Nursing in the Age of Complexity, by Claire Lindberg, Sue Nash, and Curt Lindberg, Bordentown, NJ: Plexus Press, 2008. 304 pages, $44.95.
Where was this book when I needed it when I was studying full-time for my PhD at New York University (1970-1973) while working full-time and trying to understand the theoretical foundations of nursing science and practice? I remember bits and pieces of the reductionistic, Newtonian, worldview theory (understood by studying the parts of things and keeping research separate from values, religion, and philosophy) colliding with Martha Rogers' and others' complex, interactive, postmodern, simultaneous, interaction, wholeness theories (understood by studying nonlinear, unpredictable relationships between things, not the things/parts themselves, and accepting the promise that truth and knowing is based on one's own reality).
Why would a nurse--any nurse with any level of education--want to read this book? It provides an explanation of the world we work in!! Complexity science is not a single theory. It combines multiple theoretical frameworks that can be useful to many different disciplines. The authors offer a convenient chart of examples of selected complexity scientists and their contributions on page 33. Complexity science explains the "both/and" rather than "either/or." In other words, it provides a framework for inquiry that helps explain how the world really functions. It sees paradoxes and conflicts as points of strength. It brings 2 conflicting worldviews into a complementary arrangement, recognizing that human relationships are never simple, predictable, or sequential.
The authors ask the readers to consider how complexity science helps nurses and nurse managers improve outcomes of care. An important area addressed is the tension between task orientation and relationship management, a challenge with which any nurse can identify!!
Among theoretical frameworks generally encompassed by complexity science are complex adaptive systems (CASs), which are agents, like nurses and patients, that relate to each other and the environment in nonlinear ways and complex responsive processes, which are processes of human relationships that, through the process of self-organization (defined evolution to a completely new state), create patterns of interaction that may lead to widespread, new patterns of behavior. Many nurses have an intuitive sense of CASs and complex responsive processes principles since we live with uncertainty, understand that linear control in patient care is an illusion, and recognize that human-interacting variables lead to many surprises and unintended consequences. Complexity science gives both structure and voice to our experiences.
Chapter 3 continues to help the nurse have a better understanding of the relationship of complexity science to the future of nursing theory, nursing theory development, and the science on which we base our practice. It also includes, on page 54, a useful chart on the History and Philosophy of Science's key terms and definitions.
Chapter 4 addresses CASs as they organize themselves into patterns of relationships not governed by hierarchies (eg, the interaction of nurse manager, nurses, aides, and family members in a nursing home). In fact, all health organizations are CASs. Included also is a table of examples of Empirical Research Themes and Topics. For example, one study supported the hypothesis that nurse management practices in a nursing home that increased information flow, connection, and cognitive diversity also improved resident outcomes. It was observed that the nurse management practice of "pitching in" effectively created connections among staff, broke down status barriers, and facilitated teamwork.
Chapter 5 suggests that the human body may be seen as a system of systems, each separate system being complex in its own right but contributing to a complex network of interacting networks.
Chapter 6, page 138, displays an interesting table that shows contrasting views of policy issues from both a mechanistic and a complex perspective. For example, a mechanistic solution to the nursing shortage would be mandatory nurse-to-patient ratio that could be applied in a standardized fashion for comparison purpose. We all know that this does not work!!
In chapter 7, the authors discuss the fact that the nurse managers face paradoxes in accountability that impede true accountability when treated with traditional, linear evaluation frameworks as contradictions.
Chapter 8 explores thinking strategies that enable one to perform clinical reasoning gained through practice, conscious reflection, and attention to complex issues associated with a client's stay and the context of practice. It points out that nursing diagnoses are knowledge representations that define, explain, and describe patterns of behavior and responses to illness.
Chapter 9, page 230, includes 20 questions that optimize care by allowing the nurse to appreciate the complexities in clinical reasoning that describe these patterns and responses.
Chapter 10 focuses on the leadership competencies in complex systems of shared sense making, exploring, and connecting. Obviously, leadership in complex systems is not a "lone ranger" task!! A complexity science approach to leadership recognizes that the future is unknowable and unpredictable but that it is shaped by individuals and organizations with the competencies to explore, connect, and make sense!!
The obvious purpose of nurses using theory to inform practice is to improve care, but our ability to predict and impact the efforts of our intervention on health outcomes in any predictable way, especially in chronic care, is variable. Nurses use (and need) both linear and nonlinear problem-solving skills, hence the need for this book and the need for dramatic changes in nursing (and medical) education to help clinicians make better sense of the patient care experience and to better address problems in practice.
The authors make a convincing argument that "complexity science" is more relevant to nursing practice today than nursing's historically important theories. "The future is unknowable and unpredictable, but its emerging features are shaped by those individuals and organizations with the competencies to explore, connect, and make sense of a non-linear world."
Colleen Conway-Welch, PhD, CNM, FAAN, FACNM
Dean Vanderbilt School of Nursing Vanderbilt University Nashville, TN