Complex unordered
Here, patterns emerge through the interactions of multiple physical, psychological, and social inputs that may only be perceived in retrospect and not predicted with any degree of certainty. The clinical approach is to probe the system in order to make patterns or potential patterns more visible before taking action. Patterns that are found to be desirable are stabilised and those that are not are destabilised.
A complex system is defined as a network of elements that exchange information in such a way that change in the context of one element changes the context for all others.19 Recursive feedback at a local level gives rise to non-linearity (there is no simple relationship between cause and effect — small inputs can cause large system outputs and vice versa.) Although the system is inherently unstable and unpredictable, due to the presence of multiple feedback loops the system is capable of self-organisation, and ordered and stable patterns emerge that could not have been predicted from the study of individual elements. The emphasis moves away from prediction and control to an appreciation of the configuration of relationships among a system’s components and an understanding of what creates patterns of order and behaviour among them. Some important features of complex systems are shown in Box 1.
Box 1. Some important features of complex systems
Complex systems have a large number of components that are rich and diverse.
Positive and negative feedback loops in the systems give rise to non-linear behaviour (small changes can have large effects and vice versa) but give stability.
Because of non-linearity, the future state of the system cannot be predicted with certainty or the system manipulated to desired ends.
Any observer is co-evolving with the system and cannot stand outside of it.
The behaviour of complex systems emerges from the interaction of elements at a local level.
An important but contested concept is that complex behaviour emerges from the reiteration of a small number of guiding principles or simple rules. These may be implicit or explicit. Underpinned by these simple rules, the system invariably feeds back on itself rather than feeding back with reference to external set points — the source of standards of the system is the previous history of the system itself.
Where high levels of uncertainty exist, alternative approaches to the agent–principal problem are required. Here the patient–practitioner unit is the focus of analysis rather than the single units of agent and principal. Often practitioners know more than they can say and reveal a capacity for reflection on intuitive knowledge in the midst of action, and use this tacit capacity to cope with the unique uncertain and conflicting situations of practice.20 The emphasis is on the exchange of knowledge and negotiating of meaning in a relationship that is held together by commitment and ‘holding relationships’21 — ongoing support without expectation of cure.
Practical approaches to working in complex clinical domains have been described.22–24 Patient narrative techniques reflect the interpretive aspect of practice where patients’ experiences and priorities are integrated with the practitioner’s knowledge of pathology,25 but the danger of reducing them to a level of a technical description is recognised.
Stacey expands the focus, recognising the importance of free-flowing conversation allowing the space of possibilities to be explored and the expression of novelty and creativity.26 This theory of ‘complex responsive processes of relating’ acknowledges the ability to work with uncertainty and to display a ‘good enough holding of anxiety’. Unlike the ordered domain, where the focus is on the reduction of risk and uncertainty, the focus is on the exploration of probability and the accommodation of risk. The skill required is for the practitioner to enable free-flowing conversation but to remain sensitive to potential opportunities for change in the system trajectory.
As this domain becomes increasingly unordered, the practitioner’s ‘resources of complexity’ are best suited to the expression of complex problems. The faculties of mind and the resources of language become increasingly relevant to the expression of complex problems.27 The experienced practitioner has a unique capacity for contextual understanding of meaning and the processing of non-literal aspects of language and emotional expression that include metaphor, irony, and humour and can hold ambiguous possibilities in suspension without closure on one outcome.28 This clinical approach has been called ‘perceptual capacity’ — an intellectual grasp of the situation that also embraces the use of imagination and an appropriate degree of emotional engagement.29
From a service-delivery perspective, the focus is on a generalist practitioner ‘who integrates biotechnical and biographical care that is continuous and not disease centred and where health is seen as a resource for living’.30 A key feature is a high level of interpersonal trust and recognition of a much broader range of incentives. The medical humanities, an interdisciplinary field that includes the humanities, social sciences, and the arts, can provide important insights into the skills that are essential in this domain.
In the unordered domain, the research focus shifts to research undertaken as a dialogue within a socially constructed framework rather than an expert activity.31 Techniques such as action research32 and knowledge utilisation33 emphasise collective sense-making, through which knowledge is negotiated and constructed by stakeholders. Other, more practical approaches to research in complex health systems have been proposed.34,35
In the example of Table 1, the practitioner explores the patient’s family relationships and the reason for his heavy drinking. The practitioner reflects upon his own experiences of alcohol abuse and draws upon metaphor that resonates with the patient’s experience to describe his predicament, interjecting with appropriate irony and humour. They agree on some short-term goals and frequent review.
Chaotic unordered
Here there are no perceivable relationships between elements of the system. The system is highly turbulent and system characteristics are likely to change very rapidly and dramatically. The aim is to act quickly and decisively to reduce danger and return to a complex domain.
The focus will be on crisis management with the aim of stabilisation and focused interventions, often from an authoritarian perspective. For example, in the case study in Table 1, the patient is sectioned under the mental health act and, through a system of sheltered accommodation, brought to a less unordered domain.
