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International Conference on Complex Systems (ICCS2006)

Complexity for human-environment well-being

Alice Davidson
University of Colorado

Marilyn Ray
Florida Atlantic University

Sayel Cortes
CartoData

Lisa Conboy
Osher Institute, Harvard Medical School

Mike D. Norman
Bose Corporation

Abstract
Alice Ware Davidson Complexity for Human-Environment Well-Being
Authors:
Alice W. Davidson, University of Colorado
Marilyn A. Ray, Florida Atlantic University
Sayel Cortes, CartoData
Lisa Conboy, Osher Institute, Harvard Medical School
Mike D. Norman, Bose Corporation

Nursing has the complex human-environment mutual process as its phenomenon of interest. Persons who care for others are present at times of great challenge and change that provide a unique opportunity to develop knowledge of the human-environment mutual process as a whole. The process resembles stochastic art, a creative process emerging in the uncertainty of healthcare experience and showing a sensitive dependence on previous conditions while being unpredictable as to future patterning. By grasping meaning from the local and global patterning and reflecting on the pandimensional possibilities, care facilitates living and dying. The choices made are fundamentally global but create locally defined meaning in the form of enduring structure. Intuitive knowing is coupled with a creative solution, enabling nurses to act in a manner, not planned or anticipated, but perceived as being of value at that moment and in that situation. As Bohm (1980) might say, it is like a leap into the implicate order of incoming and outgoing waves , the information enfolds into the whole and unfolds as an explicate understanding. In a book designed for nursing undergraduate and graduate education, Complexity for Human-Environment Well-Being, A.W. Davidson and M. A. Ray (Editors), the ontology and epistemology of complexity science is tied to nursing philosophy and theory and explored for new vision into the human condition. Nursing research that used complexity science methods to investigate situations involving the care of individuals, organizations, leadership, technological change, and networking are included.

Alice Ware Davidson Complexity for Human-Environment Well-Bei

Alice Ware Davidson Complexity for Human-Environment Well-Being

Authors:
Alice W. Davidson, University of Colorado
Marilyn A. Ray, Florida Atlantic University
Model: Sayel Cortes, Lisa Conboy, and Mike Norman



Abstract
Nursing has the complex human-environment mutual process as its phenomenon of interest. Persons who care for others are present at times of great challenge and change that provide a unique opportunity to develop knowledge of the human-environment mutual process. The process resembles stochastic art, a creative process emerging in the uncertainty of healthcare experience and showing a sensitive dependence on previous conditions while being unpredictable as to future patterning. By grasping meaning from the local patterning (the nursing situation) and global patterning(choice making based upon research, organizational interactions and patient relationships) and reflecting on the pandimensional possibilities, nursing care facilitates transformation for improved well-being. Intuitive knowing (intentional consciousness that integrates past knowledge, future possibilities within the present moment of caring) evolves creative solutions, enabling nurses to act in a manner not planned or anticipated, but perceived as being of value at that moment and in that situation. As Bohm (1980) might say, it is like a leap into the implicate order of incoming and outgoing waves , the information enfolds into the whole and unfolds as an explicate understanding. In a book proposed for nursing undergraduate and graduate education, Complexity for Human-Environment Well-Being, (In Process) A. W. Davidson and M. A. Ray (Editors), the ontology and epistemology of complexity science is tied to nursing philosophy and theory and explored for new vision into the human condition. Nursing research that used complexity science methods to investigate situations involving the care of individuals, organizations, leadership, technological change, and networking are included.
The questions that are being asked.

  • How do you study the complex phenomenon of interest to Nursing - the well-being of human-beings in the environment or the mutual human-environment process?

  • What methods that have been developed to study complex systems are useful for the study of the mutual human-environment process?

  • What relevant research is there from other disciplines interested in this phenomenon at different scales (Biology, Medicine, Sociology, Economics,..) ?

  • Can models be constructed of the phenomena that are the focus of Nursing that will provide information for action?

The book Complexity for Human-Environment Well-Being (Davidson & Ray, In Process and under review)), presents an introduction to complexity science for nurses as an ontology for understanding and an epistemology of new methods to study the mutual human-environment process. It ties the philosophy of nursing with complexity science to envision new ways of caring for individuals, groups, organizations, and communities. Suitable for introducing complexity science to undergraduates, it provides sufficient depth to interest graduate students while encouraging further exploration of complexity science methods. Nursing practice is a place to generate, test and apply knowledge about whole, complex macrosystems.. The work of authors cited in this paper with chapters or abstracts in the book are indicated by an asterisk (*).

This paper is developed around four key premises.

  1. Human patterns are complex, unique to individuals and link to patterns in the environment.

  2. Greater complexity and variability are related to well-being.

  3. Radical change may arise from intense, complex situations (such as health crises) and offer opportunity.

  4. The intuitive knowing and art of nursing emerges from an ensemble of interacting information and enables creative caring for human beings and the environment.

Relationship, interconnectedness and caring are the foundation of Nursing. Caring is defined as an intentional consciousness that integrates past knowledge and future possibilities within the present moment. Caring is compassion, commitment, conscience, competence, confidence, comportment and communication. Caring is holistic (transpersonal mind, body, spirit interconnectedness and harmony), a moral ideal for preservation, protection and enhancement of human dignity (Watson, 1985 ). Both nurse and patient are more unified as a result of the transpersonal caring relationship. The focus of caring is the meaning of the human-being in the environment, inseparable evolving in a process of continuous change- the mutual human-environment process. This mutual human-environment process is 1) a unitary phenomenon best viewed as a whole, 2) characterized by order and complexity, and 3) capable of co-evolving for positive outcomes through choice, where 4) small things can make a large difference, 5) a sensitive dependence on initial conditions coupled with environmental factors leads to very different outcomes, 6) intuition not only integrates past knowledge but also taps into information that is beyond our current understanding, and 7) the ensemble of these interacting parts can evolve unexpected and creative emergent behavior. Believing there is order within the complex human-environment process, it is reasonable to look at complexity science for rules and methods useful for studying this phenomenon. Complexity Science posits simple causes for complex effects. While denying the ability to clearly predict an outcome, feedback and learning algorithms are used to understand how an agent adapts to its environment over time. New unexpected, creative behaviors may emerge. Emergent behavior may resemble real world phenomena and formulating rules that describe this behavior may help scholars develop ways of controlling or explaining previously unfathomable systems. Complex dynamic systems can be modeled with generative rules (all possible expressions can be produced by applying in all possible ways the set of rules of that grammar or group). Generative rules operate across a wide range of complex systems. >

Nursing Theory of the mutual human-environment process

Observation of nature through Newtonian physics espoused the principle of “entropy” that all things in nature change in the direction of running down, decay and disappearance. Bertelanffy claimed that the life process of creatures is not running down but moving toward greater complexity and diversity, calling it ‘negentropy”. This view of the life process is espoused by Nursing theorist, Martha E. Rogers (1970) in the Science of Unitary Human Beings (SUHB). The life process of human beings is described as the human energy field embedded in the environmental energy field, continuous with the universe extending through SPACE, toward greater diversity and complexity (Reeder, *) Rogers originally called human-environment field patterning four dimensional (1970), but later expanded it to pandimensional (Eureka, 1991) to incorporate many dimensions that we are not aware of. Our senses collapse waves to create an experience of separateness. The postulate of pandimensionality of Rogerian science recognizes the possibility of new patterns unfolding in time and space which are unpredictable evolutionary patterns of change. In Rogers' view human-beings and the environment is a unitary phenomena made up of waves that are manifest as a single frequency wave pattern that responds to and influences an environment of frequency patterns. She defined four postulates as basic to the science of unitary human beings and the study of mutual person-environment process: energy fields, openness, pattern, and pandimensionality. From the open and boundaryless universe of pandimensional reality, dynamic energy fields emerge from one unified field. Manifestations of human and environmental field patterning are observable events in the real world. Three unifying principles of homeodynamics postulate the nature and process of human and environmental field change: continuous and mutual (integrality), unpredictable and increasing in diversity ( helicy) from lower to higher frequency wave patterns (resonancy) (Rogers, 1992, p.31). Harmony in the wave patterning of the human and environment energy fields facilitates the flow of energy between the fields. The human-environment mutual process is irreducible and in continuous motion toward increasing diversity and higher frequency with nonrepeating rhythmicities.
Nursing research on the mutual human-environment process
Students of Rogers studied the homeodynamic principles. Ference (1979) developed a “human energy field motion tool” (HFMT), a semantic differential tool, using two extremes, such as ( very slow-my motor is running-very fast), as an indicator of the continuously moving position and flow of the human field pattern. Studies found higher human energy field motion related to greater well-being, while it was lower with pain and chronic illness (see Davidson, 2001 for review). Gueldner (1986/2005) found higher human field motion in elderly who were moving (rocking in rocking chairs) compared to those who were not moving (sitting in stationary chairs). Further developed by Gueldner et.al.(2005) to reduce education and cultural differences, the HFMT extremes were depicted by pictures (e.g.
-Mouse |_____|Lion).
In 1982, Macrae observed higher human field motion among meditating subjects than non-meditating subjects. Rather than a quiescent phenomenon, subjects felt high frequency energy during meditation. Nearly twenty years later, this finding was supported by physiology researchers studying heart rate patterns. Peng et.al.(2006) found extremely prominent heart rate oscillations associated with slow breathing during traditional forms of meditation techniques. They concluded that this finding, along with the marked variability of the beat-to-beat heart rate dynamics during such profound meditative states, challenges the notion of meditation as only an autonomically quiescent state.
In flowing environments there is harmony of the fields and the potential for change increases. Energy was drained from the human energy field in pain, poor health, and loss of mobility, and oppressive or boring environments. Energy increased in the human field with exercise, new learning, hobbies, motion in the form of dance, exercise, travel and vicariously through another's experiences in humor, poetry, art, films, and stories. The metaphor Choice: Conductor of the Symphony emerged as a theory from studies of how human-beings use the environment to promote their well-being (Davidson, 1988, Davidson & Ray, 1991). Choices made reflect individual unique self-patterning. Manifestations of these choices intensify over time into a life-pattern, revealing more about the self-pattern of the individual. Plotted over time in phase space, recurring applications of the self-pattern curl into the ceaselessly variable life-pattern with self-similarity reflected at many different scales. Highly meaningful coincidences amplify patterns for discernible outcomes. Individual patterning determines, for example, the effects of odors on task performance or mood, and music on anxiety and pain reduction. Choice enables people to select rhythms in the environment that are harmonious with their own unique pattern. Persons who listened to music during abdominal surgery reported less pain post-operatively and used less pain medication than groups who did not (Davidson, 1995). The mechanism involved requires further exploration but perhaps an ensemble of interacting information manifest as resonance (an increase in amplitude when a vibratable system encounters an environmental field close to its own natural frequency) could increase human field motion and interfere with the perception of pain.
“Self-transcendence” emerged from peoples' stories about rising above the physical limitations of their body or environment toward achieving their unique potential. Reed (1991/2002) noted self-transcendence may occur during life experiences that are significant and increase awareness of personal mortality and is a correlate of well-being and increased complexity."Losing oneself","carried away" were colloquialisms used that hinted at our understanding of the importance of moving out of oneself into the environment for well-being. Flow was also important in the nurse-client relationship. Newman, Lamm, and Michaels (1991), using qualitative research methods, identified pattern recognition and successful resolution of client choices as themes evolving from nurse casemanagers’ description of their care of clients. Nurses let go and allowed their clients to flow to critical choice points, facilitated expanded consciousness of the choices available while being sensitive to the rhythms within the relationship and timed their interventions to facilitate the client’s becoming. Knowing when to introduce more information for choice-making, when to encourage movement, and when to relax and let the person flow easily and timelessly with the environment required understanding of the mutual human-environment process manifest as intuition.
Davidson, Kane, and Tierney (Davidson, 1995) viewed circadian rhythms (repeating twenty-four hour patterns) as manifestations of the mutual human-environment process. They collected blood pressure and skin temperature data every minute on persons hospitalized in intensive care units with suspected myocardial infarction. They altered the intensive care unit environment, decreasing noise, bright lights and unpleasant odors for one group and not another. The group that experienced the environment with lower sensory interference manifested rhythms that were more robust and closer to those of healthy controls. They theorized that decreased interference in the environment might enable persons to be more open to the environment, facilitating harmony with the synchronizers of rhythms, an "invisible" presence, for observable manifestations of well-being.
Researchers focused on the scale of the healthcare organization, reported that nurse managers respond to attractors and self-organize to change the structure of the organization (Crowell*), to create networks (Holly*), and utilize information to change the dynamics (e.g. magnetically enabling adoption of new technology (Swinderman, 2005*) and move toward achieving the caring whole they demand (Turkel & Ray, 2000, 2001).
Greater variability, diversity, and complexity are related to well-being. Sometimes complexity varies first in the person sometimes in the environment but eventually both change. Contrary to the dominant belief in healthcare, Goldberger (1997) reported the high degree of order seen with pathology. A loss of complexity and increased long range order provided by scale-invariance (the self similar nature of fluctuations observed on many different time scales) was observed with pathology. A loss of complexity in the dynamics of healthy organ function also was found with aging ( Lipsitz & Goldberger, 1992).
Rapp (*) found lower complexity of skin temperature data in frail elderly related to skin breakdown. A two group observational time series design was used to describe activity and skin temperature regularity and self-similarity, calculating entropy and the spectral exponent using detrended fluctuation analysis. Recorded skin temperature pre-bath and for 200 data points after revealed that those who had the lowest entropy (low complexity) of their skin temperature data developed the most skin ulceration, even though many looked healthy otherwise.


Davidson, A.W., Teicher, M.H., & Bar Yam, Y. (1997 and www.necsi.org/projects/yaneer/envcomp00.html)
reported that elderly persons (65-94 years of age) living in environments of higher complexity (quantitatively and qualitatively determined from 5 photographs of the home environment) showed more robust circadian rhythms of physical activity (locomotor activity) and higher cognitive function (Mini-Mental Status Exam) than those living in environments of less complexity. The quantitative measure of complexity developed for this study was based upon Shannon's theory of information (Shannon & Weaver, 1963) where a greater set of possible messages corresponds to a greater uncertainty on the part of the recipient as to the message content and a higher information content in the message. Elderly with more information in their environment were more active and had higher cognitive function. The researchers eschewed the trend to make environments simple and easy and suggested stimulating, complex environments should be available to all ages.
Radical change may arise from intense, complex situations (e.g. a health crises). Insight into the behavior of complex systems becomes possible, when the system, far from equilibrium, is driven to the point of a bifurcation, where a qualitative change occurs inducing cooperative behavior by the process of self-organization. At these critical bifurcation points, the system chooses between paths, leading to very different outcomes. Small changes accumulate and stack up before the change can be seen (e.g. tsunami, glacier melting, avalanches, desire to quit smoking). The choices that we make (control parameters) guide the dance or symphony (order parameters) of our lives. Internal and external competitive processes lead to pattern selection and result in what is observed (Davidson, Choice: Conductor of the Symphony,1988).
In human interactions, involved persons are complex, high dimensional systems that continuously exchange information on several sensorial channels. Surprisingly, in spite of this complexity, they are capable of exhibiting low dimensional behavior near regions of instability. In visually mediated movement coordination tasks, coordination dynamics, reveal emergent patterns indicating a common neural basis for the behavior (G.C. de Guzman & E. Tognoli (*). Illness may disrupt or blur boundaries with the environment requiring new patterns for life to continue (Uncertainty in Illness Theory, Mishel, 1990). In intentional dialogue, such as a nurse-person conversation about a complicating health challenge, the nurse encourages the unfolding of the experience. Reflective awareness of self-in-the-world connected with others may create a sense of relief or ease that emerges as disjointed story parts come together to make sense as a coherent whole (Liehr & Smith (2002) (*). Bar-Yam (2004) suggested that “strong emergence” is related to global restraints where unexpected pattern, not clearly related to previously seen parts, contributes to robustness in evolving systems.
The intuitive knowing and art of nursing emerges from an ensemble of interacting information and enables creative caring for human beings and the environment. Nursing is not only a science but an art. The art of nursing relates to who nurses are and what they do.“Nursing depends on scientific knowledge of human behavior in (health->illness), aesthetic perception of significant human experience, a personal understanding of the unique individuality of the self, and the capacity to make choices in situations involving moral judgments”( Carper, 1978, p.22). Nurses create art everyday, as a natural pattern, a way of being in the world. They encounter really important problems, the “messy, indeterminate situations” where they must “choose among conflicting appreciations of a situation so as to construct a coherent problem worth solving” (Schon, 1987, p.66). Artistry is an exercise of intelligence, incorporating problem framing, implementation and improvisation (Schon, 1987, p. 13). The art lies in the creativity that emerges in the uncertainty of healthcare experiences. It is in the relationship, the whole, global phenomenon. Persons who care for others are present at times of great challenge and change that provide a unique opportunity to develop knowledge of the whole. An expert caregiver gains a great deal of information over time and knows the mechanics of his or her craft so well that energy is conserved for understanding new and unique information and identifying shifts in patterning. Intuitive knowing is coupled with a creative solution that is co-created with the patient or significant others, enabling nurses to act in a manner, not planned or anticipated, but perceived as being of value at that moment of caring and in that nursing situation (Unpublished commentaries from Masters Nursing Theory students, 2004). Uncertainty enables emergence and creativity.
David Bohm (1980) would say insight or intuition is a leap into what he called the implicate order (a movement of incoming and outgoing waves). The information is enfolded into the whole and unfolds as an explicate understanding. Nurses have often observed strange events of information passed across space and healing that cannot be explained within the positivist, reductionist view of space and time. Locality is not absolute, space-time properties are implicit within the process and can emerge anywhere. Observer and observed in the same underlying process flow into each other, interweaving lives. There are some parallels to what is called the “guide wave” in quantum mechanics. An undivided movement, a subtle form of energy governs the quantum, forming beyond three dimensional time and space. It acts nonlocally anywhere and anytime, incorporating reflections of the past to guide particles. Understood as nonlocalized bits of information, the physical world is an evolving structure of information with propensities for experiences to occur. Nonlocal, in that choices made influence what happens in other, sometimes far way, areas. Global evolution occurs by the choices of local agents. Choices convert open future possibilities into fixed and recorded past events. The theories of complexity science and quantum mechanics lend respect to nurses and their intuitive ability to know. In the next section a model of Nursing Intuition was developed to explore the regularities within the phenomenon and the interactions among the regularities as an ensemble that facilitates strong emergence. We argue that Nursing Intuition is an example of strong emergence in that it can only be found in observations of the system as a whole and the whole may determine the behavior of the parts.
Modeling the intuitive art of Nursing
How can we understand nursing intuition so that we might better teach it to novice nurses and recognize the contribution of the expert nurse? Benner's original work entitled Novice to Expert in 1984 and further developed in Benner, Tanner, & Chesla (1998) used phenomenology to examine the intuition of the expert nurse. Here we present a beginning model that uses methods from Complexity Science to model the phenomenon. It is built on the belief that although it is very difficult to “extract the large-scale view from the highly detailed fine scale information the conventional and natural assumption is that it is possible in principle” (Bar-Yam, 2004b, p. 18).
The action the nurse takes emerges from many small pieces of information on many scales from laboratory data on health at the cellular and organ level to the “story” of how the current health event fits into the life of the person. Walking into an intensive care room the nurse may have an intuition that something is very wrong and quick action is needed. This intuition often cannot be fully explained by the available information, somehow it emerges from the whole of the event. In the language of complexity science this is an example of “strong emergence”. A strong emergent property cannot be “found in the properties of the system's parts or in the interactions between the parts” but in the properties of the ensemble (Bar-Yam, 2004b, p.15) . When the environment interacts with the system to select the allowable states, oscillations of multiscale variety with negative values may occur; somehow it emerges from the whole of the event. In the language of complexity science it is termed “strong emergence”. A strong emergent property can only be found in observations of the system as a whole. When the environment interacts with the system to select the allowable states, oscillations of multiscale variety with negative values may occur.
This Model of Nurse Intuition was constructed by Alice Davidson, Sayel Cortes, Lisa Conboy, and Mike Norman (unpublished, 2006).
Goal: To describe the system at a particular resolution (e.g. the macro level of the nurse/patient relationship). What can be seen at that resolution. The system has one less bit of information than the number of variables. That one is the collective behavior of all the variables. All the variables are independent, but together are mutually dependent. The nurse intuits the whole from information on the subsystems. To define a model the following are identified.
Objects:Nurse choosing action with given patient/ environment.
Space: Nurse and patient in close proximity
Time: Discrete: (1)=no action, (2)= moderate or mild action required, (3)= severe or quick action required
Dynamics: System changes as nurse

  • Considers patient information (verbal, charted, multisensory)

  • Information from the environment (family, five senses plus)

  • Utilizes knowledge (education, experience)

Information contributing to nurse intuition in five variables
To reduce redundancy in the model, it was necessary to reduce the information considered to the most theoretically influential variables determining the action a nurse would take. For example age; a nurse walking into a client' room in the Intensive Care Unit (ICU) would consider different action if the client was an adult versus a child or elderly person. Medical diagnosis, and information that could be gathered quickly with four senses: Visual (skin color, restlessness, relationship to the environment[in bed, tubes connected, temperature], Smell (odors suggesting ketoacidosis, incontinence, alcohol), and Auditory (moaning in pain, incoherent, rattling respirations) are also of primary importance. Tactile information (moistness, temperature, and turgor of skin) may also be important but to a lesser extent and thus is not included in this beginning model. The action the nurse might take is constrained by the environment: the medical records (primarily collected in the chart) which include lab values and what others had observed and actions taken. From the family she could learn the history of the person, the event that brought him/her to the ICU, patient concerns and ability to be involved.
Table 1: Probability of nurse encountering patient in either a high risk or low risk state for each of the five variables of interest.
Variable of Interest

State of risk

Age

Diagnosis

Visual

Auditory

Olfactory

Low

Adult 0.4

Acute 0.35

Normal 0.7

Normal 0.7

Strong 0.9

High

Child/Elderly 0.6

Chronic 0.65

Abnormal 0.3

Abnormal 0.3

Not strong 0.1

Environment: Family, Medical records, Technology involved
With the five most theoretically important symptom variables chosen (Table 1), we then applied a probability of the nurse finding a patient with symptoms in either a high risk or low risk state. We next wrote each of the 32 possible states that the nurse might find the patient in given the two options for each of the 5 variables. For each state we applied the type of action required ranging from 1 to 3 with one being no action, 2 being moderate or mild action required, and 3 being severe or quick action required. We then calculated the probability of each of the 32 states by multiplying the probability of action for each of the variable states given the two options. We then used this information to apply the formula in Figure 1, calculating each D(k). The calculation of the absolute values with the degree of action yielded Q1,Q2...Q5.

Figure 1

Equations

D(k) =nk means that D(k) counts the number of degrees of freedom that are k-fold redundant. The system partitions into subsets which are interdependent. Dependence indicates information at a large scale. Redundant information enables visualization at a large scale. Only when constraints are defined that act on collectives and not on components does strong emergence occur. A property of a state of the system obtained by observation is an average over the ensemble. The probability of a particular state s of the system is specified by P(s). The amount of information shared by k variables is complexity C(k) (plotted in the first graph) and increases with each variable. C(k)

To describe the complexity of a system we must specify the amount of information necessary to describe the macrostate of the system. The entropy of a physical system is the amount of information necessary to identify a single microstate from a specified macroscopic ensemble (Bar-Yam, 1997, p.718).. In non-equilibrium systems macroscopic behavior is observable when microscopic entropy is reduced by correlations and internal/relative degrees of freedom are constrained creating coherent behaviors. By examining the behavior of the state space volume at different degrees of resolution (scale), how information behaves as a function of scale becomes clearer. Negentropy measures the entropic deviation of the system from the equilibrium state and is high for systems out of equilibrium. Rather than a single number, a scale dependent complexity encompasses the complexity reported by a number of observers who observe the system at different scales. To obtain an explicit expression for the scale dependent information, the information is summed in all subsets of a particular size. Redundancy of information exists when a particular subset of the system overlaps information of other subsets of the system. To consider these overlaps, relationships or redundancies of subsets, a careful treatment of the combinatorics for all k is necessary (Bar-Yam, 2004a).
D(k) represents the information that has a redundancy of k. The values are high for some and even negative for others.
Age(1) Diagnosis (2) Visual (3) Olfactory (4) Auditory (5)
D(K)


Conclusions
The information in a system is dependent on scale. The mutual information contained within separately delineated subsystems at a certain scale is a result of the interdependence of components. This means that at a fine scale, a certain piece of information might be of extreme importance due to its inherent novelty (non-redundancy of the information contained elsewhere in the system). In an example, at the scale of olfactory sensory observation of a given patient, a strong smell could indicate to a knowledgeable practitioner that a certain ailment is the cause (e.g. diabetic ketoacidosis). Through experience, the nurse has learned that this smell, indicates a very high level of ketones creating acidosis within the body that can lead to coma and even death if not treated. If more information at a different scale, that includes not just smell but sight as well (e.g. dry skin, short and labored breathing) supports ketoacidosis in the patient, the belief becomes stronger. Since either of these pieces of evidence provide the same resultant information and either one of them alone is enough to communicate the relevant information to the nurse, there is redundant information in the system.
We believe the oscillations seen in the graph of D(k) are the result of including more variables. While certain subgroups might contain highly redundant information, adding another variable will cause more dependency between the variables of the system. This added dependency can lower the level of redundancy so much that it turns out computationally to be negative. Although it seems counterintuitive, the actuality is that these negative values represent the propagation of a constraint on the whole system down through the subsystems. What this means to a nurse is that there is a lack of necessary information needed to make an informed decision about the system when observing it at that scale. Since redundancy can be used to check for errors, having no redundancy at a certain scale means that deciding to take action based on observations made solely at that scale carries with it a higher risk of failure (to do the appropriate thing) than a scale where information can be checked for accuracy through redundancy. Another way to look at it is that the negative values are indicating that (some of) the dependencies of the subsystems are falling outside the scope of the current scale of observation (Norman, personal communication 2006). Global constraints affect individual behaviors. Strong emergent properties manifest in the response dynamics of a system as described by a fluctuating multiscale variety. The state of the whole person is seen in manifestations of many systems (e.g. pulse, electrocardiogram, tissue edema, skin color, respirations, and restlessness). In systems lacking global constraints, perturbations from the environment may disrupt parts and oscillations are seen (Bar-Yam, 2004b). Oscillations occur as a function of scale when constraints impact the values of multiple variables. Modulated by combinatorial factors from possible subsets, additional information is required to describe the system at intermediate scales. The environment may couple with the system in various ways and be impacted at all intermediate scales in many different ways. Resources allocated across a system vary in amounts to accommodate individuals with different environmental constraints. Properties of the system that do not reside in the parts but in the collective can be seen in the relationship of the system to the environment.
Future work
The patterns of knowing grounded in the mutual human-environment process and complexity science; overall a new approach to research in nursing, medicine, and healthcare, can strengthen the meaning of best practice paradigms that currently are taking hold in complex organizations in western cultures. The following methods may facilitate new understanding:

  • Over time – Utilize longitudinal research to see pattern change over time.

  • Over space – In the same study, collect data from small microsystems (genes, nerve impulses, mitochondria) to the large macrosystems (family relationship patterns, organizational change).

  • Case studies reveal the unique patterns of individuals emerging in living and dying.

  • Phenomenology involves interviewing people about their unique, lived experience.

  • Hermeneutics involves going back and forth among the data, both quantitative and qualitative, to gain understanding.

  • Models may be constructed using information from various data collection formats to interrelate them to better understand emergence. How does uncertainty enable creativity and evolve art? Our model of Nursing Intuition suggests it may be a strong emergent phenomenon.

Implications for practice
Human patterns are complex, unique to individuals and link to patterns in the environment. Greater complexity and variability are related to well-being. A new view of the world is emerging from complexity science and is useful for Nursing. More research is needed to study how variability and complexity relate to other variables in the environment and in the human-being. Environments that challenge without overwhelming offer a therapeutic goal. Environmental enrichment prescriptions developed for the unique pattern of the individual can increase the complexity of the environment pandimensionally (e.g. visual art and design, music, aromatherapy, tactile stimulation, including massage).

The ontology and epistemology of complexity science is being introduced to nursing educators. The Plexus Institute strives to promote multidisciplinary use of complexity science in relevant settings. The Plexus Nursing Education Conference 8/10-12/2005 in Kansas City provided a forum for sharing these ideas. Complexity science is being incorporated into the curriculum for new nurse leader roles (e.g. Clinical Nurse Leader, 2005).a

Radical change may arise from intense, complex situations and offer opportunity. Effort to identify and capitalize on radical shifts seen in disease and health processes may lead people to greater well-being. Longitudinal studies may reveal how small changes stack up and interact revealing manifestations on the macroscopic level. Modeling phenomena that are not well understood may provide insight into ensembles of important variables previously not suspected as involved in these phenomena. Complexity is a synthesis of wholeness and variability emerging from the mutual human-environment process.

The intuitive knowing and art of nursing emerges from an ensemble of interacting information and enables creative caring for human beings and the environment. The arts, environmental sciences, biology, and physics can widen the lens to enable a view beneath the surface. Ambiguity and broken symmetries intuitively joined emerge in new rhythmic patterns of possibility. Cross-disciplinary sharing to identify universal principles will guide and simplify our inquiries into the study of the specifics of complex systems. Connections through a wave of information facilitate coherence of many for chosen actualities.

References

Bar-Yam, Y.(2004a). Multiscale variety in complex systems. Complexity , 9 (4), 37-45.

Bar-Yam, Y. (2004b). A mathematical theory of strong emergence using multiscale variety. Complexity, 9 (6), 15-24.

Bar-Yam, Y. (1997). Dynamics of complex systems. Reading, PA: Addison-Wesley.

Benner, P., Tanner, C.& Chesla, C. (1998). Expertise in Nursing Practice: Caring, Clinical Judgment, and Ethics. New York: Springer.

Bohm, D. (1980). Wholeness and the implicate order. London: Routledge.

Carper, B.A. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Science. 1(1),13-23.

*Complexity for Human Environment Well-being (In Process and under review). *Indicates authors cited in this article with contributions in the book.

Davidson, A.W. (2001), Person-environment mutual process: Studying and facilitating healthy environments from a nursing science perspective. Nursing Science Quarterly. 14(2), 201-108.

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