La responsabilidad internacional

Introduction

In this chapter the study’s findings are discussed in relation to the literature concerning

residential care homes and district nursing. This chapter argues that one reason why healthcare needs of residents are not always met is a result of the complexity that is present in today’s residential care homes, complexity that is not always recognised or acknowledged, especially by those supporting care homes, including the district nursing service. Due to the complexity facing these care homes, and the community nurses’ response to it, this thesis will draw on complexity thinking, to better understand the complex nature of residential care homes and their relationship with the district nursing service. Complexity thinking did not drive the original design of the study, as it was only as a result of this emergent practitioner inquiry that the researcher became aware of the complexity that was present. But once aware of this complexity the findings were revisited, looking for evidence of whether the residential care homes or district nursing service were exhibiting characteristics of a complex adaptive system, as this could offer a potential way forward.

This chapter begins by outlining the strengths and limitations of this study. It defines complexity thinking and in particular the concept of complex adaptive systems (CASs) and evaluates its use in relation to healthcare studies. It analyses the findings in relation to complex adaptive systems, suggesting that residential care homes are diverse, embedded systems, which are constantly adapting, governed by simple rules, which are interpreted and applied differently by agents, according to context and individual interpretation. Characteristics, which others, including community nurses, can be unaware of, or fail to respond to. The chapter offers a ‘complexity explanation’ (Paley and Eva 2010), highlighting certain barriers, which, it will be suggested, are preventing the healthcare needs of residents from being fully met; including the suggestion that the behaviour of community nurses is also governed by simple rules, which may explain their response to this complexity. The chapter then goes on to use complexity thinking to offer possibilities for change, by encouraging participants to focus on behaviour and improving relationships with others, together with the environment in which they operate; rather than trying to control outcomes, which given the complex nature of these systems, are impossible to control. Finally it offers a number of issues for consideration, based on the findings from the study, and again informed, by complexity thinking.

Strengths and limitations of the study

One of the main strengths of this study is its use of practitioner research, with the researcher using themselves as a research instrument, as it allowed unique access to the care home setting, and gave helpful insight into the potential relevance of the findings to other community nurses. The use of this particular research method enabled the researcher to explore the type of care given in residential care homes, to uncover the complexity inherent within these homes, to

explore and better understand the working relationship that existed between community nurses and these care homes, and to question whether the service provided by these nurses was able to support these care homes to meet the needs of their residents. The strength of this approach was that it encouraged the researcher to draw on previous experience and tacit knowledge, paying attention to, and reflecting on, those findings that were a surprise or a shock. As a result the practitioner researcher may have uncovered findings that others, not in the field of district nursing, may not have felt to be of significance. By using an approach that encouraged reflexivity the researcher became aware of her own ignorance in regard to these care homes and started to question the district nursing care being provided. Her position as a district nurse also gave her clinical credibility to explore these insights with other community and specialist nurses, with the aim of understanding how the service provided may need to change.

The findings need to be treated with a degree of caution as there are limitations associated with PR, due to it being carried out by an ‘insider’. The researcher may, for example, feel they know the culture, or hold certain beliefs or assumptions that can prevent objectivity during data collection and/or analysis. Or participants may be reluctant to talk to someone they know, and their answers may not fully reflect their true experiences or feelings. For example, given that the researcher was a district nurse, the care home participants may have been unwilling to criticise the service, or the community nurses reluctant to admit to anything that could cast their practice in a poor light. However, it did appear that it was precisely because she was an ‘insider’ that staff from the care homes were willing to accept her and to become involved in the study. Whilst those from the district nursing service, appeared willing to be open and honest, as evidenced by participants admitting that they were not always providing the standard of care that they would have liked. As an ‘insider’, the researcher had in-depth knowledge of the organisations and care practices. By paying attention to her feelings and also to what surprised her whilst working in the case study care home she was able to reflect on, question and challenge her own practice and the practice of others. Further strength was added to these findings by comparing her ‘insider view’ with the situation in other care homes. By checking whether the findings resonated with those from the case study, as well as seeking findings that did not confirm her original thoughts and reflections, the potential trustworthiness of the findings was strengthened. In addition the study was further strengthened by the researcher addressing possible bias through in-depth reflexive field notes, and by acknowledging her subjectivity in the study, for others to judge possible bias.

The use of a single case study, carried out in one local authority and NHS trust is another reason to treat the findings with caution, as they may not accurately reflect the situation in all other local authorities or trusts. However, to limit this affect, rich description and detail has been provided, so the reader can decide if the findings are applicable to their own situation. As only one case study was conducted, purposive sampling was used, to ensure that the case selected offered the potential for a greater understanding of the issues being explored; in this case, a greater understanding of the care required by residents living with dementia; an issue that is of relevance, given the high levels of dementia across the resident population. The use of a case

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study also allowed a more thorough exploration of care provision in this care home than may have been revealed by simply carrying out interviews with staff; whilst the use of a variety of data collection methods deepened understanding of the case by providing insight into the day- to-day workings of the care home from a range of perspectives.

Another limitation of a case study is transferability of the findings, which is why the experiences of staff from other care homes, community nurses and specialist nurses were sought during the second phase; to identify findings that resonated with those from the case study, and reflections of the researcher, and if there were any gaps, again adding strength to the findings. Although the thoughts and experiences of staff across all grades were gathered from the case study care home, it was only possible, during the second phase, to gather the experiences of the more experienced senior care home staff, i.e. those in managerial positions, and so the findings may not necessarily reflect the experiences of other levels of care staff. It was possible to gather data from all grades in the district nursing service. Nonetheless the volume of in-depth data collected and saturation of emergent categories through the analysis gives additional confidence in the findings.

Although the findings cannot necessarily be transferred to all settings, they raise some

important issues and one can be reasonably confident of their potential value to other settings. From the perspectives of staff involved in the day-to-day care of residents, the findings give an indication of the many challenges faced in meeting healthcare needs, together with evidence of a possible dysfunctional relationship between care homes and the district nursing service. The study highlights why nursing support to residential care homes needs to be addressed. Given the resonance of the findings to other practitioners, the findings could potentially inform the future direction of the district nursing profession.

Why complexity thinking?

When reflecting on the challenges facing the care staff in this study, a word that frequently sprang to mind was complex, with complexity apparent in the changing and increasing needs of residents, the nature of the workforce, which is low skilled, poorly paid and transcultural, and the challenges of the care home environment, which is independent of the NHS and marginalised by society. Residential care homes generally rely on the district nursing service for any nursing support they need. Evidence presented in Chapter 7 indicates the practitioner researcher was both surprised by, and ignorant of, the complex nature of the work in these care homes; however, as the findings in Chapter 9 suggest she is not unusual. Other community nurses appear either ignorant of the complexity present, or are at times choosing to ignore it, as they are often dealing with challenges of their own and, as a result, the service risks failing to fully meet the needs of either the care homes, or their residents, especially those living with dementia.

For years there have been repeated calls for primary care to better support care homes (Royal College of Physicians et al 2000, Goodman et al 2003b, Gladman et al 2010, Goodman et al 2013). Yet, as the findings suggest, the situation does not appear to have changed. If care homes are to be adequately supported to care for such complex residents this situation has to change, and the complexity they are faced with has to be recognised, acknowledged and explored. This is especially true for community nurses, who need to recognise and respond to the complexity that is now present in these care homes, otherwise residents risk not receiving the levels of nursing support required.

There is a tendency by many disciplines to adopt a reductionist approach when attempting to understand a system or problem, due to the belief that breaking down complexity into its component parts, as if it was a machine, and studying these parts in isolation, it is then possible to understand the whole (Gambino 2008, Heng 2008). The problem is, as this thesis argues, that such an approach is not always helpful and may actually limit our ability to fully understand a system or problem, as the whole is often more than the sum of its parts. This is especially true for living systems such as human organisations, as humans do not function as machine parts, because they have individual choice (Sturmberg and Martin 2009, Zimmerman 2009). Although reductionism has a role to play, there are times when it is only ‘by comprehending the whole that the parts become meaningful’ (Nash 2014).

This thesis suggests that complexity thinking, and in particular the concept of complex adaptive systems, offers the means to understand the challenges facing residential care homes in meeting healthcare needs of residents, and district nursing support of them. By recognising and acknowledging the complexity that exists Chapter 10, the present chapter, then offers

possibilities for moving forwards, Bringing about change can be difficult and the reality is that, in healthcare systems, change often fails because the complex nature of systems is overlooked (McMillan 2004). Assuming that the same method and approach to change will always work ignores the fact that all organisations are different, as each will have their own unique culture, environment, set of rules and outcomes cannot be predicted. For this reason you can’t simply transfer one model of service delivery to another and expect it to work. We have to move away from the idea that we can simply ‘change’ these systems, and approach change from a different angle, by looking for different ways that we can encourage these systems to ‘evolve’. This thesis explores the applicability of complexity thinking, and in particular the concept of complex

adaptive systems, to residential care homes and the district nursing service, whether it provides a better understanding of why these systems behave as they do and offers possibilities for change that may not have previously been considered, to ensure that residential care homes, their staff and residents, receive the level of support needed.

Defining complexity thinking and a complex adaptive system

Complexity science offers a different worldview, one that doesn’t ignore the complexity inherent in many systems, but instead, seeks to understand it and how to work with it. As a science it is relatively new and can be difficult to define and its boundaries mapped (McMillan 2004). The

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use in the literature of a variety of terms interchangeably, such as complexity, complexity theory, complexity science and complex adaptive systems can be confusing. For this reason, in terms of this study, it has been decided to use the term complexity thinking, a way of thinking about, seeking to understand and to explain the findings, which has been guided by the concept of complex adaptive systems.

Complexity emerged as a major area of scientific study through the work of a number of scientists during the late 1970s and early 1980s. The Santa Fe Institute in New Mexico was established in 1984, a scientific community of researchers, from a range of disciplines, including biology, physics, economics, chemistry, anthropology, computing and mathematics, dedicated to the study of the fundamental principles of complex adaptive systems (McMillan 2004, Lindberg and Lindberg 2008, Crowell 2011). Complexity science is not a single theory, but a collection of overlapping theories from a variety of sciences, including quantum physics, chaos theory and systems theory. It comprises the study of complex adaptive systems, the patterns of relationships within in them, how they are sustained and how they self-organise and outcomes emerge (Zimmerman 2009).

According to a recent review (The Health Foundation 2010) there is no single definition of what constitutes a CAS. For example Plsek and Greenhalgh (2001) define a CAS as ‘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 actions changes the context for other agents’.

For others it is the study of ‘how relationships between components give rise to the behaviours

of a system and how the system interacts and forms relationships with its environment’ (The

Health Foundation 2010). However, whilst there appears to be no standard definition of a CAS, there are a number of principles and general properties, which it is agreed, are typical of a CAS, listed in Table 9. It is as a result of these properties that complexity, which may not necessarily be a characteristic of individual agents, can emerge at a systems level (Keshavarz et al 2010).

Table 9: Characteristics of a complex adaptive system

Characteristics Description

Adaptation or Self- organisation

A CAS is open to influence from multiple forces, both from within and from outside

Agents The numerous and diverse parts that make up a CAS

Co-evolution The interdependent and co-ordinated evolution of two or more systems within a larger system

Diversity Enables a system to adapt or change when confronted with a challenge Embeddedness Complex adaptive systems are embedded in other CASs

Emergence Evolution takes place through the process of self-organisation

Nonlinearity The ability of a small change in one agent, or between agents, to cause a large change to take place, or a large change to result in a negligible outcome

Simple rules Guiding principles held by members of an organisation. Local application of simple rules can result in complex outcomes

Complex vs. complicated

Complexity thinking suggests that the universe is full of systems e.g. weather systems, the nervous system, or social systems, which are complex and constantly changing or adapting to their environment (The Health Foundation 2010). Systems can be divided into four groups; simple, complicated, complex and chaotic, depending on the degree to which cause and effect relationships can be determined (Keshavarz et al 2010). Recognising that a system is complex, as opposed to say complicated, is important because complex systems demonstrate a number of characteristics that determine how they develop and evolve. Something that is complicated can have many components and be intricate, yet the relationship between components is fixed, clearly defined and can be accurately analysed (Cilliers 2000). Ultimately complicated systems are knowable, as outcomes can be predicted with a high degree of certainty and also

reproduced e.g. launching a rocket into space (Lindberg and Lindberg 2008). Complex systems, on the other hand, are never fully knowable. Because they comprise numerous non-linear relationships and feedback loops, only certain aspects can be analysed at a time (Cilliers 1998). It is not possible to gather a complete or exhaustive description and no set of rules is able to fully capture their nature or working (Cilliers 2000), which is why outcomes are not predictable and solutions cannot be guaranteed to work, such as raising a child for example (Lindberg and Lindberg 2008). This thesis will be drawing on one particular complex system, that of a complex adaptive system (CAS).

Strengths and limitations of complexity thinking

The value of drawing, as this thesis has done, on the concept of CASs to inform ones thinking is that it encourages the researcher to think about and challenge how they see the world, rather than trying to always predict what might happen (The Health Foundation 2010). Complexity thinking encourages the gathering of information about the dynamics of, as well as the

relationships, processes and outcomes within a system, information that can be used to develop a better understanding of why a system is behaving as it does, which in turn may be of use in informing service provision (Cilliers 2000, Paley 2007). And whilst, given the nature of complex systems, one is unable to predict the outcome of any change (Cilliers 2000, Kernick 2002), information gathered can be used to construct models of local interactions, which can provide one with a better understanding of what and why certain behaviour might be occurring, which can then be addressed (Paley 2010).

It is argued that a way of thinking, which challenges one to better understand organisations and the behaviour of agents in them, or associated with them, is of relevance to this thesis. Applying complexity thinking to this thesis is able to give a better understanding of residential care homes and the response of the district nursing service to them. An understanding of the nature of their relationship, why these services may be behaving as they do, what could encourage changes to the behaviour, as well as to gather some insight into why ultimately, any change may not