Complexity Theory and Nursing:
Explanation and Application
Complexity theory emerged from the mathematically based science of physics, particularly quantum physics in which “relationship is the key determiner of everything” (Wheatley, 1999, p.11). Studying the properties of complex systems and applying these ideas to nursing helps us to think differently about our profession. We will appreciate the vast web of interconnections that is the systemic nature of life and see how this resonates with our holistic nursing principles and the lived experience of nurses. This paper will describe concepts from complexity theory and apply the ideas to nursing.
Complexity theory has much to offer the nursing profession. It provides a framework that is far more realistic and holistic than the mechanistic, reductionistic paradigm that permeates the allopathic medical system. Complexity theory readily acknowledges the impact of the multitude of factors influencing health while accepting the uniqueness of each nursing interaction. Relationships are stressed over discrete components. It gives credence to the potential of a unique nursing intervention to have a profound affect on an individual client or even to reverberate beyond the specific interaction. Indeterminacy and unpredictability are hallmarks of this theory, allowing us to honor the creativity and innovation inherent in nursing activity.
Complexity concepts such as patterns, dynamical systems, non-linearity, sensitivity to initial conditions or the butterfly effect, disproportional effect, phase space, attractors, basin of attraction, fractals, self-similarity, dissipative structures, bifurcation, the edge of chaos, and self organizing systems seem foreign to nursing. Yet the abstract application of these ideas will help to synchronize our profession with the emerging scientific worldview.
Nursing is an open, dynamical system that gains energy from society’s need for nursing care. Dynamical systems evolve over time (Strogatz, 1994). Dissipative systems are dynamical systems in non-linear flow requiring energy to be gained externally for maintenance. Patterns are then stabilized in response to feedback. Ilya Prigogine coined the term “dissipative structures” to describe open systems that spontaneously emerge, developing and maintaining self- organization. “We have called these new structures dissipative structures to emphasize the constructive role of dissipative processes in their formation.” (Prigogine & Stengers, 1984, p.12) The potential of evolution, for an individual or a profession is acknowledged. Continuous energy flow enables order to emerge out of chaos (Marshall & Zohar, 1997).
Nursing could be viewed as a dissipative system, a self- organizing system that gains energy from the environment, is responsive to feedback and evolves over time. The need for nursing care is the energy that maintains the open system. The greater the need, the more energy input. As long as there have been people there has been the need for someone to care for the ill and injured. The organization for the care taking has varied as greatly as has our human history. Feedback influences the configuration of the patterns that emerge. In the western world, nursing has emerged as a profession, changing and evolving in response to our society.
Pattern is a word often used in complexity theory. This is because complexity theory studies the interrelationship of multiple components, a weaving of forces, interconnected parts networking to create complex form, form in motion. (Glick, 1988). “To understand a pattern we must map a configuration of relationships” (Capra, 1996, p. 81).
Mapping configurations in our world is very complex. Our mechanistic, reductionistic scientific heritage has taught us to attempt to understand the whole by examining the parts. Unlike a linear system, non-linear systems can not be broken down into parts. This is why “most nonlinear systems are impossible to solve analytically” (Strogatz, 1994, p.8). Non-linearity is a difficult idea to accept in a society that is constantly seeking specific causes and solutions for problems.
We break things down into parts so that we may attempt to describe an ineffable reality. With complex systems such as people and their social systems, the observer artificially contrives the patterns perceived by attempting to demarcate interrelated components. We do this on many levels. On the physical plane, we describe the human body as a complex system composed of multiple components such as the respiratory, neurological, and skeletal systems. Physicians even specialize in the individual systems. Nurses promote the holistic view of the human being and add other components such as mind and spirit. It is challenging to describe our world in ways that embrace complexity. We use terms such as biopsychosocial in an attempt to convey the whole but this does not fully describe the integrated being.
Complexity theory invites us to consider the interrelationships of the emotional, psychological, spiritual, cultural, social, and other patterns influencing each being’s reality at any given point in time. It would also recognize that the individual is embedded in larger patterns such as families and communities. We can easily expand this thinking to acknowledge the even broader patterns that affect people and communities such as the environment, the economy, and the political system.
With complexity theory there is acknowledgment of the interconnection of all patterns. The nurse has theoretical supports for holistic nursing, the caring of the whole human being embedded in a vast array of systems. The nurse has been taught to consider interpersonal relationships and see an entire community as a “client”. Multidimensional components impacting health and healing are nursing concerns. Florence Nightingale (1969) noted that “the effect in sickness of beautiful objects…is hardly at all appreciated” (p.58). She also noted the impact of the mind on the body and reminded nurses to consider the effect of the body on the mind.
With all components in relationship with everything else, an action in one area reverberates throughout the system. Tending to one aspect of a being then is healing energy for the whole. Nurses will tell stories about how simple caring actions such as enabling visits, washing hair, or attentive listening affected patients. Complexity theory supports the intangible nursing care that is often devalued in a task oriented, productivity based organization.
Attractors and Basin of Attraction
When dynamical systems are studied there is strong evidence of self-organization. The patterns that form spontaneously within dissipative systems are called attractors. Marshall & Zohar (1997) said that a system is in the grip of an attractor when it acts as if compelled to repeat a certain type of behavior. The “attractor” for nursing is the care of others as related to health. It is the process of alignment of the professional nurse(s) supporting the client with intentional holistic activities related to health need. Without this, the pattern is not nursing. This pattern of caring is repeated over and over, providing evidence of self-similarity. Nursing, with its infinite variety of manifestations, remains within boundaries, the attractor of nursing.
Everything that reaches the attractor must come from within the “basin of the attractor”. The basin of the attractor contains all the points that have a trajectory that may reach the attractor, that is, all possible points from which energy could be drawn to a particular pattern (Williams,1997). Nursing has a huge basin of attraction. The nursing care needs of individuals, groups, and communities provide the energy needed to sustain the system.
Attractors are classified according to the type or types of behavior that tend to be repeated within particular limits, the movement of the energy in the system. There are point or static attractors, periodic or cyclic attractors, and chaotic attractors (Abraham, Gardini, & Mira, 1997). If the pattern tends to focus toward a single area in the pattern it is described as a point or static attractor. Periodic attractors have patterns that vacillate between two points. The system is always attracted to both, tending toward one or the other according to its history. More than two areas of pull in the system create a chaotic or strange attractor with a pattern that continually ebbs and flows around the multiple points. The trajectory is dependent upon where the input enters the pattern and the varying strength of the multiple points in the attractor. The pattern appears chaotic.
Patterns may change or bifurcate, either evolving to more complex patterns or dissolving and losing form in response to nonlinear feedback. These changes occur only when there is sufficient energy in the system, when the system is in a state far from equilibrium or at the “edge of chaos” (Prigogine & Stendgers, 1984). A point attractor may respond to the intensity of the feedback, be pulled in another direction, bifurcate and evolve to a periodic attractor. Periodic attractors bifurcate to chaotic attractors.
Nurse Practitioner Role: A Dissipative Structure and a Periodic Attractor
The role of the nurse experienced an evolution, reached a bifurcation point and evolved forming a dissipative structure. The new role, that of the nurse practitioner, emerged from the disharmony and chaos of nurses functioning in an expanded, ill defined advance practice arena. The attractor pattern is periodic or cyclic with nursing and medicine each influencing the configuration of the encounter. The exact nature of the specific intervention varies dependent upon the trajectory of the client entering the basin of attraction. The need of the client, the history of the practitioner, and the feedback related to the health care issues influence the manifestation of the care. In one situation the pull of the medical point may dominate, such as when the client enters the basin of attraction because of a physical illness requiring drugs. At another time the patient may be more in need of emotional support or education and be more strongly influenced by the nursing point of the attractor. The care from a nurse practitioner is responsive to both nursing and medical sciences.
Nursing at the Edge of Chaos
Evolution occurs when a system is far from equilibrium, at the edge of chaos. A client in distress could be viewed as a dissipative system at the edge of chaos. The system reaches a bifurcation point. The system could dissolve, as in death, or evolve. The further from equilibrium the greater the potential of evolution. The nurse enters the system and the client responds to the services of the nurse. The nursing activity is the energy used with the potential of evolution to a new stable state, a more evolved dissipative structure. The more disharmony or illness, the greater the potential for change to occur.
This abstraction could also be applied to the nursing profession. The chaos and disharmony in the profession can be viewed as opportunity. A far from equilibrium state is necessary for change. The potential exists for the emergence of an organized system that is an evolution for the nursing profession.
Nursing as a Chaotic Attractor
Nursing is a complex profession. The nurse utilizes knowledge from many professions to support the client’s health. Contributions from biology, education, social services, medicine, management and other professions support the science of nursing. Each of the many influences on nursing care could be viewed as a point in the attractor pattern. The multiple skills and highly varied activities of nurses reflect the chaotic attractor. The particular pattern of each nursing encounter is dependent on the unique needs of the situation. While the intention to facilitate health remains consistent, the path to healing is variable.
Phase Space and Surface of Section
The specific state of a dynamical system, all the variables needed to specify a particular point in time, is called phase space (Williams, 1997). It is a slice in time of the pattern that is being examined. Henri Poincare called the complex configuration of a particular phase space the “surface of section” (H. Galbraith, personal communication, November 7, 2002). The surface of section of a single nursing interaction is highly variable. Just as no two snowflakes are alike, each nursing encounter is unique. The nurse cares for the physical aspects of an individual; perhaps a wound, along with the emotional component, such as body image, the intellectual arena, perhaps the ability of the client to understand wound care, and social components, such as the availability of services in the community. The surface of section would reveal the particular components of nursing that are relevant to the specific nursing encounter. What is revealed depends on one’s viewpoint and the specific phase space examined.
Fractal is the term used to describe repeating patterns when viewed from different levels, from a broad range of scale (Bar-Yam, 1997). The word is derived from “fractions”, parts of a whole number. The self-similarity of the pattern can be seen in repeated attractor of nursing, the professional nurse assisting the client along a holistic healing trajectory. The pattern is repeated on a physical, emotional, intellectual, and social level.
The fractal nature of nursing can also be seen among our many specialties. A community nurse dealing with environmental hazards, a psychiatric nurse facilitating a support group, a hospice nurse supporting a grieving family, and the intensive care unit nurse intent on the critically ill person are fractal components of nursing. The pattern of nursing is repeated with the viewpoint changing scale from an individual, to a group or to an entire community.
Studying complex problems from a single slice in time or from one particular scale can be problematic. One gets only pieces of information. The complexity of the interrelated whole is lost. It is like taking a slice of chocolate and vanilla marble cake. One might get a pure vanilla piece but it would be a mistake to recommend the cake to someone allergic to chocolate! Complexity theory invites us to consider the array of interrelated components without purporting to understand the whole from a single perspective. Nurses are invited to use a holistic approach and be continually responsive to the uniqueness the dynamic situation.
Non-linearity and Disproportional Effect
Complexity theory embraces the ideas of non-linearity and disproportional effect. Observations of a variable do not plot along a straight line and response is not proportional (Williams, 1997). The lived experience of nursing supports these ideas. Consider the bee stings that may cause some pain in one person, an emotional meltdown in another, and death in someone else. The amount of venom is the same but the effect is very different, a disproportional effect. Individual reactions to health issues and nursing interventions are as varied as are people. Sometimes a little thing will have a big effect and something that seems enormous just fades away.
The idea of sensitivity to initial conditions, or the “butterfly effect”, is related to non-linearity and disproportional effects. In 1979, Edward Lorenz presented a paper at the annual meeting of the American Association for the Advancement of Science in Washington titled “Predictability: Does the Flap of a Butterfly’s Wings in Brazil Set off a Tornado in Texas?” (Gleick, 1987). He noted that tiny variables could have huge, disproportional effects. This concept occurred to him when he made a minuscule change in a number by truncating the long decimal slightly sooner than in his original variable. At first it made little difference in the weather analysis he was re-running on his computer but the tiny change soon had dramatic effects. He named the phenomenon “sensitivity to initial conditions” because, in the artificial world of computer programs, there is a real starting point in time and the variables can be clearly identified. One is left with the idea that tiny changes can have profound effects. Each nursing intervention has the potential to generate great good. Essential information may instigate healing health care behavior, encouraging a patient to share a concern may open the door to therapeutic communication, or a timely intervention may prevent skin breakdown. The potential for healing exists but there is no guarantee that a specific intervention will have a predictable effect.
Because of the complexity of pattern, disproportional effect, and non-linearity, the exact nature of a particular phase space is unpredictable. It is not possible to decide ahead of time what something will be at a later time. We do not know how any particular person will respond to a specific nursing intervention. There are so many interwoven patterns, so many unknown and unrecognized variables that accurate prediction of the future is impossible. The nurse must live with uncertainty. Yet complexity theory is also a foundation for hope.
Complexity Theory and Nursing Practice
Complexity theory invites one to consider the pandimensional and interrelational nature of nursing. Non-linear systems, such as the health care system, may have many attractors (Capra, 1996). Nursing, medicine, pharmacology, managed care, and Medicare could each be viewed as patterns affecting each other. There is spontaneous adaptation as multiple interacting systems evolve through mutual adaptation (Waldrop, 1992). Nursing practice has changed in response to the increasing technological advances of modern medicine, and the medical profession has adjusted as nurses assume responsibility for areas once exclusive to physicians. New professions such as respiratory therapy have emerged as the need for expertise in specialized areas grows. This affects nursing practice. Nurses adapt to the changes in the health care system which in turn is influenced by social, economic, and political forces. Embracing complexity theory will promote contemplation and hopefully deliberate activities to influence the multiple systems that impact health care and nurses.
Complexity theory provides support for many nursing interventions including education. Prevention is an important component of health care but the effects are not readily quantifiable. Viewing the world using complexity theory encourages us to see the possibility of great effects with minor changes. An educational nursing activity may not have noticeable effects immediately, but it has the potential of profound ramifications many years later. Imagine the healing potential of influencing an individual not to smoke, eat more balanced meals, maintain an exercise program or avoid obesity. Small interventions can have enormous consequences. The individual enjoys better health and society maintains a productive citizen.
Complexity theory provides a theoretical base for the nurse who functions in a dynamic healthcare system intertwined within other complex systems. Science flows into art as the nurse draws on a broad knowledge base, interpersonal abilities, communication competencies, hands-on skills, and the myriad of other components that are imbedded in the practice of nursing. Nurses continually adjust care in response to multidimensional feedback using the creativity and flexibility that are valued nursing attributes. With complexity theory, nursing is recognized as a process, a state of becoming that is never repeated (Gleick, 1987). The nurse/client relationship affects and is affected by mutual interactions. The pandimensional patterns that influence the gestalt of a particular nursing relationship are comprised of multiple dynamic, fluid interrelated systems. Nurses weave the strands of countless threads, adjusting for each unique situation. Sometimes it is the physical pattern that dominates our attentions and another time it is the emotional pattern. We constantly adjust to the needs of the moment and things change moment to moment. Nursing is a dynamic process with a common pattern; intentional caring support of a client with health care needs. Complexity theory supports the multi-dimensional and inter-relational nature of health and healing embraced by the holistic framework of nursing.
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