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BACKGROUND: Emergency Departments (ED) staff, including nurses and physicians, are most directly involved in the care of people who use unregulated substances, and are ideally positioned to provide harm reduction interventions. Conceptualizing the ED as a complex adaptive system, this paper examines how ED staff experience opioid-specific harm reduction provision and engage in harm reduction practice, including potential facilitators and barriers to engagement. METHODS: Using a mixed methods approach, ED nurses and physicians completed a self-administered staff survey (n = 99) and one-on-one semi-structured interviews (n = 15). Five additional interviews were completed with clinical leaders. Survey data were analyzed to generate descriptive statistics and to compute scale scores. De-identified interview data were analyzed using a reflexive thematic analysis approach, which was informed by the theory of complex adaptive systems, as well as understandings of harm reduction as both a technical solution and a contextualized social practice. The final analysis involved mixed analysis through integrating both quantitative and qualitative data to generate overarching analytical themes. RESULTS: Study findings illustrated that, within the context of the ED as a complex adaptive system, three interrelated contextual factors shape the capacity of staff to engage in harm reduction practice, and to implement the full range of opioid-specific harm reduction interventions available. These factors include opportunities to leverage benefits afforded by working collaboratively with colleagues, adequate preparation through receiving the necessary education and training, and support in helping patients establish connections for ongoing care. CONCLUSIONS: There is a need for harm reduction provision across all health and social care settings where people who use unregulated opioids access public sector services. In the context of the ED, attention to contextual factors including teamwork, preparedness, and connections is warranted to support that ED staff engage in harm reduction practice.

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The world is grappling with emerging, urgent, large-scale problems, such as climate change, pollution, biodiversity loss, and pandemics, which demand immediate and coordinated action. Social processes like conformity and social norms can either help maintain behaviors (e.g. cooperation in groups) or drive rapid societal change (e.g. rapid rooftop solar uptake), even without comprehensive policy measures. While the role of individual heterogeneity in such processes is well studied, there is limited work on the expression of individuals' preferences and the role of anticonformists-individuals who value acting differently from others-especially in dynamic environments. We introduce anticonformists into a game-theoretical collective decision-making framework that includes a complex network of agents with heterogeneous preferences about two alternative options. We study how anticonformists' presence changes the population's ability to express evolving personal preferences. We find that anticonformists facilitate the expression of preferences, even when they diverge from prevailing norms, breaking the "spiral of silence" whereby individuals do not act on their preferences when they believe others disapprove. Centrally placed anticonformists reduce by five-fold the number of anticonformists needed for a population to express its preferences. In dynamic environments where a previously unpopular choice becomes preferred, anticonformists catalyze social tipping and reduce the "cultural lag," even beyond the role of committed minorities-that is, individuals with a commitment to a specific cause. This research highlights the role of dissenting voices in shaping collective behavior, including their potential to catalyze the adoption of new technologies as they become favorable and to enrich democracy by facilitating the expression of views.

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BACKGROUND: Unhealthy commodity industries (UCIs) engage in political practices to influence public health policy, which poses barriers to protecting and promoting public health. Such influence exhibits characteristics of a complex system. Systems thinking would therefore appear to be a useful lens through which to study this phenomenon, potentially deepening our understanding of how UCI influence are interconnected with one another through their underlying political, economic and social structures. As such this study developed a qualitative systems map to depict the complex pathways through which UCIs influence public health policy and how they are interconnected with underlying structures. METHODS: Online participatory systems mapping workshops were conducted between November 2021 and February 2022. As a starting point for the workshops, a preliminary systems map was developed based on recent research. Twenty-three online workshops were conducted with 52 geographically diverse stakeholders representing academia, civil society (CS), public office, and global governance organisations (CGO). Analysis of workshop data in NVivo and feedback from participants resulted in a final systems map. RESULTS: The preliminary systems map consisted of 40 elements across six interdependent themes. The final systems map consisted of 64 elements across five interdependent themes, representing key pathways through which UCIs impact health policy-making: (1) direct access to public sector decision-makers; (2) creation of confusion and doubt about policy decisions; (3) corporate prioritisation of commercial profits and growth; (4) industry leveraging the legal and dispute settlement processes; and (5) industry leveraging policy-making, norms, rules, and processes. CONCLUSION: UCI influence on public health policy is highly complex, involves interlinked practices, and is not reducible to a single point within the system. Instead, pathways to UCI influence emerge from the complex interactions between disparate national and global political, economic and social structures. These pathways provide numerous avenues for UCIs to influence public health policy, which poses challenges to formulating a singular intervention or limited set of interventions capable of effectively countering such influence. Using participatory methods, we made transparent the interconnections that could help identify interventions in future work.

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In this article, we argue that social systems with fission-fusion (FF) dynamics are best characterized within a complex adaptive systems (CAS) framework. We discuss how different endogenous and exogenous factors drive scale-dependent network properties across temporal, spatial and social domains. Importantly, this view treats the dynamics themselves as objects of study, rather than variously defined notions of static 'social groups' that have hitherto dominated thinking in behavioural ecology. CAS approaches allow us to interrogate FF dynamics in taxa that do not conform to more traditional conceptualizations of sociality and encourage us to pose new types of questions regarding the sources of stability and change in social systems, distinguishing regular variations from those that would lead to system-level reorganization. This article is part of the theme issue 'Connected interactions: enriching food web research by spatial and social interactions'.

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Measuring and optimizing a health system is challenging when patient care is split between many independent organizations. For example, patients receive care from their primary care provider, outpatient specialist clinics, hospitals, private providers and, in some instances, family members. These silos are maintained through different funding sources (or lack of funding) which incentivize siloed service delivery. A shift towards prioritizing patient outcomes and keeping the patient at the centre of care is emerging. However, competing philosophies on patient needs, how health is defined and how health is produced and funded is creating and engraining silos in the delivery of health services. Healthcare and health outcomes are produced through a series of activities conducted by diverse teams of health professionals working in concert. Health professionals are continually learning from each patient interaction; however, silos are barriers to information exchange, collaborative evidence generation and health system improvement. This paper presents a systems view of healthcare and provides a systems lens to approach current challenges in health systems. The first part of the paper provides a background on the current state and challenges to healthcare in Canada. The second part presents potential reasons for continued health system underperformance. The paper concludes with a system perspective for addressing these challenges.

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BACKGROUND: Effective mentorship is an important component of medical education with benefits to all stakeholders. In recent years, conceptualization of mentorship has gone beyond the traditional dyadic experienced mentor-novice mentee relationship to include group and peer mentoring. Existing theories of mentorship do not recognize mentoring's personalized, evolving, goal-driven, and context-specific nature. Evidencing the limitations of traditional cause-and-effect concepts, the purpose of this review was to systematically search the literature to determine if mentoring can be viewed as a complex adaptive system (CAS). METHODS: A systematic scoping review using Krishna's Systematic Evidence-Based Approach was employed to study medical student and resident accounts of mentoring and CAS in general internal medicine and related subspecialties in articles published between 1 January 2000 and 31 December 2023 in PubMed, Embase, PsycINFO, ERIC, Google Scholar, and Scopus databases. The included articles underwent thematic and content analysis, with the themes identified and combined to create domains, which framed the discussion. RESULTS: Of 5,704 abstracts reviewed, 134 full-text articles were evaluated, and 216 articles were included. The domains described how mentoring relationships and mentoring approaches embody characteristics of CAS and that mentorship often behaves as a community of practice (CoP). Mentoring's CAS-like features are displayed through CoPs, with distinct boundaries, a spiral mentoring trajectory, and longitudinal mentoring support and assessment processes. CONCLUSION: Recognizing mentorship as a CAS demands the rethinking of the design, support, assessment, and oversight of mentorship and the role of mentors. Further study is required to better assess the mentoring process and to provide optimal training and support to mentors.

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In the context of socio-technical systems, traditional engineering approaches are inadequate, calling for a fundamental change in perspective. A different approach encourages viewing socio-technical systems as complex living entities rather than through a simplistic lens, which enhances our understanding of their dynamics. However, these systems are designed to facilitate human activities, and the goal is not only to comprehend how they operate but also to guide their function. Currently, we lack the appropriate terminology. Hence, we introduce two principal concepts, simplexity and complixity, drawing inspiration from how nature conceals intricate mechanisms beneath straightforward, user-friendly interfaces.

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BACKGROUND: Temperament and character are useful in risk assessment and therapy of individuals in the anxiety-depression spectrum but understudied in South Korea. OBJECTIVE: The study aimed to identify the temperament and character features associated with anxiety and/or depression in individuals with clinical disorders and in the general population. METHODS: A representative sample of 1384 Korean adults over 18 years old (58 % female) were assessed with the Beck Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI), and Temperament and Character Inventory (TCI). Multivariate analyses, including structural equation modeling and complex systems analysis, evaluated how personality influenced risk and resilience for anxiety and/or depression. RESULTS: The three groups with anxiety and/or depression were strongly distinguished by temperament and character: (i) In AD (n = 58), Harm Avoidance and Reward Dependence were higher than in DD, and Self-directedness was higher than in AD+DD; (ii) In DD (n = 90), Persistence, Self-Directedness and Cooperativeness were higher than in AD+DD; and (iii) In AD+DD (n = 101), Harm Avoidance was highest and Persistence and Self-directedness were lowest (i.e., they were lowest in Resilience). Structural equation models confirmed these risk relations with strong character development reducing the adverse effects of emotional hyperreactivity from extreme temperaments. LIMITATIONS: Self-reports were measured only at one point in time, requiring collateral experimental data to support causal interpretation. CONCLUSIONS: Interactions of temperament and character are strongly predictive of risk and resilience to anxiety and/or depression by regulating both positive and negative affect. Character mediates the adverse effects of extreme temperaments on affect.

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The NHS is continuously evolving and with it, traditional notions of leadership and management must be reimagined and redefined. In order to be effective leaders, however, we must first gain a deeper understanding of the context in which we lead and recognise how to navigate the system's intricacies. This article explores the characteristics of Complex Adaptive Systems and how we can understand the patterns of these systems through our experiences leading in the NHS. It then analyses leadership approaches both past and present and considers how future leaders can be effective in tomorrow's NHS. Finally, this article identifies potential barriers and challenges that leaders must overcome as they adapt and tailor their leadership approach to meet the needs of a dynamic health service.

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Data and indicator estimates are considered vital to document persisting challenges in maternal and newborn health and track progress towards global goals. However, prioritization of standardised, comparable quantitative data can preclude the collection of locally relevant information and pose overwhelming burdens in low-resource settings, with negative effects on the provision of quality of care. A growing body of qualitative studies aims to provide a place-based understanding of the complex processes and human experiences behind the generation and use of maternal and neonatal health data. We conducted a qualitative systematic review exploring how national or international requirements to collect and report data on maternal and neonatal health indicators are perceived and experienced at the sub-national and country level in low-income and lower-middle income countries. We systematically searched six electronic databases for qualitative and mixed-methods studies published between January 2000 and March 2023. Following screening of 4084 records by four reviewers, 47 publications were included in the review. Data were analysed thematically and synthesised from a Complex Adaptive Systems (CAS) theoretical perspective. Our findings show maternal and neonatal health data and indicators are not fixed, neutral entities, but rather outcomes of complex processes. Their collection and uptake is influenced by a multitude of system hardware elements (human resources, relevancy and adequacy of tools, infrastructure, and interoperability) and software elements (incentive systems, supervision and feedback, power and social relations, and accountability). When these components are aligned and sufficiently supportive, data and indicators can be used for positive system adaptivity through performance evaluation, prioritization, learning, and advocacy. Yet shortcomings and broken loops between system components can lead to unforeseen emergent behaviors such as blame, fear, and data manipulation. This review highlights the importance of measurement approaches that prioritize local relevance and feasibility, necessitating participatory approaches to define context-specific measurement objectives and strategies.

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The Anthropocene concept raises awareness of human-induced planetary changes but is criticized for being 'too global'. We examined the social-ecological memory that emerges from people-tree relationships in South American temperate territories, Chile. We integrated dendrochronology (analysis of tree rings of 35 memorial trees; 17 species) with dendrography (participant observation complemented with semi-structured and go-along interviews with 14 interviewees; six women, eight men). We found that assemblages of people-tree relationships reflect marked historical changes in the territory, associated with the historical clearing of forests, which may be imprinted in both tree growth rings and in the social meanings and practices associated with memorial trees. In devastated territories, practices of tree care emphasize interconnectedness, multispecies collaborations, and the blurring of boundaries between humans and other-than-humans. We discuss some of the interdisciplinary and relational insights of our study, which may prove valuable for future research, political agendas, and educational programs in South America and beyond.

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BACKGROUND: Chronic Fatigue Syndrome patients suffer from symptoms that cannot be explained by a single underlying biological cause. It is sometimes claimed that these symptoms are a manifestation of a disrupted autonomic nervous system. Prior works studying this claim from the complex adaptive systems perspective, have observed a lower average complexity of physical activity patterns in chronic fatigue syndrome patients compared to healthy controls. To further study the robustness of such methods, we investigate the within-patient changes in complexity of activity over time. Furthermore, we explore how these changes might be related to changes in patient functioning. METHODS: We propose an extension of the allometric aggregation method, which characterises the complexity of a physiological signal by quantifying the evolution of its fractal dimension. We use it to investigate the temporal variations in within-patient complexity. To this end, physical activity patterns of 7 patients diagnosed with chronic fatigue syndrome were recorded over a period of 3 weeks. These recordings are accompanied by physicians' judgements in terms of the patients' weekly functioning. RESULTS: We report significant within-patient variations in complexity over time. The obtained metrics are shown to depend on the range of timescales for which these are evaluated. We were unable to establish a consistent link between complexity and functioning on a week-by-week basis for the majority of the patients. CONCLUSIONS: The considerable within-patient variations of the fractal dimension across scales and time force us to question the utility of previous studies that characterise long-term activity signals using a single static complexity metric. The complexity of a Chronic Fatigue Syndrome patient's physical activity signal does not suffice to characterise their high-level functioning over time and has limited potential as an objective monitoring metric by itself.

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Just like an army of ants caught in an ant mill, individuals, groups and even whole societies are sometimes caught up in a Death Spiral, a vicious cycle of self-reinforcing dysfunctional behavior characterized by continuous flawed decision making, myopic single-minded focus on one (set of) solution(s), denial, distrust, micromanagement, dogmatic thinking and learned helplessness. We propose the term Death Spiral Effect to describe this difficult-to-break downward spiral of societal decline. Specifically, in the current theory-building review we aim to: (a) more clearly define and describe the Death Spiral Effect; (b) model the downward spiral of societal decline as well as an upward spiral; (c) describe how and why individuals, groups and even society at large might be caught up in a Death Spiral; and (d) offer a positive way forward in terms of evidence-based solutions to escape the Death Spiral Effect. Management theory hints on the occurrence of this phenomenon and offers turn-around leadership as solution. On a societal level strengthening of democracy may be important. Prior research indicates that historically, two key factors trigger this type of societal decline: rising inequalities creating an upper layer of elites and a lower layer of masses; and dwindling (access to) resources. Historical key markers of societal decline are a steep increase in inequalities, government overreach, over-integration (interdependencies in networks) and a rapidly decreasing trust in institutions and resulting collapse of legitimacy. Important issues that we aim to shed light on are the behavioral underpinnings of decline, as well as the question if and how societal decline can be reversed. We explore the extension of these theories from the company/organization level to the society level, and make use of insights from both micro-, meso-, and macro-level theories (e.g., Complex Adaptive Systems and collapsology, the study of the risks of collapse of industrial civilization) to explain this process of societal demise. Our review furthermore draws on theories such as Social Safety Theory, Conservation of Resources Theory, and management theories that describe the decline and fall of groups, companies and societies, as well as offer ways to reverse this trend.

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Introduction: Climate change is a global phenomenon with far-reaching consequences, and its impact on human health is a growing concern. The intricate interplay of various factors makes it challenging to accurately predict and understand the implications of climate change on human well-being. Conventional methodologies have limitations in comprehensively addressing the complexity and nonlinearity inherent in the relationships between climate change and health outcomes. Objectives: The primary objective of this paper is to develop a robust theoretical framework that can effectively analyze and interpret the intricate web of variables influencing the human health impacts of climate change. By doing so, we aim to overcome the limitations of conventional approaches and provide a more nuanced understanding of the complex relationships involved. Furthermore, we seek to explore practical applications of this theoretical framework to enhance our ability to predict, mitigate, and adapt to the diverse health challenges posed by a changing climate. Methods: Addressing the challenges outlined in the objectives, this study introduces the Complex Adaptive Systems (CAS) framework, acknowledging its significance in capturing the nuanced dynamics of health effects linked to climate change. The research utilizes a blend of field observations, expert interviews, key informant interviews, and an extensive literature review to shape the development of the CAS framework. Results and discussion: The proposed CAS framework categorizes findings into six key sub-systems: ecological services, extreme weather, infectious diseases, food security, disaster risk management, and clinical public health. The study employs agent-based modeling, using causal loop diagrams (CLDs) tailored for each CAS sub-system. A set of identified variables is incorporated into predictive modeling to enhance the understanding of health outcomes within the CAS framework. Through a combination of theoretical development and practical application, this paper aspires to contribute valuable insights to the interdisciplinary field of climate change and health. Integrating agent-based modeling and CLDs enhances the predictive capabilities required for effective health outcome analysis in the context of climate change. Conclusion: This paper serves as a valuable resource for policymakers, researchers, and public health professionals by employing a CAS framework to understand and assess the complex network of health impacts associated with climate change. It offers insights into effective strategies for safeguarding human health amidst current and future climate challenges.

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The risk of famine is rising in many countries today. Bold changes to famine information and response systems are urgently needed to improve capacities to prevent famine. To this end, the paper identifies six insights from social-ecological systems (SES) thinking for understanding and preventing famine. It argues that a state of famine emerges from human-environment interdependencies, complex causality, and non-linear system dynamics, shaped by history and context. The likelihood of famine can be reduced by strengthening resilience to the diverse stresses and shocks that drive destitution, food insecurity, undernutrition, morbidity, and mortality. SES thinking offers new opportunities to understand the dynamics of famine, diagnose lesser-known drivers, pinpoint new metrics, ascertain leverage points for intervention, and develop conceptual frameworks to inform policy. SES concepts and methods could also support the development of practical analytical tools to guide decisionmakers on how, where, and when to intervene most effectively and efficiently to strengthen resilience to the drivers of famine.

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Many organisations struggle to achieve their true potential. In part it is a problem of organisational design, which is an outcome of a particularly common-command and control-leadership philosophy. The traditional linear hierarchical structure of organisations suggests that all knowledge and power concentrates at the top organisational layer, and that people in the lower layers need to be told what to do and when. These arrangements disempower people at the lower level, preventing them from providing the necessary feedback to pre-emptively address emerging concerns. Systems and complexity thinking provide different ways of understanding organisations and their complex adaptive behaviours. In this paper, we first describe the key characteristics of complex adaptive organisations-their structure and dynamic behaviours-and then propose a three-dimensional visualisation of a complex adaptive organisation that allows its members to clearly see and appreciate its interdependencies.

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While the Royal Commission into Aged Care Quality and Safety has clearly identified the issues with our Australian residential aged care system, its recommendations-so far-have not been translated into policies that will ensure a framework in which nursing home operators and care staff are empowered to focus on what matters-ensuring vulnerable residents receive care that meets their needs and preserves their dignity. For this to be achievable the system requires measures that in the first instance reflect the system's purpose, and that all stakeholders can use to improve care. Such measures need to be easy to understand and implement, and most importantly reduce bureaucratic burden.

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Policy Points The implementation of large-scale health care interventions relies on a shared vision, commitment to change, coordination across sites, and a spanning of siloed knowledge. Enablers of the system should include building an authorizing environment; providing relevant, meaningful, transparent, and timely data; designating and distributing leadership and decision making; and fostering the emergence of a learning culture. Attention to these four enablers can set up a positive feedback loop to foster positive change that can protect against the loss of key staff, the presence of lone disruptors, and the enervating effects of uncertainty. CONTEXT: Large-scale transformative initiatives have the potential to improve the quality, efficiency, and safety of health care. However, change is expensive, complex, and difficult to implement and sustain. This paper advances system enablers, which will help to guide large-scale transformation in health care systems. METHODS: A realist study of the implementation of a value-based health care program between 2017 and 2021 was undertaken in every public hospital (n = 221) in New South Wales (NSW), Australia. Four data sources were used to elucidate initial program theories beginning with a set of literature reviews, a program document review, and informal discussions with key stakeholders. Semistructured interviews were then conducted with 56 stakeholders to confirm, refute, or refine the theories. A retroductive analysis produced a series of context-mechanism-outcome (CMO) statements. Next, the CMOs were validated with three health care quality expert panels (n = 51). Synthesized data were interrogated to distill the overarching system enablers. FINDINGS: Forty-two CMO statements from the eight initial program theory areas were developed, refined, and validated. Four system enablers were identified: (1) build an authorizing environment; (2) provide relevant, authentic, timely, and meaningful data; (3) designate and distribute leadership and decision making; and (4) support the emergence of a learning culture. The system enablers provide a nuanced understanding of large-system transformation that illustrates when, for whom, and in what circumstances large-system transformation worked well or worked poorly. CONCLUSIONS: System enablers offer nuanced guidance for the implementation of large-scale health care interventions. The four enablers may be portable to similar contexts and provide the empirical basis for an implementation model of large-system value-based health care initiatives. With concerted application, these findings can pave the way not just for a better understanding of greater or lesser success in intervening in health care settings but ultimately to contribute higher quality, higher value, and safer care.

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Knowledge and knowledge transfer are often viewed in unitary and hierarchical terms, where a linear transaction exists between an individual possessing a body of knowledge and a person needing that knowledge. Although this traditional view of knowledge transfer is common within the sports domain, it is problematic because knowledge is treated as a self-contained entity. The overarching purpose of this study is to explore the ecological role of knowledge, underpinning performance preparation processes in an international coaching setting. Specifically, we investigated how bi-directional self-organising (coordination) tendencies (coach and athlete-led) can be exploited to facilitate the formation of attacking synergies within the team sport of wheelchair rugby league. A mixed-method case study approach was employed to collect data, involving semi-structured interviews, reflexive observations and field notes, and notational analysis. Results from the study described the transitional process of positioning an ecological view of knowledge transfer as a guiding principle to enhance athlete and practitioner collaboration. This reciprocal relationship provided documented opportunities to enhance on- and off-field team synergies. The pedagogical experiences we describe emerged throughout periods of uncertainty, requiring effortful interactions, forged on the continuous coupling of key agents (individuals), content, and context, enabling application, refinement, and opportunities for team synergies to evolve in performance preparation. Results suggested that the challenge of understanding and facilitating knowledge transfer could be embedded within the ecology of a complex adaptive system, sustained as a contextualised activity reciprocally constructed through on-going correspondence between athletes, scientists, practitioners, and the competitive performance context.