Nursing Standard
(C) Copyright 2000 RCN Publishing Company Ltd.
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Volume 14(32) 26 April 2000 pp 39-42
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Chaos, complexity and nursing
[Art&Science: Models And Theories]
Walsh, Michael RGN, DipN, BA(Hons), PhD, PGCE, A&E Cert
Michael Walsh RGN, DipN, BA(Hons), PhD, PGCE, A&E Cert, is Reader in Nursing, St
Martin's College, Carlisle.
Date of acceptance: January 19 2000.
These key words are based on the subject headings from the British Nursing
Index.
This article has been subject to double-blind review.
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Outline
Summary
Introduction
Dynamic systems and chaos
Complexity - or why the whole is greater than the sum of its parts
Boundaries: fractals, fuzz and fragmentation
Conclusion
REFERENCES
Graphics
Box. 1
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Summary
Chaos and complexity theories have implications for nursing practice. Chaotic
systems, potentially including health, the NHS and nursing, are governed by
rules which should be understood in order to try to predict future behaviour.
Complexity relates to the interconnectedness of things and fits neatly with the
concept of holistic care. It can also make important contributions towards
restructuring and reorganising nursing.
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Introduction
Many conventional ideas about the world we live in have been shaken to their
foundations by the emerging concepts of chaos and complexity. These new
scientific theories are being applied with startling results in the social and
natural sciences, particularly in the biological field.
Insights are now being gained from the application of complexity theory into
phenomena varying in scale from ventricular fibrillation to the spread of
epidemics. Nursing therefore needs to be aware of these new scientific ideas as
they have significant implications for the theory and practice of nursing.
Chaos and complexity theory encompasses a large field. However, in this short
article three key ideas will be introduced which are of relevance to nursing:
[black small square] Dynamic systems behave in an apparently unpredictable and
chaotic fashion, making predictions of future behaviour impossible unless the
rules governing chaotic systems are understood. Health can be argued to be a
dynamic system.
[black small square] The whole is greater than the sum of the parts, therefore
reductionism is severely limited in its use as a tool in health care.
[black small square] Boundaries between dynamic systems are naturally fragmented
and fuzzy, consequently trying to draw sharp lines between nursing and medicine,
for example, is fruitless.
Dynamic systems and chaos
One of the earliest and most accessible works which popularised chaos theory
came from Gleick (1987). He points out that science had in the past assumed that
the real world progressed in a predictable way, governed by laws and
mathematical
formulae which allowed accurate predictions to be made. The growth in computer
power enabled scientists to push their equations further as more elaborate
calculations became possible.
This led to the discovery by some scientists that, although they thought they
understood some types of systems, when they tried to run them forward and
predict future behaviour, very strange things happened. Predicting the weather
with any accuracy beyond a few days, for example, defied the most powerful
computers, despite a solid understanding of the laws governing the behaviour of
the atmosphere.
It became apparent that in certain systems what happens next is heavily
dependent on what happened last. These systems are very sensitive to feedback
and even the slightest variation can become magnified to produce major
disturbances.
This is known as sensitive dependence upon initial conditions or the 'butterfly
effect' - so called because it has been said that a butterfly flapping its wings
in the tropics can cause disturbances in air flow which become magnified so many
times over by sensitive feedback mechanisms, that the result several weeks later
is a tropical hurricane!
Such systems are known as dynamic systems and are distinct from linear systems
which have the characteristic of proceeding in a straight line. An example of a
linear system might be the catabolic processes occurring within the body after
major infection or trauma. If nothing is done, body mass will decline at a
steady and predictable rate due to a catabolic metabolism. However, dynamic
systems can produce startling variability over short time-scales due to their
sensitivity to feedback.
This variability can make the system appear chaotic and unpredictable, rather
like the weather. However, computer analysis of such systems reveals that there
is a deeper underlying order within the apparent chaos.
There are rules governing the behaviour of the system, hence it is referred to
as deterministic chaos. The challenge is to discover the rules and determine how
they operate so that we might gain insight into the apparently chaotic behaviour
before us. Deterministic chaos should be distinguished from stochastic chaos
which refers to random fluctuation or background noise, often distractingly
superimposed upon the bigger picture.
An individual's health behaviour is influenced by feedback from his or her
actions. Small decisions made today can have major, unforeseen consequences
tomorrow. A moment's reflection also reveals that the NHS has the
characteristics
of a dynamic system in that what happens today affects what happens tomorrow,
often in a very powerful and unexpected way. Sensitive dependence upon initial
conditions frequently exists together with a feedback linkage between events.
The basic ingredients are therefore present which allow us to view health, the
NHS (and nursing) at least by analogy, as potentially chaotic systems.
The implications of this insight are simple and far-reaching; small changes
today can have major and unforeseen consequences tomorrow. The corollary of
which is that it is not possible to predict with any accuracy what may be all
the effects of any healthcare reforms 10 or 20 years into the future, just as
nobody can predict the weather, even a few days ahead. Health care is a
potentially chaotic system and, until the rules governing that system have been
uncovered, long-term predictions must be hedged with considerable uncertainty.
Pediani (1996) is one of the few British nurses to have drawn attention to the
subject of chaos theory. He cites examples from the biological sciences, such as
the observation that patient responses to medication are not as predictable as
was once thought. Sensitive dependence upon initial conditions, coupled with
feedback, might produce completely unpredicted abnormal responses.
We are all familiar with patients who defy the textbooks and conventional
medical wisdom, to survive serious life-threatening illness for many years.
Others present with a minor condition and end up critically ill on intensive
care as one minor incident has a knock-on effect on something else, which
affects something else and so on. Ford and Walsh (1994) illustrated this effect
when they linked chaos theory to changes in nursing by referring to a well-known
nursery rhyme written by Benjamin Franklin in 1758 (Box 1).
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Box. 1. Franklin's nursery rhyme
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Benjamin Franklin could be said to be the first chaos theorist. His rhyme
illustrates how minor incidents can have enormous consequences. You might like
to complete a similar rhyme that starts 'For want of a battery the laryngoscope
did not work...' or 'For want of a few seconds the oxygen mask and tubing were
not replaced in resus...'.
The examples do not scan particularly well, but you can see where they might
lead and how such a rhyme might end '...and the patient was lost'.
Chaos theory therefore tells us always to expect the unexpected and never assume
that because something is predicted to happen it automatically will.
When the UKCC published the Scope of Professional Practice (1992), did it
foresee the changes it would lead to, not least the dramatic growth of the nurse
practitioner movement? Nurses began to have a new and more liberated approach to
expanding practice. This in turn opened the door to role expansion and practice
development. Nurses, patients and doctors then began to realise what nurses
could achieve. This feedback has led to further innovation and increasing
degrees of autonomous practice unthinkable in the 1980s, including the nurse
practitioner movement. Ironically, having let the genie out of the bottle, the
UKCC has since seemed incapable of knowing what to do with it!
The implications are that if change is planned in health care, it should be put
into practice cautiously. Those planning the change have to be prepared to live
with uncertainty and expect the unexpected. Careful piloting and evaluation of
new systems of working are essential so that evidence about what happens in
practice can be gathered as it happens and used to influence practice as it
develops. This action research approach is congruent with the basic idea of a
dynamic system.
Theoretical predictions are unreliable unless you know the rules governing a
chaotic system. The complete implementation of a new scheme such as the internal
market is effectively done by learning from trial and error and the nation's
health is too precious to gamble with in this way. This raises questions about
new initiatives such as NHS Direct, which is being rolled out without published
evidence demonstrating the clinical effectiveness of pilot schemes.
Nurses might be reminded of the introduction of the nursing process 20 years ago
without piloting or evaluation. Sensitive dependence upon initial conditions
suggests that if a change like this has flaws in its initiation, these will
become magnified as the change works through.
Nurses initially heard that the nursing process is difficult and time consuming,
therefore they expected it to be so and so it turned out, leading them to tell
others the same story, and so it went from bad to worse.
It has been very unpopular ever since, consuming large amounts of time and
producing documentation of poor quality. These consequences were not expected by
those who pushed through its implementation in the late 1970s. Life is easy with
the benefit of hindsight, but that is precisely the point about chaos and
unpredictability - it is never possible to be sure how things will work out.
Complexity - or why the whole is greater than the sum of its parts
One of the key elements in chaos theory is the notion of interconnectedness and
this leads into the emerging science of complexity. Put simply, this idea states
that the whole is more than the sum of its parts. A more formal definition is
that of Coveney and Highfield (1995) who state that: 'Complexity is the study of
macroscopic collections of such units that are endowed with the potential to
evolve in time'.
The key idea in this new discipline is that systems consist of individual parts
and that the effect of the parts in interacting with each other over a period of
time in which they may change and evolve is far-reaching and often
unpredictable.
The relationships between things are more important than the things themselves,
consequently it is the properties that emerge out of interactions between
entities that really matter (Goodwin 1994). Reductionism is rejected in favour
of understanding relationships. The concept of complexity has developed out of
chaos theory (Ray 1998).
The system being discussed could be a single human body or the entire NHS. Ray
(1998) has drawn attention to the relevance of this insight in nursing as it
fits neatly with the concept of holism. The reductionist approach of
conventional
science seeks to break complicated entities down into their components which are
simpler to study and understand.
Great advances in the natural sciences, including biomedicine, have been made as
a result of this reductionist methodology. This has been at the cost of losing
sight of the whole person as witnessed by the way medicine has fragmented into
so many specialties. The tremendous growth in knowledge has meant that
specialisation is perhaps inevitable, however, this has led to medicine often
ignoring the question of what happens when the pieces are put back together
again.
This reductionist approach leads some doctors into seeing patients as
malfunctioning
bits of anatomy and physiology rather than as whole persons. This problem was
neatly summed up by a busy consultant overheard admonishing his registrar in a
hectic outpatients for wasting time talking about the patient's problems and how
they were affecting his life: 'We've only got time to get on and deal with the
bits we can fix,' was his comment. A mixture of pressure of work and
reductionist
philosophy ensure that patients do not get treated as whole people, only as
'bits we can fix'.
Complexity theory offers a new way of thinking about health, one which nursing
has been working towards for the last decade or so. If nurses were to learn
about complexity theory it could provide the scientific, theoretical
underpinning
to support a holistic philosophy of care.
The reductionist approach which has dominated science since the Renaissance is
now being challenged by new ways of thinking based upon complexity. Studying the
natural and social worlds by only looking at their component parts in isolation
is missing the big picture. We have to put the pieces together again and see
what emerges in the process to understand what really happens.
Complexity is a fundamental part of nature; we have to recognise that different
entities will react with each other in strange and emerging ways, whether it be
at the level of cellular biology or social structures such as how a hospital
operates.
Not only does complexity have the potential to offer nursing a sound theoretical
base and major insights into patient behaviour, it can also make important
contributions towards restructuring and reorganising nursing.
This latter point is particularly relevant in view of our earlier discussions
about predicting the effects of change. The lesson is that if we are planning
some significant development in nursing practice, we have to look beyond nursing
to begin to gauge its likely impact. Changing nursing practice affects doctors,
porters, other ancillary staff, radiographers, the way stores are supplied, how
care is documented and recorded, staff outside the hospital, patients, carers
and a whole host of other people.
The effects of all these interactions can result in an outcome totally different
to the original intended change and greater than the simple sum of the changes
to the individuals involved. Chaos theory suggests that you will not be able to
predict the outcome, complexity suggests you should not be surprised at all
manner of unlikely outcomes. The whole is greater than the sum of its parts so
the totality of change will always be greater than the individual changes that
could be envisaged at the beginning.
This notion is captured in the phrase 'It seems to have taken on a life of its
own,' which exasperated project managers are often heard muttering when a
project refuses to go according to plan. This potential for dramatic change that
exceeds any which was foreseen could explain the strong resistance encountered
when an apparently simple change proposal is advanced. Staff soon to be moving
into the next wave of new Private Finance Initiative (PFI) hospitals might
ponder these ideas - plans might not transpire as intended and may indeed appear
to have a life of their own.
Boundaries: fractals, fuzz and fragmentation
The term fractal simply means that a boundary retains the same complicated
shape, no matter what scale it is viewed on. However much the boundary is
enlarged, new details and new areas of overlap will always emerge. It seems
impossible to resolve the boundary clearly so that all eventualities are neatly
split either side of the boundary. In nursing and health care we spend a great
deal of time arguing about boundaries, hence the relevance of gaining new
insights into boundaries.
Consider naturally occurring phenomena such as gender and life. Surely there is
a simple boundary that can be drawn separating male from female, or alive from
dead, as they are opposite conditions. For example, there will generally be no
confusing a man and woman - one is male, the other female. However, this does
not mean that it is possible to draw a simple line that delineates all males
from all females. There is much complex detail and many grey areas at the
male/female boundary, ranging from chromosomal abnormalities through a whole
range of psychosexual problems such as transsexualism, transvestism and on to
fashion trends involving one sex adopting the conventional dress characteristic
of the other.
Even the boundary between alive and dead has the same problem. Although it is
generally easy to distinguish between a person who is alive and one who is dead,
it is impossible to draw a neat line that delineates all things dead from all
things alive. On which side of the line does a virus or a prion sit? Where is
the patient in a persistent vegetative state or in those crucial few minutes of
cardiopulmonary arrest during a resuscitation attempt? Nature does not allow
neat lines that divide all eventualities into different conditions. Instead
there is a fractal fuzz - grey areas abound and there is a multiplicity of
crossover conditions. There is not a simple clear-cut boundary.
However in health care we expect such boundaries. We draw lines and say this
side of the line is nursing; that side is medicine. Nurse practitioners do not
comply with that kind of professional apartheid, which is probably why the UKCC
and some nursing leaders find them so difficult to understand. They have adopted
parts of medicine and located these skills within a holistic nursing model.
The UKCC and nursing as a whole have also propagated this artificial view of
boundaries into primary health care where we find no fewer than eight different
types of community specialist nurses separated off by professional boundaries.
Yet experience shows there are great areas of overlap between them, both in
terms of educational preparation and practice. Nature does not produce clear-cut
boundary conditions in complex situations, so why should nursing? Grey and
blurred boundaries are the norm in nature. The lesson of chaos theory is that
nursing is being unrealistic in demanding clear-cut dividing lines which cannot
be crossed.
Conclusion
As a nurse reading about chaos and complexity, I have found rational
explanations
for many things that have puzzled me about nursing. These ideas explain why
things never go according to plan, as development projects either get stalled
early on or appear to take on a life of their own. We should not struggle to
define boundaries so precisely that all possible conditions are separated off by
them. Instead we should accept that boundaries in nature are fuzzy and
fragmented areas of overlap and not waste time arguing about which professional
group should do what; rather, it is about the best qualified person carrying out
care for the patient's benefit.
Complexity and its notions of interconnectedness gives nursing a theoretical and
philosophical underpinning for practice that has much more to offer than the
limited reductionist approach of traditional science. Modern scientific thinking
can help nursing if we are prepared to accept the challenge of looking outside
our traditional narrow field of theoretical endeavour.
The application of complexity theory to nursing would make an excellent topic
for a conference which might indulge in some 'over the horizon' speculation, and
explore the future foundations of nursing
REFERENCES
Coveney P, Highfield R (1995) Frontiers of Complexity; The Search for Order in a
Chaotic World. New York NY, Fawcett Columbine.
Ford P, Walsh M (1994) Nursing Through the Looking Glass, New Rituals for Old.
Oxford, Butterworth Heinemann.
Gleick J (1987) Chaos. New York NY, Penguin.
Goodwin B (1994) How the Leopard Changed its Spots; the Evolution of Complexity.
New York NY, Simon and Schuster.
Pediani R (1996) Chaos and evolution in nursing research. Journal of Advanced
Nursing. 23, 4, 645-646. Ovid Full Text Library Holdings Bibliographic Links
Ray M (1998) Complexity and nursing science. Nursing Science Quarterly. 11, 3,
91-93. Library Holdings Bibliographic Links
United Kingdom Central Council for Nursing, Midwifery and Health Visiting (1992)
Scope of Professional Practice. London, UKCC.
Key words: Interprofessional relations; Models and theories; Outcomes and
prognoses
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Accession Number: 00002311-200004260-00053
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