An organisation working mainly reactively instead of proactively: a qualitative study of how frail users of home care services and their next of kin experience crises.

BACKGROUND: Frail people receiving home care services face an increased risk of developing crisis, which can result in adverse events, coercive measures, and acute institutionalisation. The prevalence of frailty is expected to increase due to the ageing population in most countries. However, our knowledge of the process leading to crises among frail community-dwelling patients remains limited. The aim of our study was to explore how users of home care services and their next of kin experienced crises and how these crises were approached by home care services. METHODS: A qualitative explorative design with 21 interviews was conducted. We explored crises within the last year that had led to an acute institutionalisation (hospital or nursing home) or to an unstable situation with high risk of institutionalisation. Systematic text condensation (STC) was used to analyse the data. RESULTS: Our findings are summarised into one overarching theme; an organisation working mainly reactively instead of proactively, which is supported by four subthemes: (1) insufficient communication-a determinant of crises, (2) the lack of a holistic approach, (3) a sense of being a burden, and (4) the complexity of crises. The reactive approach is demonstrated in the participant's experience of insufficient communication and the lack of a holistic approach from the service, but also in the user's sense of being a burden, which seems to be reinforced by the experienced busyness from the staff in the home care services. This reactive approach to crises seems to have contributed to difficulties in detecting the various stressors involved in the complex process leading to crisis. CONCLUSIONS: Our findings suggest that home care services tend to be characterised by a reactive approach to rising instability and the development of crises for users. This can be interpreted as an emergent property of the organisation and the adaptation towards exceeding demands due to insufficient capacity in health care services. We recommend the use of multicomponent care programmes comprising interdisciplinary case conferences in home care services to implement a cultural change that can shift the service from a reactive, fragmented, and task-oriented approach to a more proactive approach.

Integrated care systems in England: the significance of collaborative community assets in promoting and sustaining health and wellbeing.

Until recently the healthcare system in England was based on a commissioning/provider model. However, this has been replaced with an Integrated Care Systems (ICSs) approach, aimed at improving health and wellbeing and reducing inequalities through local collaborative partnerships with public sector organizations, community groups, social enterprise organizations and other local agencies. Part of this new approach is an emphasis on the role of community assets (i.e., local resources), that are considered integral to promoting positive health and wellbeing outcomes. This paper presents research from a series of three research studies on "community assets" conducted in the East of England within a newly established ICS. Based on analysis of qualitative data highlighting the lived experience of community asset members, this paper shows the positive wellbeing impact on vulnerable community members that assets provide. Further insight on the local impact and the collaborative nature of the research is provided suggesting that new asset-based approaches recognize the social determinants of health. This presents a shift away from positivistic linear approaches to population health and wellbeing to a new non-linear collaborative approach to addressing health inequalities and promoting wellbeing. The authors suggest that exploring this through a complexity theory lens could illuminate this further. Finally, the authors warn that while community assets have an important role to play in empowering citizens and providing much needed support to vulnerable and disadvantaged communities, they are not a substitute for functioning funded public sector services that are currently being undermined by ongoing local governments funding cuts. As such, while community assets can help ameliorate some of the negative effects people experience due to economic, structural and health disadvantages, only a more fair and more equal distribution of resources can address growing health inequalities.

Behaviour settings, situated action and complexity theory.

In spite of the fact that Roger Barker's groundbreaking research was acclaimed sixty years ago by his contemporaries, it has all been but forgotten among recent generations of psychologists. However, in the wake of developments in dynamical systems and complexity theory, its value for understanding psychological processes in everyday life should be recognized anew. Barker's naturalistic studies of children's daily behaviours in their community revealed that their actions which initially seemed only marginally predictable at the level of individual interaction were, in fact, reliably context-dependent. These results led to the discovery that there are nested structures operating in human habitats as there are throughout the natural world. Barker's discovery of emergent eco-psychological structures, behaviour settings, that are generated from interdependent actions among individuals in the course of everyday life has yet to be fully appreciated because of the continuing dominance of linear, mechanistic models. His recognition of nested systems operating in human habitats is finally coming into its own with the current metatheoretical shift in psychology embracing dynamical models. Additionally, new understanding arises from the consideration of convergent individual developmental histories of situated action and their role in maintaining the historical dimensions of behaviour settings. This article is part of the theme issue 'People, places, things and communities: expanding behaviour settings theory in the twenty-first century'.

El embarazo gemelar monocorial desde la perspectiva de la teoría de la complejidad / Monochorionic twin pregnancy from the perspective of the theory of complexity

En la práctica, es muy frecuente asociar las gestaciones gemelares monocoriales (MC) con embarazos complejos o complicados, utilizando ambos términos en forma intercambiable. Sin embargo, no lo son; el dinamismo es protagonista en los sistemas complejos, pero no en los complicados. Para entender a la embarazada con una gestación MC como un sistema complejo, primero se desarrollarán las características principales de los embarazos MC; su placenta es una de las principales responsables de los problemas. Luego se analizará el embarazo MC desde la complejidad, identificando las características del sistema y sus complicaciones como propiedades emergentes.

In practice, it is very common to associate monochorionic (MC) twin pregnancies with complex or complicated pregnancies, using both terms interchangeably. However, these are not synonyms; dynamism is the protagonist in complex systems, but not in complicated ones. In order to understand a MC pregnancy as a complex system, it is necessary to first look into its main characteristics. The placenta is one of the main sources of problems. Then, the MC pregnancy has to be analyzed from the perspective of complexity, identifying the system characteristics and its complications as emergent properties.

Lineages of Fractal Genera Comprise the 88-Million-Year Steel Evolutionary Spine of the Ecosphere.

Fractal evolution is apparently effective in selectively preserving environmentally resilient traits for more than 80 million years in Streptotrichaceae (Bryophyta). An analysis simulated maximum destruction of ancestral traits in that large lineage. The constraints enforced were the preservation of newest ancestral traits, and all immediate descendant species obtained different new traits. Maximum character state changes in ancestral traits were 16 percent of all possible traits in any one sub-lineage, or 73 percent total of the entire lineage. Results showed, however, that only four ancestral traits were permanently eliminated in any one lineage or sub-lineage. A lineage maintains maximum biodiversity of temporally and regionally survival-effective traits at minimum expense to resilience across a geologic time of 88 million years for the group studied. Similar processes generating an extant punctuated equilibrium as bursts of about four descendants per genus and one genus per 1-2 epochs are possible in other living groups given similar emergent processes. The mechanism is considered complexity-related, the lineage being a self-organized emergent phenomenon strongly maintained in the ecosphere by natural selection on fractal genera.

Integrated System Responses for Families Impacted by Violence: A Scoping Review.

Introduction: Violence within families is a complex problem which significantly impacts health and wellbeing. Despite the ubiquitous call for integrated family violence service delivery, integrated approaches vary significantly and challenges to implementation remain. This scoping review explored how integrated approaches to family violence service delivery are conceptualised within international and Aotearoa New Zealand literature. Methods: Following a documented scoping review process identified from literature, dynamic interplay between system agents within integrated family violence service delivery were mapped with the assistance of a complexity theory lens. We analysed characteristics of included studies, agents involved, how they interacted and the methods and mechanisms of integration among them. Results: Seventy-two published reports were included. The most common interactions occurred between statutory agencies such as police and child protection. While health care service providers were included within 55 studies, their engagement was often peripheral. Qualitative analysis elucidated three broad pathways to service delivery impact underpinned by systems-centred, person-centred, or Indigenous-centred worldviews. Discussion and Conclusion: Integrated approaches to family violence service delivery are highly variable. Despite a strong assumption that integration leads to improved safety, health, and wellbeing for care-seekers, most studies did not include evidence of such impact. Consideration of how worldviews characterise service provision provides insight into why integration has proven challenging over time.

'Atawhai': a primary care provider-led response to family violence in Aotearoa New Zealand.

BACKGROUND: As a key determinant of ill-health, family violence is inadequately responded to within Aotearoa New Zealand health policy and practice. Without adequate system support, health professionals can often be unsure of what to do, or how to help. Developed in response to this system gap, 'Atawhai' aims to make it easier for primary care professionals to respond to family violence. METHODS: Underpinned by indigenous Maori customs, Atawhai combines complexity theory and participatory research methodologies to be responsive to the complexity involved in family violence. We worked with 14 primary care professionals across ten whakawhitiwhiti korero wananga (meetings for deliberate dialogue) to identify and develop primary care system pathways and tools for responding to family violence. This paper focuses on the development of Atawhai through wananga and observation methods. Methods used to capture change will be reported separately. FINDINGS: Atawhai is a relational response to family violence, focused on developing a network of trusted relationships between health and social care professionals to support safe responses to those accessing care. This study identified four key health system pathways to responsiveness and developed associated tools to support health care responsiveness to family violence. We found the quality of relationships, both among professionals and with those accessing care, coupled with critical reflection on the systems and structures that shape policy and practice are essential in generating change within primary care settings. CONCLUSIONS: Atawhai is a unique health care response to family violence evidenced on empirical knowledge of primary care professionals. Our theoretical lens calls attention to parts of the system often obscured by current health care responses to family violence. Atawhai presents an opportunity to develop a grassroots-informed, long-term response to family violence that evolves in response to needs.

Complexity biomechanics: a case study of dragonfly wing design from constituting composite material to higher structural levels.

Presenting a novel framework for sustainable and regenerative design and development is a fundamental future need. Here we argue that a new framework, referred to as complexity biomechanics, which can be used for holistic analysis and understanding of natural mechanical systems, is key to fulfilling this need. We also present a roadmap for the design and development of intelligent and complex engineering materials, mechanisms, structures, systems, and processes capable of automatic adaptation and self-organization in response to ever-changing environments. We apply complexity biomechanics to elucidate how the different structural components of a complex biological system as dragonfly wings, from ultrastructure of the cuticle, the constituting bio-composite material of the wing, to higher structural levels, collaboratively contribute to the functionality of the entire wing system. This framework not only proposes a paradigm shift in understanding and drawing inspiration from natural systems but also holds potential applications in various domains, including materials science and engineering, biomechanics, biomimetics, bionics, and engineering biology.

Barriers and Opportunities for WHO "Best Buys" Non-communicable Disease Policy Adoption and Implementation From a Political Economy Perspective: A Complexity Systematic Review.

BACKGROUND: Improving the adoption and implementation of policies to curb non-communicable diseases (NCDs) is a major challenge for better global health. The adoption and implementation of such policies remain deficient in various contexts, with limited insights into the facilitating and inhibiting factors. These policies have traditionally been treated as technical solutions, neglecting the critical influence of political economy dynamics. Moreover, the complex nature of these interventions is often not adequately incorporated into evidence for policy-makers. This study aims to systematically review and evaluate the factors affecting NCD policy adoption and implementation. METHODS: We conducted a complex systematic review of articles discussing the adoption and implementation of World Health Organization's (WHO's) "best buys" NCD policies. We identified political economy factors and constructed a causal loop diagram (CLD) program theory to elucidate the interplay between factors influencing NCD policy adoption and implementation. A total of 157 papers met the inclusion criteria. RESULTS: Our CLD highlights a central feedback loop encompassing three vital variables: (1) the ability to define, (re)shape, and pass appropriate policy into law; (2) the ability to implement the policy (linked to the enforceability of the policy and to addressing NCD local burden); and (3) ability to monitor progress, evaluate and correct the course. Insufficient context-specific data impedes the formulation and enactment of suitable policies, particularly in areas facing multiple disease burdens. Multisectoral collaboration plays a pivotal role in both policy adoption and implementation. Effective monitoring and accountability systems significantly impact policy implementation. The commercial determinants of health (CDoH) serve as a major barrier to defining, adopting, and implementing tobacco, alcohol, and diet-related policies. CONCLUSION: To advance global efforts, we recommend focusing on the development of robust accountability, monitoring, and evaluation systems, ensuring transparency in private sector engagement, supporting context-specific data collection, and effectively managing the CDoH. A system thinking approach can enhance the implementation of complex public health interventions.

Unravelling the asymmetric effects of procurement practices on firm performance: A complexity theory approach to complementing fsQCA with NCA.

Current economic upheavals and supply chain uncertainty have threatened the profitability and sustainability of business organisations. Procurement has proved to be one of the strategies for enhancing firm performance without necessarily increasing revenue with its attendant increase in costs. However, rather than investigating the complex asymmetric relationship between procurement practices and firm performance (which this study advocates), past research engaged in a symmetric evaluation of the relationship between the phenomena. Accordingly, this study, using complexity theory, employs fsQCA and NCA on a sample of 150 respondents from private universities in Ghana to (a) identify different combinations of procurement practices, namely procurement planning, supplier partnership, contract management, and compliance, that lead to firm performance and (b) explore the necessity of these procurement practices (in kind and degree) for firm performance. Whereas the findings from fsQCA reveal three distinct combinations of procurement practices for high firm performance and further suggest that none of the procurement practices was necessary for firm performance, the NCA results suggest that two out of the four procurement practices investigated are necessary for firm performance and hence must be present in the causal recipes produced by fsQCA to guarantee that they lead to firm performance. The study offers pathways to firm performance through procurement practices and demonstrates how to complement fsQCA with NCA to ensure that causal recipes produced by fsQCA can produce the outcome.

Slack Is Needed to Solve the Shortage of Nurses.

Healthcare systems are facing a shortage of nurses. This article identifies some of the major causes of this and the issues that need to be solved. We take a perspective derived from queuing theory: the patient-nurse relationship is characterized by a scarcity of time and resources, requiring comprehensive coordination at all levels. For coordination, we take an information-theoretic perspective. Using both perspectives, we analyze the nature of healthcare services and show that ensuring slack, meaning a less than exhaustive use of human resources, is a sine qua non to having a good, functioning healthcare system. We analyze what coordination efforts are needed to manage relatively simple office hours, wards, and home care. Next, we address the level of care where providers cannot themselves prevent the complexity of organization that possibly damages care tasks and job quality. A lack of job quality may result in nurses leaving the profession. Job quality, in this context, depends on the ability of nurses to coordinate their activities. This requires slack resources. The availability of slack that is efficient depends on a stable inflow and retention rate of nurses. The healthcare system as a whole should ensure that the required nurse workforce will be able to coordinate and execute their tasks. Above that, workforce policies need more stability.

Using Systems Thinking and Complexity Theory to understand and improve Emergency Medicine: Lessons from COVID-19 in a safety net health system.

RATIONALE: COVID-19 has fundamentally changed the practice of Emergency Medicine (EM). Care delivery on the front lines has historically depended upon ostensibly reliable input-output models for staffing, supplies, policies, and therapies. Challenged by the complexity of healthcare during the pandemic, the fallibility of these reductionist models was quickly revealed. Providers and systems quickly had to reconceptualize their dependence on the wider, complex system in which healthcare operates and find adaptive solutions to rapid changes. AIMS/METHOD: This papers seeks to review and describe how Systems Thinking and Complexity Theory (ST/CT)-concepts, principles, and tools that can be used to understand and impact our constantly evolving health system-can be applied to better understand and enact change in complex settings such as during COVID-19. Some of these ST/CT are described through the real world example of the Alameda Health System Vaccine Taskforce. RESULTS: ST/CT concepts such as Unintended Consequences, Interrelationships, Emergent Behavior, Feedback Loops, and Path Dependence can help EM providers and planners understand the context in which their system operates. Key principles such as Collaboration, Iterative Learning, and Transformational Leadership can help these actors respond to current and future challenges. The integration of these concepts and principles into the Learning Health System offers a model for tying these key concepts and principles together into an adaptive, cross-sectoral organizational approach. CONCLUSION: By integrating ST/CT into the practice of EM, we can not only improve our ability to care for patients but also our capacity to understand and strengthen our wider systems of care.

Monochorionic twin pregnancy from the perspective of the theory of complexity. / El embarazo gemelar monocorial desde la perspectiva de la teoría de la complejidad.

In practice, it is very common to associate monochorionic (MC) twin pregnancies with complex or complicated pregnancies, using both terms interchangeably. However, these are not synonyms; dynamism is the protagonist in complex systems, but not in complicated ones. In order to understand a MC pregnancy as a complex system, it is necessary to first look into its main characteristics. The placenta is one of the main sources of problems. Then, the MC pregnancy has to be analyzed from the perspective of complexity, identifying the system characteristics and its complications as emergent properties.

En la práctica, es muy frecuente asociar las gestaciones gemelares monocoriales (MC) con embarazos complejos o complicados, utilizando ambos términos en forma intercambiable. Sin embargo, no lo son; el dinamismo es protagonista en los sistemas complejos, pero no en los complicados. Para entender a la embarazada con una gestación MC como un sistema complejo, primero se desarrollarán las características principales de los embarazos MC; su placenta es una de las principales responsables de los problemas. Luego se analizará el embarazo MC desde la complejidad, identificando las características del sistema y sus complicaciones como propiedades emergentes.

The lecturer-tutor in undergraduate medical education; navigating complexity as "a recruiter, a timetabler, an administrator, a counsellor".

BACKGROUND: Tutors play an important role in the delivery of effective undergraduate medical education (UGME). These roles commonly involve competing clinical, educational and research commitments. We sought to obtain a rich description of these posts from doctors working in them. METHODS: We used a pragmatist, sequential explanatory mixed-methods design with a sampling frame of clinical lecturer/tutors in 5 Irish medical schools. Purposive sampling was used for recruitment. Quantitative data collected from a validated online questionnaire were used to inform a semi-structured interview question guide. Thematic analysis was conducted independently by each of the study researchers, using a coding frame derived in part from the findings of the online questionnaire. Quantitative and qualitative mixing occurred during data collection, analysis and reporting. RESULTS: 34 tutors completed the online survey with 7 volunteers for interview. Most respondents took the job to gain experience in either educational practice (79.4%) or in research (61.8%). Major themes to emerge were the diverse interactions with students, balancing multiple professional commitments, a high degree of role-autonomy, mis-perception of role by non-tutor colleagues, challenges around work-life balance and unpredictable work demands. Using a complexity theory lens, the tutor role was defined by its relational interactions with numerous stakeholders, all in the context of an environment that changed regularly and in an unpredictable manner. CONCLUSIONS: The undergraduate tutor works in a demanding role balancing educational and non-educational commitments with suboptimal senior guidance and feedback. The role is notable for its position within a complex adaptive system. An understanding of the system's interactions recognises the non-linearity of the role. Using a complex systems lens, we propose improvements to undergraduate education centred around the tutor.

Application of the evolutionary theory of behavior dynamics to severe challenging behavior.

The evolutionary theory of behavior dynamics (ETBD) is a genetic algorithm that applies the Darwinian principles of evolutionary biology to model how behavior changes dynamically via selection by contingencies of reinforcement. The ETBD is a complexity theory where low-level rules of selection, reproduction, and mutation operate iteratively to animate "artificial organisms" that generate emergent outcomes. Numerous studies have demonstrated the ETBD can accurately model behavior of live animals in the laboratory, and it has been applied recently to model automatically maintained self-injury. The purpose of the current series of studies was to further extend the application of the ETBD to model additional functional classes of challenging behavior and clinical procedures. Outcomes obtained with artificial organisms generally corresponded well with outcomes observed with clinical cases sourced from consecutive controlled case series studies. Conceptual and methodological considerations on the application of the ETBD to model challenging behavior are discussed.

Examining the nexus between medical education and complexity: a systematic review to inform practice and research.

BACKGROUND: Medical education is a multifarious endeavour integrating a range of pedagogies and philosophies. Complexity as a science or theory ('complexity') signals a move away from a reductionist paradigm to one which appreciates that interactions in multi-component systems, such as healthcare systems, can result in adaptive and emergent outcomes. This examination of the nexus between medical education and complexity theory aims to discover ways that complexity theory can inform medical education and medical education research. METHODS: A structured literature review was conducted to examine the nexus between medical education and complexity; 5 databases were searched using relevant terms. Papers were included if they engaged fully with complexity as a science or theory and were significantly focused on medical education. All types of papers were included, including conceptual papers (e.g. opinion and theoretical discussions), case studies, program evaluations and empirical research. A narrative and thematic synthesis was undertaken to create a deep understanding of the use of complexity in medical education. RESULTS: Eighty-three papers were included; the majority were conceptual papers. The context and theoretical underpinnings of complexity as a relevant theory for medical education were identified. Bibliographic and temporal observations were noted regarding the entry of complexity into medical education. Complexity was relied upon as a theoretical framework for empirical studies covering a variety of elements within medical education including: knowledge and learning theories; curricular, program and faculty development; program evaluation and medical education research; assessment and admissions; professionalism and leadership; and learning for systems, about systems and in systems. DISCUSSION: There is a call for greater use of theory by medical educators. Complexity within medical education is established, although not widespread. Individualistic cultures of medicine and comfort with reductionist epistemologies challenges its introduction. However, complexity was found to be a useful theory across a range of areas by a limited number of authors and is increasingly used by medical educators and medical education researchers. This review has further conceptualized how complexity is being used to support medical education and medical education research. CONCLUSION: This literature review can assist in understanding how complexity can be useful in medical educationalists' practice.

Using a complexity science approach to evaluate the effectiveness of just-in-time adaptive interventions: A meta-analysis.

Objective: Just-in-time adaptive interventions (JITAIs), which allow individuals to receive the right amount of tailored support at the right time and place, hold enormous potential for promoting behavior change. However, research on JITAIs' implementation and evaluation is still in its early stages, and more empirical evidence is needed. This meta-analysis took a complexity science approach to evaluate the effectiveness of JITAIs that promote healthy behaviors and assess whether key design principles can increase JITAIs' impacts. Methods: We searched five databases for English-language papers. Study eligibility required that interventions objectively measured health outcomes, had a control condition or pre-post-test design, and were conducted in the real-world setting. We included randomized and non-randomized trials. Data extraction encompassed interventions' features, methodologies, theoretical foundations, and delivery modes. RoB 2 and ROBINS-I were used to assess risk of bias. Results: The final analysis included 21 effect sizes with 592 participants. All included studies used pre- and post-test design. A three-level random meta-analytic model revealed a medium effect of JITAIs on objective behavior change (g = 0.77 (95% confidence interval (CI); 0.32 to 1.22), p < 0.001). The summary effect was robust to bias. Moderator analysis indicated that design principles, such as theoretical foundations, targeted behaviors, and passive or active assessments, did not moderate JITAIs' effects. Passive assessments were more likely than a combination of passive and active assessments to relate to higher intervention retention rates. Conclusions: This review demonstrated some evidence for the efficacy of JITAIs. However, high-quality randomized trials and data on non-adherence are needed.

Developing an agent-based model to minimize spreading of malicious information in dynamic social networks.

This research introduces a systematic and multidisciplinary agent-based model to interpret and simplify the dynamic actions of the users and communities in an evolutionary online (offline) social network. The organizational cybernetics approach is used to control/monitor the malicious information spread between communities. The stochastic one-median problem minimizes the agent response time and eliminates the information spread across the online (offline) environment. The performance of these methods was measured against a Twitter network related to an armed protest demonstration against the COVID-19 lockdown in Michigan state in May 2020. The proposed model demonstrated the dynamicity of the network, enhanced the agent level performance, minimized the malicious information spread, and measured the response to the second stochastic information spread in the network.