Healthcare teams as complex adaptive systems: understanding team behaviour through team members' perception of interpersonal interaction.

BACKGROUND: Complexity science has been introduced in healthcare as a theoretical framework to better understand complex situations. Interdisciplinary healthcare teams can be viewed as Complex Adaptive Systems (CAS) by focusing more on the team members' interaction with each other than on the characteristics of individual team members. Viewing teams in this way can provide us with insights into the origins of team behaviour. The aim of this study is to describe the functioning of a healthcare team as it originates from the members' interactions using the CAS principles as a framework and to explore factors influencing workplace learning as emergent behaviour. METHODS: An interview study was done with 21 palliative home-care nurses, 20 community nurses and 18 general practitioners in Flanders, Belgium. A two-step analysis consisted of a deductive approach, which uses the CAS principles as coding framework for interview transcripts, followed by an inductive approach, which identifies patterns in the codes for each CAS principle. RESULTS: All CAS principles were identified in the interview transcripts of the three groups. The most prevalent principles in our study were principles with a structuring effect on team functioning: team members act autonomously guided by internalized basic rules; attractors shape the team functioning; a team has a history and is sensitive to initial conditions; and a team is an open system, interacting with its environment. The other principles, focusing on the result of the structuring principles, were present in the data, albeit to a lesser extent: team members' interactions are non-linear; interactions between team members can produce unpredictable behaviour; and interactions between team members can generate new behaviour. Patterns, reflecting team behaviour, were recognized in the coding of each CAS principle. Patterns of team behaviour, identified in this way, were linked to interprofessional competencies of the Interprofessional Collaboration Collaborative. Factors influencing workplace learning were identified. CONCLUSIONS: This study provides us with insights into the origin of team functioning by explaining how patterns of interactions between team members define team behaviour. Viewing healthcare teams as Complex Adaptive Systems may offer explanations of different aspects of team behaviour with implications for education, practice and research.

Potentially inappropriate medication in primary care at the end of life: a mixed-method study.

CONTEXT: Polypharmacy results in adverse drug interactions, high pill burden, and medication costs. Stopping or diminishing potentially inappropriate medication (PIM), is complex . Data on the use of PIM in a primary care context are scarce and deprescribing barriers for general practitioners (GP) are underexplored. OBJECTIVE: Describing the use of PIM in primary care at the end of life, and exploring the barriers for GPs to deprescribe. METHODS: Retrospective chart review of 210 consecutive patients referred to a palliative home care service and semi-structured interviews with 11 GPs. Percentages were calculated on medication use, linear regression was done to evaluate the effect of diagnosis on PIM use. Thematic analysis was used to analyze the interviews. RESULTS: In total 83 % of patients took at least one PIM. The proportion that continued taking PIMs at the time of referral, one week prior to death and at the day of dying: varies between 6% and 45% according to drug category. Linear regression showed a statistical significant (p < 0.001) higher number of PIM use with non-cancer patients (mean 3,1-SD 1,5) than with cancer patients (mean 1,6-SD 1,6). Participants reported being aware of the PIM use, making efforts to deprescribe. Main issues GPs are taking into account are medical, communicative, and collaborative in nature. CONCLUSION: This study confirms the high level of PIM use in primary care at the end of life. The views of GPs inspire support strategies for deprescribing focusing on shared decision-making with patients and on interprofessional collaboration.