I’d been sick much of the week and writing a communication textbook chapter on Complex Adaptive Systems. Believe it or not, except for my sickest day, I had fun working on it. Ironically, I was also watching a bunch of BONES episodes on Netflix and picked up on an error that Temperance Brennan made by referring to it as “Complicating Science” (Season 8, episode 17, “The Fact in the Fiction”). Even more ironically, the idea that even the smartest people in the world can make mistakes is part of being human and underscores why understanding human systems and behaviors in them is important to patients safety and supporting the work of nurses, doctors, and other healthcare professionals!
The butterfly effect is a property of Complex Adaptive Systems and refers to a small thing happening in one place, like a butterfly flapping it’s wings, contributing to a large thing happening someplace far away, like a hurricane on the opposite side of the world. There are all sorts of ‘People Skills’ that contribute to sentinel events in healthcare and can be explained by the butterfly effect of poor communication and/or toxic workplaces.'People Skills' & sentinel events explained by 'butterfly effect' of poor communication & Click To Tweet
- A doctor yells at a nurse on Tuesday. Saturday she hesitates to call him to report a subtle change in a patient’s condition and since it is close to the end of the shift, reports her concern to the oncoming nurse. The oncoming nurse, makes it a priority to check this patient, but the telemetry alarm beats him to it. The patient did not survive.
- A nurse overhears a colleague talking about her in a negative way and interrupts the conversation. “I’d appreciate it if you have concerns about my work that you discuss them with me directly and professionally.” The gossiping nurse apologized and later offered to help the nurse. The help enable the nurse to get her pain medication to her post-op patient quickly and the patient and his wife felt cared for. The patient experience scores were increasing.
Everyday healthcare professionals are presented with opportunities to give and receive constructive feedback. Whether and how they do or don’t will have a butterfly effect on a variety of outcomes including patient safety, nurse morale, and retention. But it is hard work involving skill, supportive culture, and positive workplace relationships.
What is available to help healthcare professionals develop these skills?
In addition to the obvious communication training in giving and receiving constructive feedback, there is a new process that will contribute to positive workplaces and interprofessional relationships called Medical Improv. This process holds huge promise for building individual people skills and interdisciplinary relationships! Learn more about this innovative and fun process! Medical Improv Youtube or contact firstname.lastname@example.org Also, check out the newly launched Medical Improv Website by Professor Katie Watson and Dr. Belinda Fu! We can create the right conditions for healthy change in our many CASs.
Another great resourcAppendix B by Paul Plsek in the landmark IOM book, Crossing the Quality Chasm is an excellent introduction to CASs with a focus on healthcare systems. And it is only 10 pages!