Tailoring Healthy Workplace Interventions to Local Healthcare Settings: A Complexity Theory-Informed Workplace of Well-Being Framework

Table 1

The principles of complex adaptive systems (CAS) and how each principle is relevant to developing setting-appropriate interventions in workplace systems.

CAS principle	Relevance for workplace setting-appropriate intervention development
Interrelatedness and distributed control	All elements of a complex adaptive system are interrelated and are coevolving and behaviour change in complex healthcare settings is an emergent property of the interrelated and complex interactions between different workplace elements. Control is not centralised and top-down [12] and nor is it bottom-up, with power being something that can be “given” to the agents of a system [25]. Interventions cannot empower local agents (e.g., staff) by handing them the power to change their work environment; empowerment must take the form of enabling change to emerge within their context.
Order-generating rules	Patterns of behaviour in complex adaptive systems emerge from the operation of a few simple order-generating rules [14, 30]. Order-generating rules in a workplace include staff’s shared instincts, values, priorities, constructs, and mental models, for example, in a healthcare setting, the internalised rule of “first, do no harm” [23].
Edge of chaos	The edge of chaos is a point between chaos and order where a complex adaptive system has the most creativity, growth, and ability to adaptively change; it neither settles into stable equilibrium, nor quite falls apart [11, 32]. If a workplace is too stable, nothing changes; if it is too chaotic, the workplace will be overwhelmed by change. In either case, the workplace will be unable to adaptively change to its changing environment unless new order-generating rules are established [33] that act to hold the system at the edge of chaos [30]. Interventions to change behaviour in these systems need to focus on the enablers and barriers for the system to continuously self-organise into adaptive ways of behaving in response to its changing environment, for example, by enabling the dynamics of the workplace system (e.g., increasing interaction quality and quantity between staff) such that the system can continuously adapt to its environment and establish new order-generating rules and thus be neither too chaotic nor too ordered.
Self-organisation	Self-organisation refers to the internal propensity of complex adaptive systems toward more organised patterned behaviour [10, 11]. System-level patterns of behaviour emerge without external input or central control. This patterned behaviour is emergent, emerging from the interactions and relations of the interdependent agents (i.e., staff) in the system. These interactions are constrained and guided by the implicit or explicit order-generating rules (or shared priorities and values) of the staff. Interventions to change behaviour in a complex social system should enable the self-organising dynamics to support both sustainable adaptive change in the system and the integration of the intervention into the way that the system works.
Attractor patterns	Attractor patterns are patterns of behaviour that a complex adaptive system is attracted toward because of its particular conditions [11]. Staff behaviour patterns are those staff are drawn towards behaving in by the particular conditions of the workplace system at that time (i.e., the interrelations between staff and the order-generating rules or shared values they hold): changing these conditions will attract staff toward different patterns of behaviour [18]. Understanding how people in a setting are drawn towards behaving in certain ways shows how changing the underlying context can draw people to behave in different ways.
Re-enforcing feedback loops	Patterns emerging from the interactions of agents (e.g., staff) feed back into the system and further influence the shared beliefs and interactions of the agents. Feedback loops support the continuation of particular patterns of behaviour through the local experience of agents (e.g., staff) and can support the adaptive dynamic behaviour change in a system in response to its environment [25].
Coevolution of system and its environment	A complex adaptive system has the ability to continually create new order in coevolution with its environment [24]. This involves not only continual adaptation to its environment (i.e., the workplace’s wider social, cultural, and physical environment), but also the influencing of its environment through its changed behaviour. Interventions at a local level can create distributed change throughout the wider system that the local setting is a part of, and the wider system will continuously affect the local setting. Awareness of the wider context, for example, the organisational culture when looking at an individual team or department, is important to support appropriate intervention development and also an understanding of potential barriers or enablers to intervention implementation (e.g., management level support, or not, for a local intervention).
Sensitivity to initial conditions	The characteristics of a social complex adaptive system are highly context specific, not responding in the same way to the same stimulus under different circumstances at different times [12, 15]. System change will always begin from and involve the evolution of the initial conditions present in the system at the time. Behaviour change in a particular workplace can only begin from the particular context of that workplace and thus it is crucial that interventions are tailored to local workplaces’ initial conditions.
Creation of adjacent possibilities and awareness of path dependency	The space of possibilities for a complex adaptive system includes all of the possible (adjacent) new patterns of behaviour available at that time, given the initial conditions of the system. Initial conditions determine the adjacent possible patterns of behaviour, leading to “path dependency”: a system’s current behaviour is dependent upon its history; its previous behaviour made its current behaviour possible, which determines its possible next behaviours (adjacent possibilities). System-level behaviour change emerges from the exploration of new adjacent patterns of behaviour by a system [10, 30]. Depending on its particular dynamics each workplace will have a different space of possibilities and will differ in its ability to test out new ways of behaving. An understanding of the current conditions of a complex setting will help intervention developers to design an intervention that is appropriate for that workplace and that aims to bring about changes that are feasible given the characteristics of that workplace.