It is highly likely that a pragmatic approach will not always support the application of complexity theory in healthcare implementation research. Complexity theory is an interdisciplinary theory that grew out of systems theory in the 1960s. 2008;10(3):401â19. 1998;49(3):200â9. While inputting the data to rerun a previous weather model, he abbreviated one number from 0.50612 to 0.506 to save time. State budget submission 2015â16. The physiological parameter in question will then display variability which rather than being purely random will be seen to display self-similarity over time or in other words show temporal fractal variation. Herein, we describe our experiences implementing and evaluating a health services innovation in the form of simulation modeling. This can allow information to spread more rapidly through such a system, i.e. Recent applications of complexity theory to healthcare have branched out into more qualitative methods, including ethnography, case studies, caseâcomparison or time-series analyses, and social surveys [10, 18, 20, 34]. We then explore the possibilities of using pragmatism to provide the missing epistemological foundation required to structure the study of social complexity theory in healthcare. We then argue for the potential of pragmatism as an epistemic foundation for the methodological pluralism currently found in complexity research. Edward Lorenz was a meteorologist at the Massachusetts Institute of Technology who in 1961 was trying to develop a computer model to allow accurate long-range weather forecasting. These issues lead us to a key consideration â in light of these debates in social complexity theory, how can complexity researchers make transparent and consistent decisions regarding research methodology. Fundamental to this approach is the requirement that the problem being examined is a linear system (TableÂ 1). For implementation science, the merging of complexity theoryâs deep focus on contextual interactions and emergent outcomes, coupled with pragmatismâs perspective on knowledge translation, provides a way of fostering collective implementation learning [16, 46], without bowing to the need for research generalizability. Kirchhof P, Meseth N. A survey on the use of simulation in German healthcare. For Permissions, please email: firstname.lastname@example.org, Examples of complex systems in clinical medicine, Implications of complexity theory in healthcare management, Output is reproducible over time for a given inputÂ. BMC Med 16, 94 (2018). Case study research: the view from complexity science. At face value, the arguments of complex realism seem not incommensurate with pragmatism ; however, we will leave a detailed comparison of these two approaches to future scholars. https://doi.org/10.1186/s12916-018-1087-6, DOI: https://doi.org/10.1186/s12916-018-1087-6. Oxford: Oxford University Press; 2014. J Simulation. The project involved multiple nested systems, namely the researcher group, SLG, MHS, and the state and federal governments. However, these approaches have had limited success in healthcare, with low rates of modeling implementation [22,23,24] often being attributed to the lack of good data from which to build models [25,26,27,28]; the complex social and organizational context of healthcare, with multiple intersecting and nested stakeholder groups [1, 2, 25, 27, 29, 30]; and the high expertise and time costs of creating sufficiently complex, ecologically valid models [25,26,27,28,29, 31,32,33]. Likewise, the boundaries of the implementation context proved hard to define. By viewing an organization as a complex system, then a greater focus is placed upon the connections between individual components, how their interactions may lead to the emergence of novel, unpredictable outcomes, and the understanding that human behaviour shows âattractor patternsâ10 whereby individuals will tend to default to a certain set of attitudes which can be misconstrued as resistance to change. Paradigms lost and pragmatism regained: methodological implications of combining qualitative and quantitative methods. There are two pervasive issues with defining a social system, nesting and fuzzy boundaries, both of which are implicated in, and complicate, complexity research . KL was responsible for the development of the ideas expressed, and drafting of the article. In our project, this led to a fundamental shift in the implementation evaluation from a focus purely on the participant experience, to one that included the experiences of the researchers. Byrne DS. Pragmatism calls for choices of research questions and methods to be driven by the social purpose of the research, not the other way around [42, 45, 51]. Any solutions generated would then be shared with the organization as a whole. Correspondence to Pino - logical board game which is based on tactics and strategy. Political Studies. Given that Byrne et al.  identified agency as a key defining feature of social complexity theory, and a key target for research, how are we to study it, considering these definitional issues? Complexity theory has been used to study different aspects of healthcare, including management , continuity of care , nursing , and decision-making . In fact, more than half of US consumers do not understand how to navigate the current healthcare landscape because it is so complex, reveals Accenture research. We found the commonalities between pragmatism and complexity theory to be striking. 2009;57(4):699â719. Therefore, the experiences and reflections of the researchers became pivotal in understanding the projectâs implementation after the organizational restructure. Thus, rather than rejecting the reductionist approach of classic complexity theory , pragmatism allows for the contribution of both quantitative and qualitative methods in addressing the research question. Geoforum. An example of this might be the response of blood glucose to a dose of exogenous insulin.2 Frustrations arise however when the problem we wish to examine is not a simple linear system but rather shows non-linear behaviour (TableÂ 1). All modes of experience, including research, are treated as interventions . The appropriation of complexity theory in health care. Complexity Theory is primarily made up of 4 different theories that are used for modeling and analyzing complex systems. Emergence. Yet, ques-tions are increasingly being asked of whether the MRC guidance does enough to address the challenges involved in evaluating complex interventions [2â6]. This tool allows us to measure the degree of variability within a data set obtained over a given period of time. ArticleÂ These approaches emerged from the seminal work of Byrne , who translated many of the concepts of complexity theory into the social realm. The evaluation component of the project received reciprocal approval by the Human Research Ethics Committee at Monash University (CF14/48â2,013,001,967). Lane DC, Monefeldt C, Husemann E. Client involvement in simulation model building: hints and insights from a case study in a London hospital. 2013;64(2):157â68. Greene JC, Hall JN. ArticleÂ Complexity theory in organization science: seizing the promise or becoming a fad? The nurse has theoretical supports for holistic nursing, the caring of the whole human being embedded in a vast array of systems. Consequently, some simulation models in development were no longer of immediate relevance to the participants, while other issues that came to the fore, such as the redrawing of clinical catchment areas, did so with time-decision horizons not compatible with the development time costs of discrete event simulation. Herein, we described a too-familiar experience in health services implementation â a constantly changing implementation contextâ followed by a discussion of how complexity theory and pragmatism provide complementary approaches to the difficulties in evaluating such implementations. how to improve operating theatre efficiency). Unpredictability: The behavior of a CAS cannot be predicted due to its non-linearity, sensitivity to initial conditions, and historicism. Herein, we discuss our recent experiences implementing and evaluating healthcare simulation modeling in a large Australian health service. Google ScholarÂ. We then began the data analysis with a critical incident approach to identify turning points in the system, which were investigated further with thematic analysis. Plsek PE, Greenhalgh T. The challenge of complexity in health care. Privacy Melbourne: VHA; 2015. Output for the same input value may not be constant over time, Events occur both sequentially and simultaneouslyÂ, Each variable within a linear system acts independently of anotherÂ, Each component of the system influences the other, i.e. We present this article in that spirit and hope that our contribution sparks further discussion about the potential collaboration of pragmatism and complexity theory in informing implementation science and health services research. Embeddedness/nested systems: CASs are embedded within a wider context and other CASs. 2001;3(1):5â23. This social healthcare context involves the interaction between professionals, patients and the organizational systems in care delivery. The 3-year research project aimed to develop simulation models to provide strategic decision support for a senior leadership group (SLG) in a large public mental health service (MHS) in Australia. 2015; https://www.smh.com.au/healthcare/innovative-mental-health-program-falling-victim-to-funding-freeze-20150423-1ms0wm.html. Arndt M, Bigelow B. Commentary: the potential of chaos theory and complexity theory for health services management. Sanderson I. As one of the key epistemologies for mixed method research, pragmatism offers a more structured approach to mixed methods research . Rockwell Automation. In order to evaluate the effect of the simulation modeling on the decision-making processes of the SLG, we attempted to use interviews to establish a baseline picture of the relationships, mental models, and expectations of the individual participants. Extensive practical applications of the theoretical concepts outlined in these articles have been described and published, and support consideration of more widespread application (2-5). Washington, DC: National Institute for healthcare management foundation and National Committee for. © 2020 BioMed Central Ltd unless otherwise stated. Cordery A. 2000;25(1):35â8. Emergence. 2nd edn. Sensitivity to initial conditions and historicism: Future agent actions are affected by past changes in the system, leading initial conditions to exert a strong influence on system behaviors. Thus, a key question facing complexity researchers is which systems should form the core of the analyses, and how many levels of analysis are sufficient to provide a complete understanding of the system. doi:https://doi.org/10.1109/WSC.2009.5429190. For example, Bar-Yam  built his analysis of the entire US healthcare system around an organizational definition of complexity, in which complex organizations (such as those engaged in healthcare practice) were distinguished by their â¦ This book illustrates the relevance of chaos and complexity theory to healthcare organisations, public health, clinical governance and the consultation. Holland JH. Key concepts in complex systems theory presented in pictures. Paley J(1), Eva G. Author information: (1)Department of Nursing and Midwifery, University of Stirling, Stirlingshire, United Kingdom. We begin by describing the initial aims and scope of the healthcare simulation modeling project, which provides the practical case study for this article. For example, as the state government signaled an increased interest in infrastructure planning for population growth through a series of discussion papers, the researchers refocused their modeling efforts on the area. It draws from research in the natural sciences that examines uncertainty and non-linearity. Both the SLG and the researchers exhibited adaptation and co-evolution, changing strategic priorities and approaches based on the changes in context. Pragmatism: a guide for the perplexed. Various methods exist to analyse HRV (TableÂ 3), all of which at present are experimental8 but of particular interest is the statistical technique of approximate entropy (ApEn). Control was distributed, with members of the SLG holding responsibility and autonomy over the running of different programs within theÂ MHS, researchers exerting control over the implementation activities, and politicians, bureaucrats, and senior healthcare managers making policy and funding decisions that affected the operating context of the SLG and researchers. This allowed us, as the context changed, to maintain the same focus for the project, but change and expand the evaluation focus from the experiences of the SLG to include, for instance, adaptations of the researchers to the changing stakeholder needs. 2005;15(5):669â85. Fuzzy boundaries: System boundaries are permeable and hard to define. Health Care Manag Rev. University Park: Pennsylvania State University Press; 2012. The excellent series of articles on complexity science in health care (1) highlights a decade long quest to bring chaos and complexity science to medicine, health and health care delivery (2). In: Applying complexity theory. California Privacy Statement, It explains the terms and ideas at the heart of complexity, the unfamiliar science behind it, and how it applies to the real world. What can we learn of value through this process? Despite beginning with a focus on the MHS as the key implementation context and the SLG as the key agents, it emerged through the course of the evaluation that the context of individual researchers (e.g., contract changes, relocations, life events), researcher team dynamics, and the wider government contexts exerted very significant influences on the trajectory of the project. Data already collected will still be used in the analysis unless the discontinuing participant specifically requests that it be removed. As we discovered in our efforts to develop simulation models of mental health patients, a patient may pass through multiple different practices, hospitals, and even districts over an episode of care, interacting with scores of individual agents, each operating in a different context. Proceedings of the 29th Conference on Winter Simulation 1997. Goldstein J. Being pragmatic about healthcare complexity: our experiences applying complexity theory and pragmatism to health services research Katrina M. Long1*, â¦ When a true consensus exists as to what constitutes best practice (i.e. J Oper Res Soc. Several studies have now demonstrated a correlation between loss of heart rate variability (HRV) and various disease states including congestive cardiac failure and MODS, the same pattern is also seen in normal human ageing3â7 (see Fig.Â 1 where HRV on the y-axis changes over time on the x-axis). 2008; Ruwhiu D, Cone M. Advancing a pragmatist epistemology in organisational research. In addition to this, there must be effective feedback mechanisms in place to allow solutions to be shared throughout the organization. We will return to the case study throughout the article to demonstrate some of our theoretical arguments. In healthcare, the NHS is a complex adaptive system. J Health Serv Res Policy. It is in these situations that adopting an alternative viewpoint, informed by complexity theory, may allow more productive solutions to emerge. While survival in biological systems can be treated as a key driver and outcome measure, the survival of organizations, systems of operations, and even ideas are less necessary, or observable, in social systems . Discussion: Chaos and Complexity Theory in Health Care. Furthermore, a derivative of this method, Cross-ApEn, allows us to quantify the degree of connectivity between two separate data sets, potentially giving an even more accurate insight into the degree of connectivity within the system as a whole.4 A further advantage of the ApEn method is that it can be performed on a relatively small data set (100â900 data points). Complexity theory as an approach to explanation in healthcare: A critical discussion. Oxford University Press is a department of the University of Oxford. Complexity theory has increasingly been incorporated within healthcare research , most commonly to conceptualise variables for data analysis or for interpreting findings. However, several more exist within the health service system, including general practices, practice networks, hospitals, hospital networks, and national programs . Public Manage Rev. Seeing beyond this complexity, successful health leaders recognize, leverage and nurture the connections that will help them intentionally drive their system. Below we explore key synergies (BoxÂ 2). The initial scope included a model of the whole MHS, with the option of additional scenarios of specific interest to managers. No 26 of 2014. http://www8.austlii.edu.au/cgi-bin/viewdb/au/legis/vic/num_act/mha201426o2014174/. The project was approved by the Human Research Ethics Committee of the partner Mental Health Service, with approval from 5 December 2013 until 9 January 2019. A CAS is formally defined as âa collection of individual agents with freedom to act in ways that are not always totally predictable, and whose actions are interconnected such that one agentâs actions change the context for other agentsâ (, p. 625). For implementation and evaluation, this fusion of approaches has significant implications: A focus on researcher and stakeholder agency, in shaping the direction and outcomes of interventions. Thus, system boundaries are often arbitrary, with implementation and evaluation researchers required to balance descriptive sufficiency with practicality. BMC Medicine One of the more promising alternatives comes from Byrne et al.âs  application of complex realism to complexity theory. Clin Investig Med. 2015;66(4):602â14. 2nd edn. Rather, it allows for the flexible use of multiple methods to capture insights in a complex environment, which may later be interpreted using a range of frameworks. Different authors have posited different typologies of complexity science to address this lack of coherence (e.g., [1, 8, 18, 38]), with a clear delineation emerging between the complexity theory of things (classic complexity theory, e.g., cells, animals, atomic particles) and that of humans (social complexity theory). So are hospitals, general practices, diseases and patients. A view from different directions. It occurs when a biological system moves from a highly ordered state (health) towards a less ordered state (disease or ultimately death)Â, Relatively simple technique whereby the standard deviation of a collection of RâR intervals is used to generate a measure of variability (as standard deviation is equal to the square root of variance from the mean).Â, A time domain analysis can be converted into a frequency domain analysis (FDA) via a Fourier transform. Two of these researchers were existing members of the SLG, and brokered research access with the MHS. Complexity theory offers an alternative approach to quantifying the degree of physiological derangement in multi-system disorders such as sepsis. Whether we are experts on complexity theory or not (and most of us are not), we know in our bones that delivering high-quality services in such a complex environment will not be achieved merely by following a standard operating procedure, inserting the results of a randomised controlled trial or adopting the seven habits of highly successful people. Being pragmatic about healthcare complexity: our experiences applying complexity theory and pragmatism to health services research. This idea of valuing the applied over the theoretical is mirrored in the philosophy of Pragmatism. However, the experience of interviewing suggested that disclosureÂ levels varied significantly between participants, influenced by their perceptions of the vested interests of the research group, and the existing personal relationships between researchers and SLG members. (2009). Yet the impact in hard dollars on payers is news. Qual Health Res. International Journal of Nursing Studies 48, 269â279. a system is always trying to move from a highly ordered state to a less ordered state. 2010;15(1):59â61. This low healthcare system literacy is creating an estimated â¦ The epistemology of social complexity theory, on the other hand, is unclear. In: accelerating quality improvement in health care: strategies to accelerate the diffusion of evidence-based innovations. Miles, A. However, empirical evidence that this lens has been useful in designing health care remains elusive. PubMedÂ Google Scholar. The redefinition of local rules as human instincts, constructs, and mental models has also been subject to debate [5, 39]. Furthermore, a certain number of these characteristics may present us with novel opportunities to better understand and even predict the outcome in conditions characterized by non-linear behaviour. Fone D, Hollinghurst S, Temple M, Round A, Lester N, Weightman A, Roberts K, Coyle E, Bevan G, Palmer S. Systematic review of the use and value of computer simulation modelling in population health and health care delivery. However, the organizational restructure of the SLG affected not only access to participants for evaluation data collection, but also affected the researchersâ approach to the simulation modeling development and implementation. Paley J. Katrina M. Long. Quality in Health Care. If social complexity theory does represent a purely descriptive epistemology, which makes no claims to the translation of findings across contexts, then its ability to contribute to implementation science may be minimal. While pragmatism does hold that knowledge is not completely generalizable, it also argues that imported knowledge can play a role in shaping observation and perception and in suggesting possible solutions to the current problem . Indeed, the mismatch between this hypercomplexity  and the dominant mechanistic conception of healthcare [5, 6] has been used as a key explanation for the lack of implementation of evidence-based medicine [4, 7] and healthcare innovation [6, 8,9,10]. volumeÂ 16, ArticleÂ number:Â 94 (2018) Adaptation and co-evolution: Agents and systems evolve together, reacting to changes in the context to ensure optimal functioning and survival. 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