession level, the sensing did not reach the regional
disaster management, thus could not appropriately sup-
port the transformation and their power was reduced
in favor of the normal management and cooperation
between hospital managers in the region. However, in
case B, where the contingency plans stated LCC were
not started, the hospital suered from lack of manage-
ment and started their own department manager group
to be able to take care of the incoming patients. e seiz-
ing was high in the organization with the department
management developing their own routines, while the
regional level and regional hospital level got stuck in dis-
cissions about the best choice of management between
disaster management or normal management. However,
both cases did use DC’s and the capabilities were syn-
chronized enough to withstand the COVID-19 pandemic
at the level needed.
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Rosenbäck and Eriksson BMC Health Services Research (2024) 24:759
e managerial contributions from thisresearch are
in line with other scholars.Crisis management in a pan-
demic need to be more distributed and dynamic and this
view need to be the starting point for top management
to develop a contingency plan specialized for pandemics.
e pandemic plan should manage to develop routines
according to the demand from an ongoing pandemic,
develop and use DC’s in the whole organization to sup-
port the profession to sense, seize and transform. More-
over, building professional networks could help reaching
an early sensing, where two examples are, the one that
made case A start early to build capacity and the one at
case B that reduced the infection rate, which will give
an opportunity to save lives. In a long-lasting pandemic,
cyclic and continuous improvement seems to be needed.
Limitations and future research
A limitation of this paper,, is its potential to generalize
the ndings from two Swedish hospitals’ case studies
to other healthcare facilities or dierent organizations.
THowever, this limitation is somewhat outweighed by
the successful intention of obtaining rich data coupled
with an in-depth analysis based on interviews with dif-
ferent manager groups’ view of the management at
dierent organizational levels, which contributes an
encompassing view of the applicability of the DC frame-
work in health care. Nevertheless, additional research is
needed to enhance the promising method’s eectiveness
and support its broader development. It is highly recom-
mended to conduct further studies in this area, expand-
ing its application to diverse types of organizations and
environments. It would be interesting to supplement
the data with further inquiries about the current appli-
cation of lessons learned during the pandemic. Espe-
cially what was learnt about the possibilities for exible
organizations to make multiple transformation to fol-
low the changing environment during av pandemic. Not
just that they transformed but also why some managers
was able to build trust and avoid power games and nega-
tive story telling in the organisation. To summarize it is
important that the insights gained from the COVID-19
pandemic should be carefully rened to strengthen disas-
ter management, thus improving our readiness for future
pandemics.
Abbreviations
DC Dynamic Capabilities
R Resilience
SC Static Capabilities
SuC Surge capacity
DC and SC Framework categories
Sens Sensing
Seiz Seizing
Trans Transformation
NonSens Non-Sensing
NonSeiz Non-Seizing
NonTrans Non-Transformation
LCC Local command centre
RCC Regional command centre
DepLev Department level
RegHealthLev Regional healthcare level
HospLev Hospital level
RegLev Regional level
ICU Intensive care unit
PPE Personal protective equipment
Acknowledgements
Professor Björn LantzProfessor Ann SvenssonAssociated professor Peter Rosén.
Author contributions
R.R initiated the paper, planned, and collected the empirical data. Both
authors conceptualized, analyzed, and wrote the paper. K.E. contributed with
guidance and improving readability of the paper.
Funding
Not applicable.
Open access funding provided by University West.
Data availability
No datasets were generated or analysed during the current study.
Declarations
Ethics approval and consent to participate
The Swedish ethical legislation (Law (2003:460) om etikprövning av forskning
som avser människor) outlines that in cases where a research project collect
data that in the sense of the law concerns “sensitive personal data” then the
project requires approval by the national ethical review authority, Sensitive
personal data is dened in the legislation on the bases that it concerns data
on the research subjects according to the following: • racial or ethnic origin •
political views • religious or philosophical beliefs • membership of trade unions
• health • sexual orientation or sexual life • personal data on violations of the
law. Ethical legislation and the requirement for ethical review also include
research that involves a physical intervention on people or methods aimed
at inuencing the research subjects physically or mentally. In this study, no
sensitive personal data, of the nature mentioned above, has been collected.
Nor has the research been carried out using methods aimed at inuencing the
research subjects or involving any form of physical intervention on humans. In
the interviews conducted, no questions have been asked related to sensitive
personal data. The informed consent was obtained from all study participants.
There were no subjects under 16. The informed consent obtained was written.
All research subjects have before the interviews received information about
the study, have received the interview guide in advance, and have consented
to participation in writing, in accordance with the recommendations given
by the Swedish Ethical Review Authority. The research has essentially been
carried out in accordance with the ethical guidelines formulated in “The
European Code of Conduct for Research Integrity”, ALLEA – All European
Academies (Revised Edition 2017). The research presented in the current
article does not fall within the scope of the Swedish Ethical Review Act and
therefore cannot be ethical reviewed in accordance with the law. This has also
been conrmed by the secretary of the Ethics Review Authority in Sweden.
The secretary of the Ethics Review Authority in Sweden informed that the
committee would not take the approval into consideration due to the lack of
collection of sensitive personal data in the study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Author details
1Department of Engineering Science, University West, Gustava Melins
gata 2, Trollhättan 46132, Sweden
Received: 4 December 2023 / Accepted: 12 June 2024
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Rosenbäck and Eriksson BMC Health Services Research (2024) 24:759
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