Understanding Whole Systems Change in Health Care: The Case of Nurse Practitioners in Canada

Abstract

Nurse practitioners (NPs) were introduced into the Canadian health system almost half a century ago. Despite early evidence of their effectiveness, it took decades to establish a substantial critical mass of NPs. Using the NP as a case study exemplar, we adopted a whole system change perspective to understand what else besides evidence was needed to ensure the success of desirable health systems innovations. We identified elements of whole systems change to analyze literature on the NP movement in terms of leverages, blockages, and system dynamics. Results suggest that evidence was only one of many factors shaping the uptake of NP services as part of larger, ongoing, adaptive whole systems change. The changes required to integrate the NP role within the health system reflect a socio-ecological perspective that may be used to understand sustainable health systems innovation and improvement.

Priority setting and policy advocacy by nursing associations: A scoping review and implications using a socio-ecological whole systems lens

“…where a small shift in one thing can produce big changes in everything" (p. 1) [116], can be used to foster resilience, sustainability, or change. Identifying blockages that hinder, scale down, or create inertia is essential for finding ways to manage them [110,111]. Furthermore, the paradoxical presence of both leverage points and blockages to change within a given organization that we noted in our findings is consistent with the paradoxical system dynamics that are well described in ecosystems management case studies [110,114].…”

“…The scale, duration, and non-linear nature of this kind of co-evolution also mean that a variety of structures and processes can serve as leverage points or blockages for systems change at any given point in time [111]. Leverage points, defined as "places within a complex system .…”

“…Case comparisons would be particularly useful for identifying cross-cutting themes that contribute to, or constrain nursing organizations' public policy efforts at different systems levels. Furthermore, as case exemplars in ecosystems management [110] and health systems change [111] illustrate, longitudinal studies are also needed to understand changes that occur at different time scales. Data collection requires tracking change from multiple perspective and multiple levels in order to identify patterns and ambiguities, and to identify where different changes may occur.…”

“…This systems theory approach was applied to a recent analysis of Canadian nursing associations' joint policy efforts over several decades to introduce and sustain the use of nurse practitioners across Canada [111]. In this form of systems thinking, whole systems change is defined as "uneven, nested cycles of adaptation that evolve within closely coupled, complex socio-ecological systems over time" (p. i) [115].…”

“…Various forms of systems theory have been applied in organizational studies to understand strategic and organizational decision-making [107][108][109], and to develop knowledge for human and health care problems that involve cross-disciplines-sectors-jurisdictions [55,[110][111][112][113]. Organizational systems theorists conceptualize organizations as "collections of human and physical capital that exchange and process information, transform physical objects, and make decisions for the purpose of achieving some set of objectives related to their external environment" (organizations are open systems section) [108].…”