Making sense of complexity: A qualitative 'Framework' analysis of naturopathic case management and clinical reasoning.

BACKGROUND AND PURPOSE: The clinical encounter is inherently complex and uncertain. Naturopathic clinical practice is shaped by a traditional philosophy and practice guiding principles, with a therapeutic framework that incorporates a complex inter-systems approach. It is possible that this foundation may orient naturopathic practitioners to manage clinical complexity and uncertainty in a distinct manner. The aim of this study is to explore the perceptions of experienced naturopathic practitioners to the management of clinical complexity within naturopathic care. MATERIALS AND METHODS: Twenty experienced Australian naturopathic practitioners participated across four focus groups, responding to semi-structured questions regarding their clinical reasoning strategies and case management processes. The data were analysed using a seven step Framework analysis method. RESULTS: Three primary themes were identified: i) patient is encountered as a whole entity, ii) clinical reasoning is ampliative and explicative, and iii) treatment reflects systems thinking. Participants perceived a focus on the connections between various case elements, building a comprehensive internalised schematic of each case. Participants saw treatments as meeting various needs including prevention, symptom alleviation, causal mitigation, and support of innate healing processes. CONCLUSION: Naturopathic practitioners perceive they clinically embody the traditional holistic philosophy of naturopathy as a systems orientation, incorporating traditional and contemporary bioscience knowledge. This appears to shape a distinct naturopathic case management approach, oriented to working with patients in a complexity-informed manner.

The converging paradigms of holism and complexity: An exploration of naturopathic clinical case management using complexity science principles.

RATIONALE: Traditional whole systems of medicine, such as naturopathy, are founded upon holism; a philosophical paradigm consistent with contemporary complexity science. Naturopathic case management is predicated upon the understanding of an intimately interconnected internal physiological and external context of the human organism-potentially indicating a worldview aligned with a complexity perspective. In this study we investigate naturopathic clinical reasoning using a complexity lens with the aim of ascertaining the extent of correspondence between the two. METHOD: Mind maps depicting case presentations were sought from Australian degree qualified naturopaths. A network mapping was undertaken, which was then analysed in accordance with a complexity science framework using exploratory data analysis and network analysis processes and tools. RESULTS: Naturopathic case schematics, in the form of mind maps (n = 70), were collected, network mapped, and analysed. A total of 739 unique elements and 2724 links were identified across the network. Integral elements across the network were: stress, fatigue, general anxiety, systemic inflammation, gut dysbiosis, and diet. A modularity algorithm detected 11 communities, the primary ones of these representing the nervous system and mood; the gastrointestinal tract, liver, and nutrition; immune function and the immune system; and diet and nutrients. CONCLUSIONS: Naturopathic case management is holistic and based on a perspective of an integrated physiology and external context of the human organism. The traditional concept of holism, when subjected to a complexity lens, leads to the emergence of a contemporary holistic paradigm cognisant of the human organism being a complex system. The application of complexity science to investigate naturopathic case management as employed in this study, demonstrates that it is possible to investigate traditional philosophies and principles in a scientific and critical manner. A complexity science research approach may offer a suitable scientific paradigm to develop our understanding of traditional whole systems of medicine.

Primary health care case management through the lens of complexity: an exploratory study of naturopathic practice using complexity science principles.

BACKGROUND: Advances in systems science creates an opportunity to bring a complexity perspective to health care practices and research. While medical knowledge has greatly progressed using a reductionist and mechanistic philosophy, this approach may be limited in its capacity to manage chronic and complex illness. With its holistic foundation, naturopathy is a primary health profession with a purported alignment with a complexity perspective. As such this pilot study aimed to investigate the application of complexity science principles, strategies, and tools to primary health care using naturopathy as a case study. METHODS: A network mapping and analysis of the naturopathic case management process was conducted. Mind maps were created by naturopathic practitioners to reflect their clinical conceptualisation of a common paper clinical case. These mind maps were inputed into Gephi, a network mapping, exploration, and analysis software. Various layouts of the data were produced, and these were analysed using exploratory data analysis and computational network analysis. RESULTS: Seven naturopathic practitioners participated in the study. In the combined network mapping, 133 unique elements and 399 links were identified. Obesity, the presenting issue in the case, was centrally located. Along with obesity, other keystone elements included: systemic inflammation, dysbiosis, diet, the liver, and mood. Each element was connected on average to 3.05 other elements, with a degree variation between one and 36. Six communities within the dataset were identified, comprising: the nervous system and mood, gastroinstetinal and dietary factors, systemic inflammation and obesity, the endocrine system and metabolism. CONCLUSIONS: This pilot study demonstrates that it is feasible to apply a complexity science perspective to investigating primary health care case management. This supports a shift to viewing the human organism as a complex adaptive system within primary health care settings, with implications for health care practices that are more cognisant with the treatment of chronic and complex conditions and research opportunities to capture the complex clinical reasoning processes of practitioners.

Embracing the Complexity of Primary Health Care: System-Based Tools and Strategies for Researching the Case Management Process.

The provision of health care is frequently a complex process, and favourable clinical outcomes are dependent on the effective management of this complexity. Contemporary medicine and health care practices that are biomedically aligned have been informed by a reductionist paradigm, potentially creating a misalignment between health care and the human organism as a complex adaptive system. Complexity science is increasingly gaining momentum within the academic literature and is being employed across a wide range of scientific disciplines, although this is less evident in medicine. Limited evidence was found within the literature of a complexity science framework being used to explore and inform individual health care practices; in this paper, this gap will be explored through consideration of the use of strategies and tools (specifically mind maps, computer-generated network mappings, exploratory data analysis, and computer-derived network analysis) which are congruent with a complexity science framework. This information may be useful to researchers investigating health care provision and to clinicians wishing to incorporate a complexity sensibility within their practice.

The Intersection Between Models of Health and How Healing Transpires: A Metaethnographic Synthesis of Complementary Medicine Practitioners' Perceptions.

Introduction: This metaethnography provides an interpretative synthesis of complementary medicine (CM) practitioners' perceptions toward their health model and the healing process. CM is commonly described on the basis of its distinction from biomedicine with limited research available on CM practitioners' understanding of what the essence of their practice is and how healing transpires as a result. This is despite the significant patronage of CM and high rates of couse with biomedical services. Materials and Methods: An extensive and systematic search of the literature was conducted across seven databases (AMED, SINAHL, Medline, PsycINFO, PUBMED, Science Direct, and Scopus) with no date, language, or region restrictions applied. The basis for the search was MeSH terms and keywords relating to (1) CM practitioners, (2) perceptions, and (3) healing. A screening process was conducted and articles were identified for inclusion based on their addressing the research question. These articles were then quality appraised. A seven-stage metaethnographic framework was utilized to assist with identifying and interpreting the themes within the data. Results: Following the screening process, merely 10 qualitative studies were identified, which represented practitioner views across 22 CM professions. CM practitioners believe they provide a distinct model of care informed by a traditional shared holistic and vitalistic philosophy. Nonspecific factors, such as an augmented therapeutic relationship, empathy, and patient empowerment, are actively and deliberately incorporated into the treatment process alongside specific interventions and afforded equal valued. Conclusions: This metaethnographic synthesis brings together the perceptions of CM practitioners on how healing transpires within the CM clinical setting. In a context of medical pluralism and aspirational integrative health care, this synthesis highlights the understanding and approach CM practitioners bring to health management and may assist in further defining CM philosophy and practice, and the positioning of CM in the contemporary health care landscape.