The Paradox of Intervening in Complex Adaptive Systems Comment on "Using Complexity and Network Concepts to Inform Healthcare Knowledge Translation".

This commentary addresses two points raised by Kitson and colleagues' article. First, increasing interest in applying the Complexity Theory lens in healthcare needs further systematic work to create some commonality between concepts used. Second, our need to adopt a better understanding of how these systems organise so we can change the systems overall behaviour, creates a paradox. We seek to manipulate systems that self-organise and follow their own internal rules. Although, our actions may impact and indeed meet some of our objectives, system behaviour will always emerge with unpredictable consequences. Likewise, outcomes at the aggregated level of the system never reaches an optimal point as defined by the 'external controller.' Kitson and colleagues' theoretical model may struggle to resolve the paradox of gaining control over the multiple knowledge translation (KT) systems covered by the model, because theoretically these systems retain control under the principle of self-organisation. That is not to suggest that individual agents cannot influence system dynamics just that the desired outcome cannot be guaranteed. Indeed, for systems to change they will need strong incentives.

Applying GRADE-CERQual to qualitative evidence synthesis findings-paper 6: how to assess relevance of the data.

BACKGROUND: The GRADE-CERQual (Confidence in Evidence from Reviews of Qualitative research) approach has been developed by the GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group. The approach has been developed to support the use of findings from qualitative evidence syntheses in decision-making, including guideline development and policy formulation. CERQual includes four components for assessing how much confidence to place in findings from reviews of qualitative research (also referred to as qualitative evidence syntheses): (1) methodological limitations, (2) coherence, (3) adequacy of data and (4) relevance. This paper is part of a series providing guidance on how to apply CERQual and focuses on CERQual's relevance component. METHODS: We developed the relevance component by searching the literature for definitions, gathering feedback from relevant research communities and developing consensus through project group meetings. We tested the CERQual relevance component within several qualitative evidence syntheses before agreeing on the current definition and principles for application. RESULTS: When applying CERQual, we define relevance as the extent to which the body of data from the primary studies supporting a review finding is applicable to the context (perspective or population, phenomenon of interest, setting) specified in the review question. In this paper, we describe the relevance component and its rationale and offer guidance on how to assess relevance in the context of a review finding. This guidance outlines the information required to assess relevance, the steps that need to be taken to assess relevance and examples of relevance assessments. CONCLUSIONS: This paper provides guidance for review authors and others on undertaking an assessment of relevance in the context of the CERQual approach. Assessing the relevance component requires consideration of potentially important contextual factors at an early stage in the review process. We expect the CERQual approach, and its individual components, to develop further as our experiences with the practical implementation of the approach increase.

Application of simplified Complexity Theory concepts for healthcare social systems to explain the implementation of evidence into practice.

AIM: To examine the application of core concepts from Complexity Theory to explain the findings from a process evaluation undertaken in a trial evaluating implementation strategies for recommendations about reducing surgical fasting times. BACKGROUND: The proliferation of evidence-based guidance requires a greater focus on its implementation. Theory is required to explain the complex processes across the multiple healthcare organizational levels. This social healthcare context involves the interaction between professionals, patients and the organizational systems in care delivery. Complexity Theory may provide an explanatory framework to explain the complexities inherent in implementation in social healthcare contexts. DESIGN: A secondary thematic analysis of qualitative process evaluation data informed by Complexity Theory. METHOD: Seminal texts applying Complexity Theory to the social context were annotated, key concepts extracted and core Complexity Theory concepts identified. These core concepts were applied as a theoretical lens to provide an explanation of themes from a process evaluation of a trial evaluating the implementation of strategies to reduce surgical fasting times. Sampled substantive texts provided a representative spread of theoretical development and application of Complexity Theory from late 1990's-2013 in social science, healthcare, management and philosophy. FINDINGS: Five Complexity Theory core concepts extracted were 'self-organization', 'interaction', 'emergence', 'system history' and 'temporality'. Application of these concepts suggests routine surgical fasting practice is habituated in the social healthcare system and therefore it cannot easily be reversed. A reduction to fasting times requires an incentivised new approach to emerge in the surgical system's priority of completing the operating list. CONCLUSION: The application of Complexity Theory provides a useful explanation for resistance to change fasting practice. Its utility in implementation research warrants further attention and evaluation.