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Managing Complexity in Healthcare
Lesley Kuhn, Kieran Le Plastrier
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eBook - ePub
Managing Complexity in Healthcare
Lesley Kuhn, Kieran Le Plastrier
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About This Book
Managing Complexity in Healthcare introduces the ComEntEth (Complex Entropic Ethical) model as an integrated bio-medical and philosophical approach to understanding how people get things done in healthcare. Drawing on the complexity sciences, studies of entropy in living organisms and the ethics of Emmanuel Levinas, healthcare is theorised as energetic relational exchanges between people as entropic and ethical entities that unfold around a central attractor: Reduction in elevated entropy or suffering in patients.
Living entities are engaged in a continuous struggle against the tendency to produce entropy. From the cellular to the collective of human endeavours, the tendency of complex systems is to disorder and decay. Yet in the micro-activity of healthcare enterprise, people resist this tendency by expending energy to create order and sustain life. Making sense of how this miraculous work is made possible is the foundation of this book.
Through practical examples – from analysis of practitioner burnout, rural and remote healthcare, the functioning of emergency departments, to government, social and institutional responses to the COVID-19 pandemic – this new integral philosophy provides practitioners, managers, policy designers, and scholars an effective way to understand the dynamics of daily processes and practices that link the micro of everyday interactions with the macro-trends of healthcare.
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1 Healthcare as Complex, Entropic and Ethical
DOI: 10.4324/9781003197454-1
Introduction
So, you’re a physician in a busy hospital emergency department, and as you’re introduced to your next patient you think ‘How can I best find out what is really going on with this patient? What communication style should I adopt to have you tell me what I need to know to make a diagnosis?’
To define the case before you, you interpret the signs and symptoms presented by the patient and map out a course of action towards diagnosis and treatment. This involves additional information gathering, such as interviews with extended family, radiology and pathology, or another specialist review. It will be an iterative process as you test and re-test your hypothesis, all the while aware of the nurse manager’s urgent reminder that you have this patient out of the emergency department within four hours.
Born of the uncertainty of the initial encounter and the models of working through the clinical problem, you arrive at your diagnosis and management, and ask yourself, ‘Have we missed something? Are these medications worth it? How does this person understand what is going on?’ So, you begin with some fluids and come back and check vital signs. Actually, you repeatedly return, re-examine and reassess.
This patient is one of 80 you will supervise treatment for in a shift (roughly a day). To do this well, you are dependent on staffing levels and expertise, effective working relationships between and with staff, patients and their carers, hospital administrators, availability of necessary technology and so on, and you are dependent upon the layout of the clinical environment so that you can physically get to each patient to check on them.
Importantly, aware of managing your cognitive load, you notice that your capacity to cope with huge amounts of stuff at once reduces when you are stressed and in survival mode. At those times, you pull back to become intensely focused on the patient in front of you, and you know that then you lose awareness of others and tend to become snappy with colleagues.
In popular culture, the emergency department (ED) has become a symbol of healthcare. It is for this reason that we chose to depict an ED as the opening vignette to this book. Based on a compilation of verbatim reflections of physicians, this vignette is intended to indicate something of the multitude of complex relationships that make the provision healthcare challenging.
Every day of the year, people experiencing illness or trauma and seeking care (the ‘patient’ in our shorthand terminology) and healthcare practitioners (registered health practitioners such as a physician, nurse, psychiatrist, physiotherapist podiatrist, chiropractor or other accredited health professionals) encounter each other at all hours of the day and night, in a diversity of dynamic and energetic environments – local medical practices, specialist clinics, allied health professional practices, hospital EDs and so on. Moments of loss and heartache unfold alongside triumph and banality, as humans and technology interact and engage to transform the experience of suffering towards its relief and the restoration of health and wellbeing. This is complexity in action.
Aside from appreciating the provision and practice of healthcare as exquisitely complex, we are interested in better understanding the nature of this complexity so that we might better understand what constitutes improvement.
Essentially, a theoretical explanation of the nature of healthcare, our intention in this book is to outline a complexity informed conceptualisation of healthcare and to thereby identify principles and practical implications, for improving patient experiences and health outcomes.
The ComEntEth (Complex Entropic Ethical) model of healthcare
Our fundamental postulate is that in complex phenomena, such as health-care, complexity unfolds in entropic flows, under the influence of an ethical attractor.
We construe healthcare as complex because we understand that it is via multi-layered social interactions (such as between patients, practitioners, managers, administrators, policy makers) that healthcare exists. We say that in healthcare, ‘complexity unfolds in entropic flows’, because from a complexity perspective, these social interactions give rise to emergent collective behaviours, and because, characterised thermodynamically, these social interactions constitute energetic transactions and transformations (entropic flows). We describe these social interactions as ethical because we conceptualise the social interactions constituting healthcare, as based on, and organised in response to, an ethic of responsibility to relieve the suffering of others.
Thus, we propose the central attractor motivating and organising health-care activities as, efforts to reduce elevated entropy or suffering in patients, with this being achieved via ethically motivated reciprocal energetic interventions between healthcare practitioner and patient. In this framing, improvement in healthcare occurs through reduction in development of entropy across the whole landscape of healthcare, including in patients and practitioners.
To explain the logic of this novel theoretical framing, we employ and integrate concepts from the complexity sciences, thermodynamics and the ethical thinking of Emmanuel Levinas. Firstly, we make use of the complexity sciences to present a conceptual framing of the structure of relations between stakeholders in healthcare. Secondly, we draw on the second principle (or law) of thermodynamics as it is understood to operate in complex living organisms, to describe the structure of relations in terms of energetic transactions, transformations and management of entropy. Thirdly, we turn to the ethical thinking of Levinas to explain a relation of responsibility between the patient and healthcare practitioner as the impetus for enabling action within the structure of relations (why the person suffering illness/trauma turns to healthcare for help and why the practitioner cares). Bringing together complexity, entropy and ethics, we refer to our conceptualisation as the ComEntEth (Complex Entropic Ethical) model of healthcare.
In framing healthcare as complex, as unfolding through entropic exchanges and enlivened through an innate sense of responsibility towards the other, we offer a descriptive rather than prescriptive explanation. We are, in effect, offering a considered theorisation of ‘how things are’ rather than ‘how they ought to be’.
Generative context
One of us (Le Plastrier) is a medical practitioner working in Australian public hospitals, who has long been interested in the factors that shape his and his colleagues’ performance in the practice of medicine. The other of us (Kuhn) is a transdisciplinary thinker who, for more than 25 years, has been active in developing complexity thinking in philosophical and social inquiry. This book has its origins with the doctoral work undertaken by one of us (Le Plastrier) and supervised by the other (Kuhn).
An extensive review of healthcare research literature (Le Plastrier, 2019) revealed that while there are significant contributions and important insights offered within healthcare research into interactions between patients, practitioners and managers, an ontological, epistemological and axiological framing was either assumed or incomplete.
The research team of the Norwegian interdisciplinary research project ‘Causehealth, Causation, Complexity and Evidence in health Sciences’ (Anjum, Copeland and Rocca, 2020) likewise critiques the lack of a secure philosophical grounding to healthcare and the way that philosophical assumptions motivating particular processes and practices have not been explicitly examined. They draw attention to the dominant influence of the bio-medical model of health and disease where all health complaints are assumed to be explained as physiological abnormalities rather than as containing biological, social and psychological elements, and to the way that care is often fragmentised, due to the compartmentalisation of healthcare into specialised medical disciplines.
This book represents an attempt to articulate a secure philosophical grounding for healthcare, and as such, it is concerned with applied philosophy. It is philosophical because it addresses fundamental assumptions concerning the nature of reality (ontological beliefs), the nature of knowledge (epistemological beliefs) and the role of values (axiological beliefs). It is applied because it explains how understanding healthcare as complex, entropic and ethical can enable and shape improved practice.
The perspective we bring to this undertaking is one that recognises, along with pragmatist philosopher, Richard Rorty, the folly of thinking ‘that true beliefs are accurate representations of a pre-existent reality’ (Rorty, 1999, p. 296). Rather, we are mindful that our beliefs about the world, our fundamental assumptions, determine what it is that we ‘see’ and give rise to strategies of action. As biologist and cybernetician Gregory Bateson reminds us, human knowing is ‘bound within a net of epistemological and ontological premises which … become partially self-validating’ (Bateson, 1972, p. 314).
We set out in this book a new way of conceptualising the complexity of healthcare that provides practitioners, managers and policy designers, an effective and novel way to easily identify links between macro manifestations and trends in healthcare, and the micro of everyday activities. It is expected that this novel ComEntEth model will assist practitioners, managers and policy designers to gain insight into the mechanisms by which the behaviour of departments, institutions and sectors arise, and facilitate the capacity of those involved to more constructively work together to improve the practice of healthcare.
History shows that humans have a predilection to explain experience and over time certain explanations have come to shape cultural, social and historical norms of understanding. Just as others have formed theories when they found themselves in the midst of certain life experiences (in a complex and ever-changing world) that they wanted to understand, this book presents our theorising of the processes and practices of healthcare. In accord with cultural historian Richard Tarnas’s view that intellectual history is informed by ‘tension and interplay – between critical rigor and the potential discovery of larger truths’ (Tarnas, 1991, p. xiii), we do not see our theorising as indicative of understanding that is closer to the ‘truth’ of ‘reality’, but rather as useful to facilitating effective coordination of behaviour in healthcare.
A complexity perspective positions the human knower as ensconced within that which we observe, rather than as a separate independent observer. In this way, complex thinking construes human observing as participation in a relational universe where both the nature of the universe and human sense making (observing or knowing) are understood to be self-organising, dynamic and emergent. As Belgian Nobel Laureate Ilya Prigogine and colleague, Belgian philosopher Isobel Stengers, note: ‘Whatever we call reality it is revealed to us only through an active construction in which we participate’ (Prigogine and Stengers, 1984, p. 293).
In recognising the fundamental interdependence between the perceiver and perceived phenomenon, complex thought retains a sense of humility and requires that we build into our knowledge generation an epistemic level of awareness of the means by which our understanding develops. Our theo-rising, in effect, begins with ‘Let us assume that …’ and continues with a reminder: ‘Don’t forget that reality is changing, don’t forget that something new can (and will) spring up’ (Morin, 2008, p. 57). Thus, positioned between certainty and hope, we aim to provide useful indications for successful future action in healthcare.
Over the past 20 years, researchers have found value in viewing health-care from the perspective of complexity (see, for example, Kuhn, 2002; Plesk and Greenhalgh, 2001; Sheill, Hawe and Gold, 2008; Sturmberg, 2019; Sweeney and Griffiths, 2002), where humans are conceived as ‘composed of and operating within multiple interacting and self-adjusting systems (biochemical, cellular, physiological, psychological and social systems)’ (Wilson, Holt and Greenhalgh, 2001, p. 685). The World Health Organization (WHO, 2006) similarly advocates that healthcare be understood as a complex system, ‘in which there are so many interacting parts that it is difficult, if not impossible, to predict the behaviour of the system based on knowledge of its component parts’ (WHO, 2006, p. 1). Our theoretical model of healthcare extends complexity based conceptions by explaining complex emergence in terms of entropic flows.
We understand healthcare as complex because it arises through multilayered social interactions between people, who learn and who are changed through these interactions.
Consider, for example, how dentistry, physiotherapy, podiatry, speech pathology, or other professional practices evolve. Whether as a private practice business or as part of the public sector, individual practices exist in a web of interactions, both contemporaneous and historical. Educational experiences, professional alliances, patient cohorts, client groups, research bodies, government policies and regulations, and the economic climate, all contribute to how healthcare practices function. Both professional practices and the individuals involved learn and are changed through these webs of interactions.
Other broader social interactions, such as contemporary dominant discourses (about, for example, what is important or how best to get things done) and dominant discursive styles of communication, contribute to how healthcare is manifest. Traditional as well as contemporary social media (such as Facebook and Twitter) strongly influence socio-political discourse and communication about healthcare related matters and influence public consciousness of what needs doing. Socio-political, social media-based influence on the practice of healthcare, while mostly devoid of an empirical base, can nudge contemporary dominant discourses towards accepting those views currently ‘trending’ on social media. So, ideas about what is acceptable in healthcare come to be those ideas that are socially approved, rather than those based on scientific and medical research.
The present prevalence of an economic rationalist perspective brought to most human activities also shapes healthcare, so that governments judge and are judged upon, how econom...