November 2009

Grant Results

SUMMARY

Complexity science is the discipline of how living systems self-organize, evolve and adapt. From 2004 to 2006, the Plexus Institute supported two networks of scholars and clinicians—devoted to nursing and clinical practice—to raise awareness about complexity science and develop strategies for using it to address key challenges in health care.

Key Results
The project resulted in a book, four articles and nine reports:

  • A book, On the Edge: Nursing in the Age of Complexity, about the implications of complexity science for clinical practice, leadership, nursing theory development, research, policy-making and understanding human physiology
  • Four articles posted on the Plexus Web site:
    • "The Practice of Medicine is in the Interactions: A Day with Robert A. Lindberg, M.D.," by Arvind Singhal. Available online.
    • "Trust is the Lubricant of Organizational Life: Lessons from the Life and Career of Henri Lipmanowicz," by Arvind Singhal. Summary available online.
    • "When the Task is Accomplished, Can We Say We Did it Ourselves?: A Quest to Eliminate MRSA at the Veterans Health Administration's Hospitals in Pittsburgh," by Arvind Singhal and Karen Greiner. Summary available online.
    • "Which Nursing Home Would You Put Your Mother In?" A Conversation with Complexity Scholars Reuben McDaniel, Jr. and Ruth Anderson, by Arvind Singhal. Available online.
  • Nine reports, including:
    • Microbial Mutations Test Human lngenuity. Available online.
    • Complexity and Change on the Indian Reservation. Available online. Scroll to the bottom to get to the link to the PDF.
    • Tiny Conspirators Talk to Each Other In Microscopic Bacterial Communities. Available online.
    • A New Wrinkle in Fighting Bad Bugs: Don't Let Your Fashion Be Infectious. Available online.
    • A Paradox: Communication is the Issue and the Answer. Available online.

Funding
The Robert Wood Johnson Foundation (RWJF) funded this project with a grant of $214,440 from October 2004 through December 2006.

 See Grant Detail & Contact Information
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THE PROBLEM

The health care system has had only limited success addressing several major challenges, including:

  • Increasing numbers of people afflicted with chronic diseases
  • Steeply rising costs for care
  • Reducing errors and improving quality of care

One underlying reason for this disappointing progress may be an incomplete understanding of the complexity of human physiology and of human organizations such as hospitals, nursing homes and primary care practices.

The Institute of Medicine, in its 2001 report, Crossing the Quality Chasm, a critique on health care delivery in this country, noted that "Complexity science provides a new paradigm to guide system design." Complexity science is the discipline of how living systems self-organize, evolve and adapt.

The Plexus Institute, a nonprofit organization based in Bordentown, N.J., was formed in 2001 to explore beneficial uses for the insights from complexity science. In 2003, it formed a Complexity Science and Nursing Network to develop concepts based on complexity and human physiology for application in primary care practice and quality. The network grew in part from a 2003 conference largely funded by RWJF. See Grant Results.

RWJF also funded Plexus to work on reducing methicillin-resistant staphylococcus aureus infections in hospitals by using the positive deviance approach to organizational change (ID# 055726). This work resulted in a 73 percent decrease in the pilot units in six hospitals. See Grant Results.

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THE PROJECT

This project had two objectives:

  • To develop and test new strategies suggested by complexity science for reducing the impact of chronic illness and improving health care quality
  • To raise awareness within the nursing, medical and health care management communities of complexity science and the promise it offers

To accomplish these goals, the team at Plexus employed two learning networks of researchers, academics, clinicians, medical educators and complexity scientists:

  • The Complexity Science and Nursing Network, operating since 2003 (see The Problem), had about 50 members (see Appendix 1), mostly nurses, and focused on nursing education, management and practice.
  • The Complexity Science and Clinical Practice Learning Network, established in 2004, had about 30 members (see Appendix 2), mostly physicians, and focused on clinical practice.

Plexus staff helped each network to foster work collaborations and the exchange of information and ideas as well as other forms of interaction among its members. This support included:

  • A password-protected Web site where network participants could communicate online
  • Biweekly conference calls among network members
  • Approximately biannual network meetings or conferences

Plexus also charted growth in the strength and capability of the nursing network over a two-year period using social network analysis, which measures network characteristics that enhance information flow, innovation and collaboration.

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RESULTS

The project director, Curt C. Lindberg, M.H.A., reported to RWJF that Plexus staff and network participants produced the following products (see the Bibliography for publication details) under the grant:

  • A book, On the Edge: Nursing in the Age of Complexity, published in 2008. The book presents articles by scholars and nurse leaders about the implications of complexity science for clinical practice, leadership, nursing theory development, research, policy-making and understanding human physiology.
  • Four articles posted on the Plexus Web site:
    • "The Practice of Medicine is in the Interactions: A Day with Robert A. Lindberg, M.D.," by Arvind Singhal. Available online.
    • "Trust is the Lubricant of Organizational Life: Lessons from the Life and Career of Henri Lipmanowicz," by Arvind Singhal. Summary available online.
    • "When the Task is Accomplished, Can We Say We Did it Ourselves?: A Quest to Eliminate MRSA at the Veterans Health Administration's Hospitals in Pittsburgh," by Arvind Singhal and Karen Greiner. Summary available online.
    • "Which Nursing Home Would You Put Your Mother In?" A Conversation with Complexity Scholars Reuben McDaniel, Jr. and Ruth Anderson, by Arvind Singhal. Available online.
  • Nine reports, including:
    • Microbial Mutations Test Human lngenuity. Available online.
    • Complexity and Change on the Indian Reservation. Available online. Scroll down to click for the PDF.
    • Tiny Conspirators Talk to Each Other In Microscopic Bacterial Communities. Available online.
    • A New Wrinkle in Fighting Bad Bugs: Don't Let Your Fashion Be Infectious. Available online.
    • A Paradox: Communication is the Issue and the Answer. Available online.
  • Two workshops and two small conferences on issues involving health care and complexity science:
    • "Complexity Science: Opportunities for Nursing Education. An Introductory Workshop for Nurse Educators" took place August 10–11, 2005, at the University of Kansas School of Nursing, Kansas City, Kan. Co-sponsored with the American Association of Colleges of Nursing, it drew 182 registrants.
    • "End of Life Communications Impasse: A Dialogic Intervention" took place February 24, 2006, at the University of Texas Health Science Center School of Nursing, Houston, and drew 24 registrants.
    • "Complexity Science: Knowledge, Learning and Resources to Advance Nursing Education, Practice and Leadership: A Workshop for Nurses Shaping 21st Century Healthcare" took place May 31–June 1, 2006, at the College of New Jersey School of Nursing, Ewing, N.J., and drew 54 registrants.
    • "Creating Interdisciplinary Cultures: Insights from Complexity Science and Relationship-Centered Care" took place November 18–19, 2006, at Indiana University, Indianapolis. Co-sponsored with the American Academy on Communications in Healthcare and the National Academies of Practice, it drew 68 registrants.
  • Four telephone conference presentations by experts for network participants and other interested individuals:
    • "Positive Deviance, the Solutions Within," led by Jerry Sternin and Monique Sternin, May 2005.
    • "Smart Networks and How They Work," led by Kevin Dooley, Lisa Kimball and June Holley, March 2006.
    • "Appreciative Leadership and Network Weaving," led by Jack Ricchiuto, Lisa Kimball and June Holley, June, 2006.
    • "How to Halt Hospital Infections," led by Betsy McCaughey, Ph.D., and Jerry Zuckerman, November 2006.

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LESSONS LEARNED

  1. For robust learning networks in health care, the more nurses involved the better. Generally speaking, nurses are more attuned to complexity and relational networking than physicians, according to Curt Lindberg, M.H.A.,D.Man., of the Plexus Institute. "We might have tried to mix nurses in more so we would get the benefit of their orientation to the entire network. Some of the physicians said, 'We want a group of our own.' But we didn't have the skills to do that.! And the nurses did. We're not as skilled as nurses in building effective groups." (Project Director/Lindberg)
  2. Physician retention in learning networks probably will benefit from increased face-to-face contact early on. Lindberg: "If I had it to do over I'd consider more face-to-face get-togethers for physicians at the beginning of their network developing relationships so relationships among them could take off. That may have made a difference in their rate of network participation later." (Project Director/Lindberg)
  3. A focus on the nursing profession should speed future advancement and development of complexity as a field and in its introduction into health care. According to Lindberg, there's a true compatibility between nursing education and the work of nursing on the one hand, and complexity on the other: "The uptake and appreciation of complexity concepts is more significant among nurses than any other professional discipline that I'm aware of." (Project Director/Lindberg)

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AFTER THE GRANT

The Complexity Science and Nursing Network continues functioning as of mid-2009, with Plexus support. They have annual meetings and conference calls several times a year.

In 2007, the American Association of Colleges of Nursing adopted national curriculum standards for a masters degree program training clinical nurse leaders, who oversee integration of care as part of a professional team and have decision-making authority over patient care plans. The curriculum incorporates complexity science principles. Nursing network members and Plexus staff participated in the development of the curriculum.

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GRANT DETAILS & CONTACT INFORMATION

Project

Using complexity science concepts to enhance health care quality

Grantee

Plexus Institute Inc. (Bordentown,  NJ)

  • Amount: $ 214,440
    Dates: October 2004 to December 2006
    ID#:  051504

Contact

Curt C. Lindberg, M.H.A.
(609) 298-2140
curt@plexusinstitute.org

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APPENDICES


Appendix 1

The Complexity Science and Nursing Network

This network has operated since 2003 (and is still operating as of mid-2009). It focuses on nursing education, management and practice.

Members in 2006:

Vinita Agarwal
Purdue University
West Lafayette, Ind.

Ruth A. Anderson, Ph.D., R.N.
Duke University School of Nursing
Durham, N.C.

Susan Bakewell-Sachs, Ph.D., R.N., A.P.R.N., B.C.
College of New Jersey
Ewing, N.J.

James W. Begun, Ph.D.
University of Minnesota
Minneapolis, Minn.

Marge Benham-Hutchins, R.N., Ph.D.
Northeastern University
Boston, Mass.

Michael R. Bleich, Ph.D., M.P.H., R.N.
Oregon Health & Science University
Portland, Ore.

Marjorie J. Bott, Ph.D., R.N.
University of Kansas School of Nursing
Kansas City, Kan.

Peter Bradford
Berryvillle, Va.

Cynthia Capers, Ph.D., R.N.
University of Akron School of Nursing
Akron, Ohio

Ramona Charles
Veterans Administration Illiana Healthcare System
Danville, Ill.

Thomas R. Clancy
Mercy Hospital
Iowa City, Iowa

Donna Cole, R.N., Ph.D., C.N.O.R., C.N.A.
Hunterdon Medical Center
Flemington, N.J.

Annie Collins
Washburn University
Topeka, Kan.

Linda R. Conover
St. Joseph's College of Maine
Standish, Maine

Diana Crowell, R.N., Ph.D.
Leading Your Life
Kittery, Maine

Alice Ware Davidson, Ph.D., R.N.
University of Colorado
Boulder, Colo.

Shirley Dinkel, Ph.D., A.R.N.P.-B.C.
Washburn University
Topeka, Kan.

Joan C. Engebretson, Dr.Ph., A.H.N.-B.C., R.N.
University of Texas Health Science Center
Houston, Texas

Patricia Fazzone, D.N.S.C., M.P.H., R.N.
Southern Illinois University
Edwardsville, Ill.

Mary L. Gambino, R.N., M.N., Ph.D.
University of Kansas School of Nursing
Kansas City, Kan.

Rose Girgenti
St. Joseph's Medical Center
Paterson, N.J.

Karen A. Grigsby, Ph.D., R.N.
University of Nebraska Medical Center
Omaha, Neb.

Donna S. Havens, Ph.D., R.N.
University of North Carolina at Chapel Hill
Chapel Hill, N.C.

Cynthia A. Hornberger, Ph.D., R.N., M.B.A.
Washburn University School of Nursing
Topeka, Kan.

Margaret Hourigan, R.N., Ed.D., C.N.A.A., B.C.
St. Joseph's College of Maine
Standish, Maine

Christine Hoyle
University of Washington
Seattle, Wash.

Marian Jamison
Washburn University
Topeka, Kan.

Deborah Lekan-Rutledge, M.S.C., R.N.C., C.C.C.N.
Duke University School of Nursing
Durham, N.C.

Tona L. Leiker, M.N., A.R.N.P.-C.N.S., A.P.R.N., B.C.
Tabor College
Andover, Kan.

Claire Lindberg, Ph.D., R.N., A.P.R.N., B.C.
The College of New Jersey
Ewing, N.J.

Curt Lindberg, D.Man.
Plexus Institute
Bordentown, N.J.

Henri Lipmanowicz
Plexus Institute
Bordentown, N.J.

Anita L. Macan
University of Kansas
Lawrence, Kan.

Jane S. Mahoney, D.S.N., R.N., C.N.S.-P/M.H., B.C.
Menninger Clinic
Houston, Texas

Sue Nash, R.N., Ed.D.
Augsburg College
Rochester, Minn.

Maria Nemeth, Ph.D.
Academy for Coaching Excellence
Sacramento, Calif.

Cherie Marie Parker
Kansas University
Kansas City, Kan.

Brenda J. Patzel
Washburn University
Topeka, Kan.

Premruetai Rattanavilai
University of Kansas
Lawrence, Kan.

William Warren Riffle
University of Texas at Austin
Austin, Texas

Linda Rusch, R.N.
Hunterdon Medical Center
Flemington, N.J.

Paul Shank
Harris County Hospital District
Houston, Texas

Sherri Solomon-Jozwiak, R.N., B.S.N., M.P.A.
St. Vincent Catholic Charities
Lansing, Mich.

Robert Prasaad Steiner, M.D., Ph.D.
University of Louisville
Louisville, Ky.

Nancy L. Stuever
Menomonee Falls, Wis.

Ann L. Swartz, M.S.N., A.P.R.N., C.R.N.P.
Penn Sylvania State University
Harrisburg, Pa.

Jolene Tornabeni, M.A., R.N.
Scottsdale, Ariz.

Connie Visovsky
University of Nebraska Medical Center
Omaha, Neb.

Marjorie S. Wiggins, R.N.
Maine Medical Center
Portland, Maine

Donna M. Yadrich
University of Kansas
Lawrence, Kan.


Appendix 2

The Complexity Science and Clinical Practice Learning Network

The Plexus Institute established this network in 2004. It is no longer in operation. It focused on clinical practice, primarily medical practice.

Members (2005):

Susan Bakewell-Sachs
College of New Jersey
Ewing, N.J.

Peter Boggs, M.D.
Director, Asthma 2000 Group
Shreveport, La.

Elizabeth D. Carlson, Ph.D., R.N., N.P.
M.D. Anderson Cancer Center University of Texas
Houston, Texas

Joan Engebretson, Dr.P.H., A.H.N.-B.C., R.N.
University of Texas Health Science Center
Houston, Texas

Patricia Fazzone, D.N.S.C., M.P.H., R.N.
Southern Illinois University
Edwardsville, Ill.

James J. Giordano, Ph.D.
University of Texas Health Sciences Center
Houston, Texas

Frances Griffiths, M.D.
Warwick Medical School
Coventry, U.K.

Dale Guenter, M.D.
McMaster University
Hamilton, Ontario, Canada

Linda Harris, Ph.D.
National Cancer Institute
Bethesda, Md.

Bethany M. Hays, M.D.
True North Health Center
Falmouth, Maine

Eileen Hoffman, M.D.
New York University School of Medicine
New York, N.Y.

Tim Holt, M.D.
Warwick Medical School
Coventry, U.K.

Marshal Levine, M.D.
NASA
Washington, D.C.

Curt Lindberg, M.H.A.
Plexus Institute
Bordentown, N.J.

Robert Lindberg, M.D.
Columbia University
New York, N.Y.

Henri Lipmanowicz
Plexus Institute
Bordentown, N.J.

Jane Mahoney, D.S.N., R.N., C.N.S.-P./M.H., B.C.
University of Texas Health Science Center
Houston, Texas

Dannen D. Mannschreck, M.D.
Texas Tech University Health Sciences Ctr.
Odessa, Texas

Stewart P. Mennin, Ph.D.
Mennin Consulting & Associates
Albuquerque, N.M.

Dan Munday, M.D.
Warwick Medical School
Coventry, U.K.

Dan Pesut, Ph.D., R.N., A.P.R.N., B.C.
Indiana University School of Nursing
Indianapolis, Ind.

Mary K. Pierce, R.N.
Tucson VA Medical Center
Tucson, Ariz.

Diane M. Pittman, M.D.
Indian Health Service
Bemidji, Minn.

William Warren Riffle
University of Texas at Austin
Austin, Texas

Patricia Rush, M.D.
Primary Care Plus
Chicago, Ill.

Robert Prasaad Steiner, M.D., Ph.D.
University of Louisville
Louisville, Ky.

Anthony L. Suchman, M.D.
Relationship Centered Health Care
Rochester, N.Y.

Ann L. Swartz, M.S.M., A.P.R.N., C.R.N.P.
Penn State University
Harrisburg, Pa.

Muneesh Tewari, M.D., Ph.D.
Fred Hutchinson Cancer Research Center
Seattle, Wash.

Ralph M. Waugh, Ph.D.
Florida State University
Tallahassee, Fla.

Norbert A. Wetzel, Th.D.
Center for Family, Community & Social Justice
Princeton, N.J.

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Books

Lindberg C, Nash S and Lindberg C. On the Edge: Nursing in the Age of Complexity. Bordentown, NJ: PlexusPress, 2008.

Articles

Singhal A. "Complexity in Practice: The Practice of Medicine is in the Interactions: A Day with Robert A. Lindberg, M.D." (Web posting), 2005. Available online.

Singhal A. "Trust is the Lubricant of Organizational Life: Lessons from the Life and Career of Henri Lipmanowicz" (Web posting), 2006. Summary available online.

Singhal A and Greiner K. "When the Task is Accomplished, We Can Say We Did it Ourselves: A Quest to Eliminate MRSA at the Veterans Health Administration's Hospitals in Pittsburgh" (Web posting), 2007. Summary available online.

Singhal A. "Which Nursing Home Would You Put Your Mother In?" A Conversation with Complexity Scholars Reuben McDaniel, Jr. and Ruth Anderson. (Web posting). Available online.

Reports

Positive Deviants Inspire Positive Change (Web posting), Bordentown, NJ: Plexus Institute, 2005. Available online.

A Paradox: Communication is the Issue and the Answer (Web posting), Bordentown, NJ: Plexus Institute, 2005. Available online.

Microbial Mutations Test Human lngenuity (Web posting), Bordentown, NJ: Plexus Institute, 2005. Available online.

Positive Deviance Helps Mankind Fight Microbes (Web posting), Bordentown, NJ: Plexus Institute, 2006. Available online.

Complexity and Change on the Reservation (Emerging newsletter Web posting), Bordentown, NJ: Plexus Institute, 2006. Available online. Scroll to the end and link to the PDF.

Cleanliness is a Fine Life Preserver-George Herbert, English Poet, 1693–1733 (Web posting), Bordentown, NJ: Plexus Institute, 2006. Available online.

Tiny Conspirators Talk to Each Other In Microscopic Bacterial Communities (Web Posting), Bordentown, NJ: Plexus Institute, 2006. Available online.

A New Wrinkle in Fighting Bad Bugs: Don't Let your Fashion be Infectious (Web posting), Bordentown, NJ: Plexus Institute, 2006. Available online.

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Report prepared by: James Wood
Reviewed by: Robert Narus
Reviewed by: Molly McKaughan
Program Officer: Rosemary Gibson