The theory of complex adaptive systems, as one aspect of complexity science, adds a di- mension called “the edge of chaos, which lies between stability and chaos and where cre- ativity thrives” (Penprase & Norris, 2005, p. 128). Burns (2001, p. 475) described this edge as the area where “there is not enough stability to have repetition or predictability; but not enough instability to create anarchy.” Although complex adaptive systems appear to be unpredictable, order is inherent and emerges in change and within complexity.
Cilliers (1998, pp. 3–5) and Holden (2005, p. 654) outlined the specific characteristics of a complex adaptive system: many elements that interact in a dynamic way exchanging information; rich, nonlinear interactions with a limited range; open systems with enhanc- ing or detracting feedback loops; continual change and constant flow of energy where there is no equilibrium; embedding in a context of history, where no single element can control or comprehend the whole and “systems are embedded within other systems”
and continue to coevolve (Plsek & Greenhalgh, 2001, p. 626). Complexity is the result of patterns of interactions.
A complex adaptive system is an “open, dynamic and flexible network that is con- sidered complex due to its composition of numerous interconnected, semi-autonomous competing and collaborating members” (Indianapolis Discovery Network for Dementia, n.d.). It is “a collection of individual agents with freedom to act in ways that are not always totally predictable, and whose actions are interconnected so that one agent’s ac- tions change the context for other agents” (Plsek & Greenhalgh, 2001, p. 625). It can be seen as a large network of agents and interactions. The behavior and nature of the entire system emerge from the interaction among the agents.
Many professionals refer to various aspects of health care as complex adaptive systems (Miller, Crabtree, McDaniel, & Stange, 1998), although the term healthcare system has a variety of meanings itself. It may refer to the entire health care industry, including struc- tures, processes, and personnel, or it may refer to a single organization or system within an organization. Some may argue that although health care is complicated, it may not be the best example of a complex adaptive system. A complex adaptive system is char- acterized by flexibility and patterns of emerging change as opposed to predetermined change based on hierarchical or central control. Any clinician can enumerate a long list
of areas in health care that persist in the linear, hierarchical paradigm. Nevertheless, quanta, chaos, and complexity offer models to frame the issues in the current realities of health care toward a hopeful transformation to a better future. Indeed, some of the current problems of health care may relate to the challenging transition from traditional thinking to a complexity perspective.
There are several key characteristics of complex systems. The first is emergence, or the idea that behaviors, patterns, and order emerge as a result of nonlinear patterns of relationships and interactions among the elements or units of the organization. Second, relationships are short range, or interchanged from within a unit or near neighbors in a matrix of networks within the larger whole. The units, or parts, cannot contain, deter- mine, or control the whole. Relationships are nonlinear, seldom cause-and-effect, and contain feedback loops. Feedback may be damping (negative) or amplifying (positive), and a small stimulus may have a large powerful effect or none at all. Because complex systems are open, energy and information constantly cross boundaries and create con- stant change (Seel, 2008; Stroebel et al., 2005). Coevolution is a “process of mutual trans- formation” for both smaller units and the larger organizational environment (Stroebel et al., 2005).
The “fitness landscape” is how an organization fits within an independent/dependent interaction with other agents, units, or organizations. Penprase and Norris (2005, p. 128) explained within the complexity of a hospital environment:
As one unit makes changes, other nursing units are positively or negatively affected depend- ing upon how each unit elects to adapt to that change. Because change cannot occur without its effects rippling into other competing areas or units, both competition and coevoluation work together, as characterized by dynamic equilibrium and causing continuous changes in outcomes (Seel, 2008). Thus, each nursing unit is dependent on another nursing unit as each hospital is dependent on the actions of other hospitals and must adapt to change caused by internal and external factors in order to survive.
Such interactions among various groups of people or units form feedback loops that move the organization toward its fitness landscape. It is important to understand that such feedback loops are not conceptualized in the same way as feedback loops of tradi- tional systems or leadership theories, where such loops serve to support homeostasis.
Rather, feedback loops in complexity theory support communication within the larger organization, feeding new information and creative thinking throughout the organiza- tion (Penprase & Norris, 2005). Think of them as webs of informal communication net- works interconnected across and within all levels of the organization.
Another important concept is “attractors.” Attractors are values, ideas, activities, is- sues, plans, or other entities to which individuals or groups are naturally drawn. At- tractors serve to “stabilize” or provide order from the evolving networks and guide or govern behavior. They serve as an institutional memory and place of information pro- cessing. Attractors may be stable or unstable, hidden or overt (Kaufman, 1995; Penprase
& Norris, 2005; Walls & McDaniel, 1999).
The very language of complexity theories can be intimidating: chaos, unpredictabil- ity, and change as desirable. Such ideas set fear inside traditional clinicians and leaders accustomed to predictable and controlled systems where change initiatives are based on top-down implementation of prescribed protocols or “best practices.” For example, one
nurse leader framed alarm about hospital errors in a context of complexity theory as she warned, “Because health care is a . . . complex adaptive system, it’s more prone to acci- dents. . . . By definition, a complex system has interacting components that work in both expected and unexpected ways. If one component fails, all downstream components may fail . . . we can’t predict how each component will respond. . . . In our healthcare system, humans contribute to this element of unpredictability, creating the possibility of error or innovation” (Cipriano, 2008, p. 6). The very image of “downstream” reflects linear, unidirectional thinking. Leaders of the next generation will embrace complexity and promote positive emergence. Complexity and chaos viewpoints promote the oppor- tunity for integrated independent autonomy and action to prevent (rather than cause) error onsite in real time. Complexity models may also promote accountability for more effective error prevention. We must move beyond the idea that complexity promotes er- ror. Inherent in the challenges of complexity are opportunities for creativity and power to make critical immediate decisions and actions that change lives for the better. But it requires personal integrity, accountability, commitment, and creative leadership.
The concepts and images of complex adaptive systems may inspire or confuse the leader dealing with real life-and-death issues on a daily basis. Specific application can be challenging. Penprase and Norris (2005) provided a specific example of the application of complex adaptive systems theory to nursing leadership.
A vice president for nursing was frustrated at attempts to implement a new commu- nity outreach program:
She became frustrated with her staff’s lack of ability to move the nursing department for- ward to adopt a community outreach program that was needed within their hospital sys- tem. In response, she disbanded previous committees that had been formed to develop and implement strategies for the new community outreach program and instead implemented a complex adaptive system framework for institutional change. She promoted her vision of what she hoped for the new community outreach program, stressing its importance to the community and the hospital. In doing so, she gave the staff three basic and simple rules to follow: any nurse could take up to a half-day a week to undertake a community health interaction that she cared about; nothing could be done that was illegal; and nurses could take funds needed to support the initiative from the nursing department’s outreach budget. Within a short time, 27 projects had been initiated, some more successful than oth- ers, but all that helped create a very successful community outreach program. Through a clear vision, [a few simple rules and guidelines] . . . and the freedom to spontaneously regroup into similar interests, results were quickly obtained. (Penprase & Norris, 2005, p. 131)
Margaret Wheatley (2007) summarized what she called “the real world” from a com- plexity perspective:
It is a world of interconnected networks, where slight disturbances in one part of the system create major impacts far from where they originate. In this highly sensitive sys- tem, the most minute actions can blow up into massive disruptions and chaos. But it is also a world that seeks order. When chaos erupts, it not only disintegrates the cur- rent structure, it also creates the conditions for a new order to emerge. Change always involves a dark descent into meaninglessness where everything falls apart. Yet if this
period of dissolution is used to create new meaning, then chaos gives way to the emer- gence of new order.
This is a world that knows how to organize itself without command and control or charisma.
Such perspectives provide images for leadership that border on the poetic. They offer an invitation for the most adventurous and courageous actions to lead others into the next century of health care where systems truly offer hope and healing.