Chronic pain as an emergent property of a complex system and the potential roles of psychedelic therapies.

Despite research advances and urgent calls by national and global health organizations, clinical outcomes for millions of people suffering with chronic pain remain poor. We suggest bringing the lens of complexity science to this problem, conceptualizing chronic pain as an emergent property of a complex biopsychosocial system. We frame pain-related physiology, neuroscience, developmental psychology, learning, and epigenetics as components and mini-systems that interact together and with changing socioenvironmental conditions, as an overarching complex system that gives rise to the emergent phenomenon of chronic pain. We postulate that the behavior of complex systems may help to explain persistence of chronic pain despite current treatments. From this perspective, chronic pain may benefit from therapies that can be both disruptive and adaptive at higher orders within the complex system. We explore psychedelic-assisted therapies and how these may overlap with and complement mindfulness-based approaches to this end. Both mindfulness and psychedelic therapies have been shown to have transdiagnostic value, due in part to disruptive effects on rigid cognitive, emotional, and behavioral patterns as well their ability to promote neuroplasticity. Psychedelic therapies may hold unique promise for the management of chronic pain.

Investigating practice integration of independent prescribing by community pharmacists using normalization process theory: a cross-sectional survey.

BACKGROUND: Independent prescribing (IP) has not been extensively investigated in community pharmacy (CP). Normalization process theory (NPT) constructs help explain how interventions are integrated into practice and include: 'coherence' (understanding), 'cognitive participation' (what promotes engagement), 'collective action' (integration with existing systems), and 'reflexive monitoring' (evaluation). AIM: To use NPT to investigate the integration of pharmacist IP in CP. METHOD: NHS Scotland Pharmacy First Plus (PFP) is a community pharmacy IP service. Questionnaire items were developed using the NPT derived Normalisation MeAsure Development (NoMAD) tool for an online survey of all PFP IP pharmacists. Demographic data were analysed descriptively and scale scores (calculated from item scores for the 4 NPT constructs) were used for inferential analysis. RESULTS: There was a 73% (88/120) response rate. Greater than 90% 'strongly agreed'/'agreed' to NoMAD items relating to most NPT constructs. However, responses to 'collective action' items were diverse with more participants answering 'neither agree nor disagree' or 'disagree'. A statistically significant difference in NPT construct scale scores with significant p-values (ranging from p < 0.001 to p = 0.033) was shown on all the NPT constructs for the variable 'On average, how often do you consult with patients under the PFP service?'. CONCLUSION: This theory-based work offers perspectives on IP integration within CP. Despite its geographic focus this work offers insights relevant to wider contexts on IP integration. It shows 'collective action' focused 'organisation' and 'group process' challenges with a need for further work on staff training, resource availability and utilisation, working relationships, communication and management.

Influence of early childhood parental hostility and socioeconomic stress on children's internalizing symptom trajectories from childhood to adolescence.

Introduction: Children and adolescents with elevated internalizing symptoms are at increased risk for depression, anxiety, and other psychopathology later in life. The present study examined the predictive links between two bioecological factors in early childhood-parental hostility and socioeconomic stress-and children's internalizing symptom class outcomes, while considering the effects of child sex assigned at birth on internalizing symptom development from childhood to adolescence. Materials and Methods: The study used a sample of 1,534 children to test the predictive effects of socioeconomic stress at ages 18 and 27 months; hostile parenting measured at child ages 4-5; and sex assigned at birth on children's internalizing symptom latent class outcomes at child ages 7-9, 10-12, 13-15, and 16-19. Analyses also tested the mediating effect of parenting on the relationship between socioeconomic stress and children's symptom classes. Other covariates included parent depressive symptoms at child ages 4-5 and child race and ethnicity. Results: Analyses identified three distinct heterogenous internalizing symptom classes characterized by relative symptom levels and progression: low (35%); moderate and increasing (41%); and higher and increasing (24%). As anticipated, higher levels of parental hostility in early childhood predicted membership in the higher and increasing symptom class, compared with the low symptom class (odds ratio (OR) = .61, 95% confidence interval (CI) [.48,.77]). Higher levels of early childhood socioeconomic stress were also associated with the likelihood of belonging to the higher-increasing symptom class compared to the low and moderate-increasing classes (OR = .46, 95% CI [.35,.60] and OR = .56, 95% CI [.44,.72], respectively). The total (c = .61) and direct (c' = .57) effects of socioeconomic stress on children's symptom class membership in the mediation analysis were significant (p <.001). Discussion: Study findings suggest that intervening on modifiable bioecological stressors-including parenting behaviors and socioeconomic stressors-may provide important protective influences on children's internalizing symptom trajectories.

Picking Apart a Program Evaluation Committee: A Multiple Case Study Characterizing Primary Care Residency Program Evaluation Committee Structure, Program Improvement, and Outcomes.

BACKGROUND: As of 2014, the Accreditation Council for Graduate Medical Education (ACGME) mandates initiating a Program Evaluation Committee (PEC) to guide ongoing program improvement. However, little guidance nor published reports exist about how individual PECs have undertaken this mandate. OBJECTIVE: To explore how four primary care residency PECs configure their committees, review program goals and undertake program evaluation and improvement. METHODS: We conducted a multiple case study between December 2022 and April 2023 of four purposively selected primary care residencies (e.g., family medicine, pediatrics, internal medicine). Data sources included semi-structured interviews with four PEC members per program and diverse program artifacts. Using a constructivist approach, we utilized qualitative coding to analyze participant interviews and content analysis for program artifacts. We then used coded transcripts and artifacts to construct logic models for each program guided by a systems theory lens.  Results: Programs adapt their PEC structure, execution, and outcomes to meet short- and long-term needs based on organizational and program-unique factors such as size and local practices. They relied on multiple data sources and sought diverse stakeholder participation to complete program evaluation and improvement. Identified deficiencies were often categorized as internal versus external to delineate PEC responsibility, boundaries, and feasibility of interventions. CONCLUSION: The broad guidance provided by the ACGME for PEC configuration allows programs to adapt the committee based on individual needs. However, further instruction on program evaluation and organizational change principles would augment existing PEC efforts.

"You Can Do So Much Better Than What They Expect": An Arts-Based Engagement Ethnography on School Integration With Newcomer Youth.

Newcomer adolescents make up a large minority of Canada's population and their positive integration experiences with education systems across the country are critical for both their development and the country's long-term success. The current study examined newcomer adolescents' (n = 4, between 16 and 18 years old) integration experiences using an arts-based engagement ethnography to understand what influences their positive integration into the school system. Artifacts, interview, and focus group data were analyzed systematically using ethnographic research guidelines. Five structures were identified: (1) barriers to advancement at individual, school, and macro levels, (2) fluctuating relationship with cultural identity, (3) limited trust in systems, (4) resilience through independent learning, and (5) facilitating factors to positive integration experiences at the family and school level. In keeping with a relational developmental systems theory framework, each structure accounts for multiple inter- and intra-individual factors at multiple environmental levels. These findings outline considerations for systemic issues in academic institutions and offer suggestions for how institutions can better support newcomer adolescents.

Perseveration on suicidal thoughts and images in daily life: An examination of the cognitive model of suicide through a dynamic systems lens.

According to the cognitive model of suicide, interactions between hopelessness and attentional biases toward suicidal information create a narrowed attentional focus on suicide as a viable solution, particularly in the presence of life stress, leading to increased suicide risk. This study used a dynamic systems approach to examine the short-term temporal patterns between stress, hopelessness, suicide-specific rumination, and suicidal intent. Adults (N = 237; M = 27.12 years; 62% cisgender women; 87% White/European American) with elevated suicidal ideation completed ecological momentary assessments six times a day for 14 days. A multilevel model approach informed by dynamic systems theory was used to simultaneously assess stable and dynamic temporal processes underlying perceived stress, hopelessness, suicide-specific rumination, and suicidal intent. Each variable demonstrated temporal stability. In support of the cognitive model of suicide, we observed (1) a reciprocal relationship between stress and hopelessness such that stress and hopelessness amplified each other (early-stage processes), and (2) reinforcing loops such that hopelessness, suicide-specific rumination, and suicidal intent amplified each other (later-stage processes). A dynamic systems modeling approach underscored the negative impact of a perpetuating cycle of suicide-specific rumination, deepening hopelessness, and escalating suicidal intent on increasing suicide risk, which may be targets for intervention.

A Test of the Behavioral Model of Tic Disorders Using a Dynamical Systems Framework.

Tic disorders are a class of neurodevelopmental disorders characterized by involuntary motor and/or vocal tics. It has been hypothesized that tics function to reduce aversive premonitory urges (i.e., negative reinforcement) and that suppression-based behavioral interventions such as habit reversal training (HRT) and exposure and response prevention (ERP) disrupt this process and facilitate urge reduction through habituation. However, previous findings regarding the negative reinforcement hypothesis and the effect of suppression on the urge-tic relationship have been inconsistent. The present study applied a dynamical systems framework and within-subject time-series autoregressive models to examine the temporal dynamics of urges and tics and assess whether their relationship changes over time. Eleven adults with tic disorders provided continuous urge ratings during separate conditions in which they were instructed to tic freely or to suppress tics. During the free-to-tic conditions, there was considerable heterogeneity across participants in whether and how the urge-tic relationship followed a pattern consistent with the automatic negative reinforcement hypothesis. Further, little evidence for within-session habituation was seen; tic suppression did not result in a reduction in premonitory urges for most participants. Analysis of broader urge change metrics did show significant disruption to the urge pattern during suppression, which has implications for the current biobehavioral model of tics.

Research on factors influencing Chinese parents' support for death education: a cross-sectional survey.

Objective: This study aims to explore the factors influencing Chinese parents' attitudes toward death education. Given the current lack of such education in China, this research is particularly significant. Death education is vital for shaping the values of young people and alleviating mental health issues, such as depression and suicidal tendencies. By identifying these influencing factors, this study seeks to provide guidance for policymakers and educators in promoting the development and widespread adoption of death education. Methods: To do so, a national cross-sectional quota sample of 12,435 Chinese parents was used. Borrowing from social-ecological theory, the researchers carried out multiple stepwise regression analyses to examine the individual, family, and social-level factors that shape the supportive attitudes of Chinese parents toward death education. Results: The findings revealed that at the individual level, parent (ß = 0.04, p < 0.001), education level (ß = 0.07, p < 0.001), and religious belief (ß = -0.02, p < 0.05) were significant predictors of Chinese parents' support for death education. Meanwhile, at the family and social level, average monthly household income (ß = 0.07, p < 0.001), family health (ß = 0.03, p < 0.05), family communication (ß = 0.02, p < 0.05), social support (ß = 0.15, p < 0.001), neighborhood relations (ß = 0.11, p < 0.001), and social network size (ß = 0.05, p < 0.001) were significant predictors of Chinese parents' supportive attitudes toward death education. Conclusion: Based on these findings, it is suggested that the relevant development, planning, publicity, and public welfare groups and government departments should promote death education, provide more social support, and encourage neighborhood harmony. As higher education and average monthly household income were found to significantly impact the support, the government should improve access to higher education and actively work to increase residents' income to facilitate the development of death education.

Differences in Lower-Extremity Joint Coordination During Two Landing Phases of a Drop Jump Task.

The aim of the present study was to compare the differences in joint coordination patterns and variability in the lower extremity between the first and second landing phases of the drop jump. Eighteen resistance-trained men (age: 22.8 ± 1.8 years) performed drop jumps from a height of 0.40 m. An eight-camera motion capture system was utilized to record kinematic trajectories. Modified vector coding technique and circular statistics were used to determine the coordination pattern and variability of the following joint couples during the first and second landings: hip frontal-knee frontal (HfKf), hip sagittal-knee frontal (HsKf), hip sagittal-knee sagittal (HsKs), knee frontal-ankle frontal (KfAf), knee sagittal-ankle frontal (KsAf), and knee sagittal-ankle sagittal (KsAs). Statistical differences in the distribution frequencies of coupling angles and variability between the dominant and nondominant limbs across the two landing phases were compared using two-way repeated analysis of variance and Wilcoxon rank-sum tests. During the second landing phase, the proportion of HsKs, KfAf, and KsAs showing in-phase coordination was reduced but the proportion of KfAf and KsAs showing proximal joint (knee) coordination was increased (p < .05). Significant differences in bilateral asymmetry were observed only for the HfKf and KfAf patients (p < .05). HsKs, KfAf, and KsAf varied considerably during the second landing phase (p < .05). Joint coordination patterns during the second landing phase of the drop jump differed considerably from those during the first landing phase, thereby increasing the risk of knee and ankle injuries.

Design Principles for Biological Adaptation: A Systems and Control-Theoretic Treatment.

Establishing a mapping between (from and to) the functionality of interest and the underlying network structure (design principles) remains a crucial step toward understanding and design of bio-systems. Perfect adaptation is one such crucial functionality that enables every living organism to regulate its essential activities in the presence of external disturbances. Previous approaches to deducing the design principles for adaptation have either relied on computationally burdensome brute-force methods or rule-based design strategies detecting only a subset of all possible adaptive network structures. This chapter outlines a scalable and generalizable method inspired by systems theory that unravels an exhaustive set of adaptation-capable structures. We first use the well-known performance parameters to characterize perfect adaptation. These performance parameters are then mapped back to a few parameters (poles, zeros, gain) characteristic of the underlying dynamical system constituted by the rate equations. Therefore, the performance parameters evaluated for the scenario of perfect adaptation can be expressed as a set of precise mathematical conditions involving the system parameters. Finally, we use algebraic graph theory to translate these abstract mathematical conditions to certain structural requirements for adaptation. The proposed algorithm does not assume any particular dynamics and is applicable to networks of any size. Moreover, the results offer a significant advancement in the realm of understanding and designing complex biochemical networks.

From Stress to Screen: Understanding Cyberloafing through Cognitive and Affective Pathways.

This investigation delves into the pervasive yet insufficiently examined phenomenon of "cyberloafing", characterized by employees engaging in non-work-related internet activities during office hours. Despite its frequent occurrence in contemporary work environments, the fundamental mechanisms underpinning cyberloafing remain largely uncharted. This study uses the conservation of resources theory and the cognitive-affective personality system framework to demystify the relationship between role stress and cyberloafing. We developed a dual-path model to assess the mediating roles of perceived insider status and emotional exhaustion. Employing SPSS and Smart PLS for data analysis, our research sampled 210 corporate employees. The findings reveal that role stress predicts perceived insider status and emotional exhaustion significantly. Notably, while perceived insider status negatively correlates with cyberloafing, emotional exhaustion shows a positive correlation. These factors mediate the relationship between role stress and cyberloafing, underscoring a multifaceted dynamic. Our results provide new theoretical insights into the mechanisms of employee counterproductive behavior, specifically in the context of cyberloafing, and broaden our understanding of its determinants. This study illuminates theoretical nuances and offers practical implications for managerial strategies and future scholarly inquiries into organizational behavior.

Farm to Preschool Programs and Its Impact on Children's Dietary Health: Evaluation Through Bronfenbrenner's Socio-Ecological Model.

Children's development is shaped by the world around them. According to Bronfenbrenner's theory, children are influenced by direct interactions and the broader environment, which includes family, community, and society. This concept aligns with initiatives like farm-to-preschool programs. These programs forge connections between communities and local food sources, introducing gardening and nutritional education. This approach aligns seamlessly with Bronfenbrenner's theory, creating a multi-layered learning experience and fostering children's healthier eating habits. This review delves into how farm-to-preschool efforts enhance young children's diets through the ecological model evaluation framework, encompassing health, education, economics, and the environment.

The selfish network: how the brain preserves behavioral function through shifts in neuronal network state.

Neuronal networks possess the ability to regulate their activity states in response to disruptions. How and when neuronal networks turn from physiological into pathological states, leading to the manifestation of neuropsychiatric disorders, remains largely unknown. Here, we propose that neuronal networks intrinsically maintain network stability even at the cost of neuronal loss. Despite the new stable state being potentially maladaptive, neural networks may not reverse back to states associated with better long-term outcomes. These maladaptive states are often associated with hyperactive neurons, marking the starting point for activity-dependent neurodegeneration. Transitions between network states may occur rapidly, and in discrete steps rather than continuously, particularly in neurodegenerative disorders. The self-stabilizing, metastable, and noncontinuous characteristics of these network states can be mathematically described as attractors. Maladaptive attractors may represent a distinct pathophysiological entity that could serve as a target for new therapies and for fostering resilience.

Rabies management structures and challenges in the North in a One Health framework.

Rabies is often described as the quintessential One Health problem, linking especially animal health to human health. I examined how rabies is managed in the circumpolar North through semi-structured interviews of key informants in three cases: Alaska, Northwest Territories, and Svalbard. While rabies is controlled at the territorial or state level in the Northwest Territories and Alaska, respectively, the perception of where authority lies in rabies management is less evident in Norway concerning Svalbard than in the other two cases. Respondents generally characterised the working relationship between sectors and scales of governments as positive. However, coordination remains one of the main challenges to rabies management, with harsh environmental conditions and small remote communities adding additional challenges in all three cases. Rabies managers in Svalbard also face unique conditions, such as risks associated with hunting and the particular administrative structure of Svalbard. Due to limited veterinary services in dispersed small and remote communities, dogs present challenges to rabies management in Alaska and the Northwest Territories. Personal relationships are important in disease management across agencies, and the unique challenges in the far North will likely pose challenges in adopting approaches to disease management from temperate climates.

Age-related differences in the interplay of fluency and complexity in Chinese-speaking seniors' oral narratives.

BACKGROUND: Previous studies on language production in normal ageing have primarily focused on distinct dimensions of older adults' spoken language performance, such as fluency and complexity. However, little attention has been paid to the complex, interconnected relations between these dimensions. Additionally, older adults have been treated as a homogeneous group, with little consideration for the differential characteristics of language performance across different stages of ageing. AIMS: This study aims to investigate how increasing age impacts Chinese seniors' oral language performance, focusing on fluency (articulation rate and dysfluency rate), complexity (lexical and syntactic) and the potential interactions between these dimensions. METHODS & PROCEDURES: Spontaneous oral narratives were collected from 60 normally ageing individuals, who were categorised into three groups: young-old (60-69 years old), middle-old (70-79 years old) and old-old (≥80 years old). Four measures for assessing language performance, namely, articulation rate, dysfluency rate, lexical complexity and syntactic complexity, were derived from the oral narratives. Dynamic systems techniques, including moving correlations, locally estimated scatterplot smoothing and Monte Carlo simulations, were employed for data analysis. OUTCOMES & RESULTS: This study revealed two major findings. First, across different age groups, the seniors' oral narratives significantly differed in the aspect of articulation rate and syntactic complexity. Specifically, both the young-old and the middle-old groups exhibited significantly higher articulation rates than the old-old group; the middle-old group also demonstrated significantly higher syntactic complexity compared to the old-old group. Second, the distinct subsystems (i.e., articulation rate, dysfluency rate, lexical and syntactic complexity) of seniors' oral narratives demonstrated varying interactions across different stages of ageing. While these subsystems tended to coordinate with each other in young-old individuals, they exhibited a greater tendency to compete in middle-old and old-old individuals. CONCLUSIONS & IMPLICATIONS: The findings reveal that subsystems of older adults' oral narratives display varying interactions with the increase of age, indicating that focusing solely on one dimension of language performance may result in inaccurate or misleading conclusions. Therefore, a multi-index comprehensive assessment should be employed for the enhancement of clinical evaluations of language performance in older adults. Additionally, it is vital to consider the interactional patterns (i.e., support or competition) between language subsystems when assessing language performance in normal ageing. WHAT THIS PAPER ADDS: What is already known on the subject Previous research on language production in normal ageing has primarily focused on distinct dimensions of older adults' spoken language performance, such as fluency, vocabulary richness and grammatical complexity, overlooking the intricate interconnections between these dimensions. However, investigating these connections is significant for a thorough and in-depth understanding of language production in late adulthood, which operates as a system comprising interconnected components. Furthermore, existing studies have predominantly treated older adults as a homogeneous group, comparing their language use to that of young people. This approach lacks justification, given the substantial variations in language use among seniors at different stages of ageing. What this paper adds to existing knowledge The present findings illuminate the dynamic nature of language production in normal ageing. Not only do the distinct dimensions or subsystems of older adults' oral narratives (e.g., articulation rate, dysfluency rate, syntactic complexity) change with age, but more important, the ways in which these subsystems interact with each other also evolve with age, resulting in changing states of spoken language production in the ageing process. More specifically, our study provides evidence that the interactions among subsystems of older adults' oral narratives predominately transition from supportive relationships in earlier stages to competitive ones at later stages of ageing. What are the potential or actual clinical implications of this work? The present study suggests the use of multiple linguistic indices related to various aspects of language performance to assess the spoken language production of older adults. This is highlighted by the observation that various dimensions of older adults' oral narratives continuously interact with one another across different stages of ageing, and hence focusing solely on one dimension of language performance tends to lead to inaccurate or misleading results. Additionally, the patterns of interaction (i.e., support or competition) between different dimensions of language performance may reflect older adults' capacity to coordinate and control attentional resources and therefore should be taken into consideration in clinical evaluations of language performance in older adults.

Couple differentiation and health-related quality of life.

The purpose of this study was to examine whether couple differentiation influenced mental and physical health-related quality of life in couple members. Data for this study were derived from a larger study at a couple a family therapy clinic. One hundred and thirty-three couples were included in a latent profile analysis, and seventy-two couples were included in analyses of mean differences. The latent profile analysis resulted in three distinct groups by level of couple differentiation: high, moderate, or low in differentiation of self. Analyses of variance indicated evidence that couple differentiation influenced health-related quality-of-life measures. Findings are discussed in the context of Bowen Family Systems Theory and the existing literature.

Medical student experiences of equality, diversity, and inclusion: content analysis of student feedback using Bronfenbrenner's ecological systems theory.

BACKGROUND: Issues relating to equality, diversity, and inclusion (EDI) significantly impact on medical student achievement and wellbeing. Interventions have been introduced at curricular and organisational levels, yet progress in addressing these issues remains limited. Timely evaluation is needed to assess effectiveness of interventions, and to explore issues and interactions in learning environments impacting on student experience. We introduced an anonymous question concerning students' experiences of EDI into routine online student feedback questionnaires, to scope the nature of ongoing issues and develop greater understanding of students' experiences in our programme environment. Ecological systems theory, which conceptualizes learning as a function of complex social interactions, determined by characteristics of individual learners and their environment, provides a framework for understanding. METHODS: Free-text responses regarding experiences of EDI gathered over 20 months from all programme years (n = 760) were pooled for analysis, providing a holistic overview of experiences in the learning environment. A counting exercise identified broad categories reported by students. Content analysis of the qualitative dataset was undertaken. Bronfenbrenner's ecological systems theory was applied as a framework to demonstrate interdependencies between respondents' experiences and environments, and associated impacts. RESULTS: Three hundred and seventy-six responses were received relating to wide-ranging EDI issues, most frequently gender or ethnicity. Responses mapped onto all areas of the ecological systems model, with frequent links between subsystems, indicating considerable complexity and interdependencies. Interpersonal interactions and associated impacts like exclusion were frequently discussed. Differential experiences of EDI-related issues in medical school compared to clinical settings were reported. Impacts of institutional leadership and wider societal norms were considered by respondents. Respondents discussed their need for awareness of EDI with reference to future professional practice. CONCLUSIONS: Implementation of a regular free-text evaluation question allowed data-gathering across cohorts and throughout several stages of the curriculum, illuminating student experience. Connections established demonstrated intersectionality, and how environment and other factors interact, impacting on student experiences. Students experience EDI-related issues on multiple levels within the educational environment, with consequent impacts on learning. Any successful approach towards tackling issues and promoting equity of opportunity for all requires multi-level actions and widespread culture change. Students can offer fresh and distinct perspectives regarding change needed, to complement and diversify perspectives provided by staff and organisational leadership. Student voice should be enabled to shape change.

Toward a Theory of Organizational DNA: Routines, Principles, and Beliefs (RPBs) for Successful and Sustainable Organizational Change.

Organizational change is a key mechanism to ensure the sustainability of healthcare systems. However, healthcare organizations are persistently difficult to change, and literature is riddled with examples of failed change endeavors. In this chapter, we attempt to unravel the underlying causes for failed organizational change. We distinguish three types of change with different levels of depth that require different change approaches. Transformations are the deepest forms of change where beliefs and principles need to be modified to successfully influence routines. Renewals are deep forms of change where principles need to be modified to successfully influence routines. Improvements are shallow forms of change where only modifications at the level of routines are needed. Using deoxyribonucleic acid (DNA) as our metaphor, we propose a theory of "organizational DNA" to understand organizations and these three types of organizational changes. We posit that organizations are made up of a double helix consisting of a so-called "social string," which contains the "soft" interaction or communication among the organization's members, and a so-called "technical string," which contains "hard" organizational aspects such as structure and technology. Ladders of organizational nucleotides (i.e., Routines, Principles, and Beliefs) connect this double helix in various combinations. Together, the double helix and accompanying nucleotides make up the DNA of an organization. Without knowledge of the architecture of organizational DNA and whether a change addresses beliefs, principles, and/or routines, we believe that organizational change is constrained and based on luck rather than change management expertise. Following this metaphor, we show that organizational change fails when it attempts to change one part of the DNA (e.g., routines) in a way that renders it incompatible with the connecting components (e.g., principles and beliefs). We discuss how the theory can be applied in practice using an exemplar case.

"100 Things I Wish Someone Would Have Told Me": Everyday Challenges Parents Face While Caring for Their Children With a Tracheostomy.

Equitable access to appropriate care, emergency department services, and in-home support aids are needed to minimize the occurrences of adverse events that have a significant impact on families. However, many families of children with medical complexity (CMC) lack consistent care due to issues of health inequity. We conducted 11 qualitative interviews with primary caregivers who were asked about their experiences of providing care to children who have a tracheostomy and are supported by multiple life-saving machines at home. Guided by ecological systems theory, we identified three themes that contextualize the lived experiences of the participants who expressed needs that arose from poor interactions within the mesosystem. Findings convey participant frustrations that result from insufficient support, ineffective training, and inadequate healthcare coverage. Although each theme is organized systematically to emphasize specific concerns within the mesosystem, together these themes emphasize the inextricable relationship between daily needs with systemic barriers to care. We provide a discussion of these needs with a broader context that also impacts the perceived quality of care among families managing the needs of their children who are supported by life-saving technology. By addressing existing challenges and identifying opportunities for improvement within the healthcare system, we seek to contribute to the collective effort of advocating for ethical systemic change on behalf of CMC and their families.