Content uploaded by Ippolito Notarnicola
Author content
All content in this area was uploaded by Ippolito Notarnicola on Jan 02, 2019
Content may be subject to copyright.
Metadata of the chapter that will be visualized in
SpringerLink
Book Title Methodologies and Intelligent Systems for Technology Enhanced Learning, 8th International Conference
Series Title
Chapter Title Systems Thinking, Complex Adaptive Systems and Health: An Overview on New Perspectives for Nursing
Education
Copyright Year 2019
Copyright HolderName Springer Nature Switzerland AG
Corresponding Author Family Name Notarnicola
Particle
Given Name I.
Prefix
Suffix
Role
Division
Organization Centre of Excellence for Nursing Scholarship
Address OPI Rome, Italy
Email ippo66@live.com
Author Family Name Stievano
Particle
Given Name A.
Prefix
Suffix
Role
Division
Organization Centre of Excellence for Nursing Scholarship
Address OPI Rome, Italy
Email
Author Family Name Pulimeno
Particle
Given Name A.
Prefix
Suffix
Role
Division
Organization Centre of Excellence for Nursing Scholarship
Address OPI Rome, Italy
Email
Author Family Name Rocco
Particle
Given Name G.
Prefix
Suffix
Role
Division
Organization Centre of Excellence for Nursing Scholarship
Address OPI Rome, Italy
Email
Abstract This article describes a new concept of health, originally developed and published in 2014. This model
offers a new understanding of health, disease and healing that may be very useful for patient care. In fact,
the Meikirch model leads to a new comprehension of health as a complex adaptive system. Systems
thinking and complex adaptive systems share a number of components, namely: emergence, self-
organization, and hierarchies of interacting systems. Systems thinking, especially with simulation models,
facilitates understanding of health as a complex phenomenon. Therefore, the simulation model is becoming
an excellent translator of complex problems in easily understandable results. Systemic thinking is a process
that can influence cause and effect and prompts solutions to multifaceted tribulations. In conclusion, this
paper describes the principles of complementarity and of differences between scientific approaches for
systemic thinking and traditional thinking and suggests that it is time for research approaches that fosters a
non-mechanistic thinking.
Keywords
(separated by '-')
Systems thinking - Complex adaptive systems - Health - Systems modeling - Nursing
Systems Thinking, Complex Adaptive Systems
and Health: An Overview on New Perspectives
for Nursing Education
I. Notarnicola
(&)
, A. Stievano, A. Pulimeno, and G. Rocco
Centre of Excellence for Nursing Scholarship, OPI Rome, Italy
ippo66@live.com
Abstract. This article describes a new concept of health, originally developed
and published in 2014. This model offers a new understanding of health, disease
and healing that may be very useful for patient care. In fact, the Meikirch model
leads to a new comprehension of health as a complex adaptive system. Systems
thinking and complex adaptive systems share a number of components, namely:
emergence, self-organization, and hierarchies of interacting systems. Systems
thinking, especially with simulation models, facilitates understanding of health
as a complex phenomenon. Therefore, the simulation model is becoming an
excellent translator of complex problems in easily understandable results. Sys-
temic thinking is a process that can influence cause and effect and prompts
solutions to multifaceted tribulations. In conclusion, this paper describes the
principles of complementarity and of differences between scientific approaches
for systemic thinking and traditional thinking and suggests that it is time for
research approaches that fosters a non-mechanistic thinking.
Keywords: Systems thinking Complex adaptive systems Health
Systems modeling Nursing
1 Introduction
Health is defined by the World Health Organization (WHO) as a “state of complete
physical, mental and social well-being and not just the absence of disease”; therefore,
it is considered a fundamental right of every human being. This concept plays an
important role in every State because it determines what a health system must deliver
equally to all individuals. As such, it is of fundamental importance to identify and try to
modify those factors that negatively affect health, while, at the same time, supporting
the positive ones [1]. Health can be considered a constant resource, which allows every
human being to lead a profitable life at economic, social and individual levels.
The WHO concept of health is very important and always stirs reflections and dis-
cussions in the scientific environment. However, the concept of health continues to be
accepted, particularly in the biomedical sciences, as a disease-free condition or state
[2].
AQ1
©Springer Nature Switzerland AG 2019
T. Di Mascio et al. (Eds.): MIS4TEL 2018, AISC 804, pp. 1–8, 2019.
https://doi.org/10.1007/978-3-319-98872-6_34
Author Proof
2 Background
We can consider human beings as an open system. A system that cannot be considered
closed, but a complex system with the ability to interact with the external environment
in a dynamic and continuous way. The relationships that each individual has in society
are fundamental for his/her social life. We do not have to have a vision of the human
being as an individual, but as a system of relationships or rather a complex adaptive
system (CAS) [3]. Therefore, the quantity and quality of information that each indi-
vidual is able to receive, communicate and, then, process is important. A human being
can be considered a multilevel agent that operates in different environments incessantly
and is capable of participating in its own overall and collective development. We can
consider our health as a manifestation and result of a myriad of complex inter-
relationships in structure and function, both within and throughout many levels of
organization—from molecules and cells to systems functioning throughout the body
and their interfaces with whole ecosystems [4]. The traditional, “reductionist”view of
health care has unquestionably succeeded and led to great progress and remarkable
insights, but it may be time for a more integrated approach to integrate traditional
nursing. According to some researchers, the science of complexity is simply the next
stage in understanding how systems work [5]. In fact, nursing is the tradition of
studying systems, seen as connections and interactions within a systems paradigm, and
must continue in a modern vision [6]. Therefore, it is important to clarify the meaning
of the well-being of each individual in a systemic vision. According to Bircher & Hahn,
“Health is a state of well-being emerging from the conductive interactions between the
potentials of individuals, the needs of life and social and environmental determinants.
Health outcomes throughout the course of life when the potential of individuals -and
social and environmental determinants -are sufficient to respond satisfactorily to the
demands of life. The demands of life can be physiological, psychosocial or environ-
mental, and vary between individual and context, but in any case, unsatisfactory
answers lead to disease.”[7].
In recent years, the science of complexity has been gradually entering nursing field.
This becomes relevant as an explanation of health and disease as different states of a
CAS. An understanding of the state of health care requires a complexity science
approach, introducing a new dimension to patient care and assistance [8]. According to
some Netherlands researchers [9], a systemic approach, such as systemic thinking,
incorporates interactions between relevant factors by providing additional information
for planning and evaluating health promotion [9].
Precisely for this reason, systemic thinking has been defined as: a process applied to
individuals, teams and organizations to influence the cause and the effect where
solutions to complex problems are realized through a collaborative effort based on
personal abilities compared to the improvement of components and to the complex.
The main attributes that characterize systemic thought are: the dynamic system, the
holistic perspective, the identification of the model and the transformation [10].
Systemic thinking, therefore, is the ability to recognize, understand and synthesize
interactions and interdependencies in a system. This method includes the ability to
recognize patterns and repetitions in interactions and an understanding of how actions
2 I. Notarnicola et al.
Author Proof
and components can reinforce or neutralize each other [11]. In other words, systemic
thinking relates the environment of a person to his/her way of acting within a system. In
nursing delivery, this implies the nurse understands the assessment of how the com-
ponents of a complex health care system affect the care of an individual patient [11].
Systemic thinking is an essential attitude for nurses. Even if, this ability is important,
there is little knowledge of this thought process, so we need to work towards ensuring
that it plays a key role in improving patient care in increasingly complex health
organizations. To educate nurses in systemic thinking, it is important to improve their
awareness of this topic. Nurses should also be encouraged to see interdependencies
between people, processes and services, and to see problems that have occurred as part
of a chain of events of a larger system, rather than as independent events. Learning is a
dynamic process; as nurses discover new knowledge and build new insights, the
development of systemic thinking will help to improve their decision-making pro-
cesses. For example, in an academic and health setting, nurses can use systemic
thinking, both to improve decision-making skills and to improve clinical practice by
increasing essential skills.
Systemic thinking, through simulation models, can facilitate the understanding of
complex health policy problems. In fact, simulation models educate health profes-
sionals to improve their skills, serving as tools capable of translating complex scientific
evidence into easily understood results [12]. In this sense, a system that could help
clarify what health is, in other words, to propose a valid concept of health to apply to
the care of people and public health has been developed by Bircher and Kuruvilla [13],
with their Meikirch Model.
3 Aim
The purpose of this article is to summarize the relevant characteristics of the Meikirch
Model and to show, in detail, how to apply this Model to better understand patient care.
The Meikirch Model is a new definition of health that has all the characteristics of a
CAS.
4 Data Source
A bibliographic search, without time limits, was undertaken to retrieve articles pub-
lished using the following databases: Cumulative Index for Nursing and Allied Health
Literature (CINAHL
©
), PubMed
©
and Google Scholar
©
. Once the articles were iden-
tified, with the analytical support of ENDNOTE X8 (Thomson Reuters©, New York),
duplicates were excluded and articles of interest were selected. Only articles in English
were retrieved and included. Furthermore, both the title and the abstract had to contain
the following keywords: Meikirch model, health, system thinking, complex adaptive
system, nursing. The aim was to identify the evidence in the literature that outlined the
concept of health and how this was examined through systemic thinking. Initially, 811
articles were found; after the removal of duplicates, 646 articles were left. The articles
found used various research methodologies. The material available was interesting for
Systems Thinking, Complex Adaptive Systems and Health 3
Author Proof
the various topics analyzed, above all, those on systemic thinking according to the
concept of health. This led to the identification of 278 articles; these articles were then
analyzed, focusing on those in which systemic thought and the concept of health were
in the title and in the abstract or those which contained contents related to this concept.
This led to an analysis and discussion of 10 articles. These were read and re-read
analyzed carefully through a content based process (See Fig. 1).
Fig. 1. Flow chart of the data selection process
4 I. Notarnicola et al.
Author Proof
5 Results and Discussion
The concept of health, when explained as a CAS, offers new perspectives, particularly
to nurses and nursing staff. We agree with Bircher & Kuruvilla that the Meikirch Model
could lead to significant improvements in the world of health [13]. This discussion
seeks to briefly clarify the Meikirch Model, describing its parts and what possible
consequences it can have on the individual and his/her health, as well as its possible
interactions with nursing.
The Meikirch Model is based on five components—demands of life (LD); bio-
logically given potential (BGP); personally acquired potential (PAP); social deter-
minants of health (SD); and, finally, environmental determinants of health (ED)—and
10 complex interactions (See Fig. 2). This framework allows us to define health and
diseases as a CAS. Therefore, according to the Meikirch Model, health can be defined
as “a state of dynamic well-being emerging from the interactions conducted between
the potentials of an individual, the needs of life and the social and environmental
determinants,”[13] while the following can explain disease: The results of health in
the course of life when the potentials of an individual and the social and environmental
determinants are sufficient to respond satisfactorily to the needs of life, these may be
physiological, psychosocial or environmental and they vary between individuals and
contexts, but in any case, the unsatisfactory answers lead to the disease [13].
Fig. 2. The Meikirch model
Systems Thinking, Complex Adaptive Systems and Health 5
Author Proof
Figure 2also shows five components, while interactions are exposed as double-
edged arrows from 1 to 10.
Every human being potentially seeks to satisfy his/her life’s demands. In part, this
is due to the biologically given potential, congenital in every person, which has been
acquired to a certain extent during a person way of life, and the personally acquired
potential. Equity and equality, social concerns, working conditions, autonomy and
social participation interact strongly with the needs of life and the potential of the
individual, constituting the social determinants of health. We can consider these are the
main determinants of health [13]. While the living and working conditions of every
human being constitute the environmental determinants of health, sometimes these can
have global significance, such as natural resources, climate change and population
growth [13]. In nursing, it is especially important to understand the health status of
patients in order to improve their essential competence and clinical practice. In this, the
Meikirch Model takes on particular importance, as it considers the patient a CAS, with
all the properties of a system. All of this is significant because the relationships
between CAS and other concepts provide the basis for new perspectives of nursing
theory development. In fact, this discussion provides us with further elements to outline
the CAS concept within nursing, developing different theoretical perspectives of the
discipline itself, which can be used in different clinical and academic fields [3]. For the
most part, nurses analyzing CASs in particular, have the opportunity to redesign
clinical and academic practice, integrating them with theories and models used by other
health professionals, in order to solve and simplify complex problems, such as the state
of health. At an academic level, for example, in simulation labs, systemic thinking
increases the initial perceptions of students and teachers, as well as expands their
capacities for critical thinking, inter-professional communication and laboratory
operations [14,15]. In addition, new computational tools are emerging, ranging from
computational simulation to analysis of social networks to data mining. For example, in
computational modeling, a number of tools are interconnected and developed to answer
questions about the functioning of CASs, including the behavior of individuals in those
systems, which cannot be addressed using other traditional research methods [16]. In
the care of patients who do not have the capacity to develop systemic thinking,
understanding of health remains fragmented, creating factors that are harmful to patient
safety. Therefore, the lack of systemic thinking creates a negative care treatment
environment in which the patient is seen as the passive recipient of care; this creates
additional deficits in the whole system, in terms of cost of care, financial burdens,
mortality, morbidity and decline of the patient satisfaction [10]. Through systemic
thinking, we can organize, model, guide and, finally, build a conceptual model, offering
a vision through which we can focus on ideas and relationships [17]. Applying the
principles of systemic thinking and CAS in nursing care and using a new model (See
Fig. 3), opens up new ideas of thought and study, offering insights and new points of
view.
6 I. Notarnicola et al.
Author Proof
6 Conclusion
The Meikirch Model is a theoretical framework based on scientific evidence. Compared
to other definitions of health, the model seeks to understand the concept of health in a
rational way by offering innovative opportunities [13]. It further tries to combine both
the concept of health and illness. The theoretical framework the model provides is in
line with the theory and practice of evidence-based medicine and nursing. In addition,
the care is centered on the person, offering the opportunity for each individual to self-
motivate and, therefore, to improve their health [18]. Until today, traditional nursing
has not dealt with health care in a rational manner, but instead has used an intuitive
process, which has not provided new evidence to better comprehend the concept of
health. In the care of patients who do not have the capacity to develop systemic
thinking, the understanding of health remains fragmented, creating factors that are
harmful to patient safety.
References
1. WHO. The world health report 2000: health systems: improving performance: World Health
Organization (2000)
2. Simmons, S.J.: Health: a concept analysis. Int. J. Nurs. Stud. 26(2), 155–161 (1989)
Fig. 3. The Meikirch model with Nursing
Systems Thinking, Complex Adaptive Systems and Health 7
Author Proof
3. Notarnicola, I., Petrucci, C., De Jesus Barbosa, M.R., Giorgi, F., Stievano, A., Rocco, G.,
et al.: Complex adaptive systems and their relevance for nursing: an evolutionary concept
analysis. Int. J. Nurs. Pract. 23(3), e12522 (2017)
4. West, G.B.: The importance of quantitative systemic thinking in medicine. Lancet 379
(9825), 1551–1559 (2012)
5. Fawcett, J., Barrett, E.A., Wright, B.W.: Development of a new conceptual model of
nursing. Nurs. Outlook 56(2), 49 (2008)
6. Holden, L.M.: Complex adaptive systems: concept analysis. J. Adv. Nurs. 52(6), 651–657
(2005)
7. Bircher J, Hahn EG. Understanding the nature of health: New perspectives for medicine and
public health. Improved wellbeing at lower costs. F1000Res 5, 167 (2016)
8. Bircher, J., Hahn, E.G.: Applying a complex adaptive system’s understanding of health to
primary care. F1000Res 5, 1672 (2016)
9. Naaldenberg, J., Vaandrager, L., Koelen, M., Wagemakers, A.M., Saan, H., de Hoog, K.:
Elaborating on systems thinking in health promotion practice. Global Health Promot. 16(1),
39–47 (2009)
10. Stalter, A.M., Phillips, J.M., Ruggiero, J.S., Scardaville, D.L., Merriam, D., Dolansky, M.A.,
et al.: A concept analysis of systems thinking. Nurs. Forum. 52(4), 323–330 (2017)
11. Dolansky, M.A., Moore, S.M.: Quality and Safety Education for Nurses (QSEN): the key is
systems thinking. Online J. Issues Nurs. 18(3), 1 (2013)
12. Powell, K.E., Kibbe, D.L., Ferencik, R., Soderquist, C., Phillips, M.A., Vall, E.A., et al.:
Systems thinking and simulation modeling to inform childhood obesity policy and practice.
Public Health Rep. 132, 33S–38S (2017)
13. Bircher, J., Kuruvilla, S.: Defining health by addressing individual, social, and environ-
mental determinants: new opportunities for health care and public health. J. Public Health
Policy 35(3), 363–386 (2014)
14. Gill, T.: Development and implementation of a simulated laboratory information system to
enhance student critical thinking skills and laboratory operations. Clin. Lab. Sci. 30(2), 88–
89 (2017)
15. Petrucci, C., La Cerra, C., Caponnetto, V., Franconi, I., Gaxhja, E., Rubbi, I., et al. (eds.)
Literature-based analysis of the potentials and the limitations of using simulation in nursing
education. In: International Conference in Methodologies and Intelligent Systems for
Technology Enhanced Learning. Springer (2017)
16. Clancy, T.R., Effken, J.A., Pesut, D.: Applications of complex systems theory in nursing
education, research, and practice. Nurs Outlook. 56(5), 248–256.e3 (2008)
17. Chaffee MW, McNeill MM. A model of nursing as a complex adaptive system. Nursing
Outlook 55(5), 232–241.e3 (2007)
18. Bircher, J., Hahn, E.G.: Will the Meikirch model, a new framework for health, induce a
paradigm shift in healthcare? Cureus. 9(3), e1081 (2017)
8 I. Notarnicola et al.
Author Proof
Author Query Form
Book ID : 469893_1_En
Chapter No : 34
123
the language of science
Please ensure you fill out your response to the queries raised below
and return this form along with your corrections.
Dear Author,
During the process of typesetting your chapter, the following queries have
arisen. Please check your typeset proof carefully against the queries listed below
and mark the necessary changes either directly on the proof/online grid or in the
‘Author’s response’area provided below
Query Refs. Details Required Author’s Response
AQ1 This is to inform you that corresponding author has been identified as per the
information available in the Copyright form.
Author Proof
MARKED PROOF
Please correct and return this set
Instruction to printer
Leave unchanged under matter to remain
through single character, rule or underline
New matter followed by
or
or
or
or
or
or
or
or
or
and/or
and/or
e.g.
e.g.
under character
over character
new character
new characters
through all characters to be deleted
through letter or
through characters
under matter to be changed
under matter to be changed
under matter to be changed
under matter to be changed
under matter to be changed
Encircle matter to be changed
(As above)
(As above)
(As above)
(As above)
(As above)
(As above)
(As above)
(As above)
linking characters
through character or
where required
between characters or
words affected
through character or
where required
or
indicated in the margin
Delete
Substitute character or
substitute part of one or
more word(s)
Change to italics
Change to capitals
Change to small capitals
Change to bold type
Change to bold italic
Change to lower case
Change italic to upright type
Change bold to non-bold type
Insert ‘superior’ character
Insert ‘inferior’ character
Insert full stop
Insert comma
Insert single quotation marks
Insert double quotation marks
Insert hyphen
Start new paragraph
No new paragraph
Transpose
Close up
Insert or substitute space
between characters or words
Reduce space between
characters or words
Insert in text the matter
Textual mark Marginal mark
Please use the proof correction marks shown below for all alterations and corrections. If you
in dark ink and are made well within the page margins.
wish to return your proof by fax you should ensure that all amendments are written clearly
