Unpredictable predictables : complexity theory and the construction of order in intensive care
- Publication Type:
- Thesis
- Issue Date:
- 2009
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The Intensive Care Unit (ICU) is a unit that manages the most critically ill, complex and
unstable patients in the hospital. As a result, the ICU is characterised by a high degree of
clinical and organisational unpredictability and uncertainty. In Western discourse,
uncertainty is often portrayed as problematic, and as something to be controlled and
reduced. This research challenges this discourse by examining the productive relationship
between certainty and uncertainty in the work practices of ICU clinicians, and
subsequently, how intensive care clinicians utilise uncertainty to construct order in a highly
unpredictable work environment. To understand how order can coexist with ICU’s
unremitting unpredictability, complexity theory is used to frame this investigation.
This research engaged an emergent, interventionist methodology, deploying multiple
methods. Using ethnography, video-ethnography, and video-reflexivity, this research relied
on clinicians’ participation in the construction and analysis of video data of the ICU
clinicians’ work practices. This resulted in clinician-led practice change in the ICU. This
research suggests that methods need to be deployed adaptively in order to deal with the
complexity of ICU, in addition to the moment-to-moment emergence of events that require
the researcher’s own work plans to be revisited. Moreover, in order to gain traction with,
and understand highly complex and changeable environments, the researcher needs to also
enter and experience uncertainty herself.
Using complexity theory as its analytical tool, this research shows an inseparability of
uncertainty and certainty in the ICU which is labeled ‘un/certainty’. Three main
conclusions emerge from this research. First, un/certainty predominates in intensive care,
and due to this, ordering is a process rather than a final state. Un/certainty is at the heart of
the adaptive practices that clinicians enact. These adaptive practices are highly
interconnected to the changes that the ICU environment may require, and thus produce a
dynamic order in the unit. Second, the researcher herself, in order to come to terms with
the complexity and un/certainty of the ICU environment must also enter un/certainty in
order to gain traction with the ICU environment: unpredictability and complexity cannot be
studied from a neat and disengaged distance. Third, the presence of un/certainty in the ICU
can be significant and enabling rather than disabling for clinicians in their ongoing pursuit
of dynamically ordering practice. The contribution of un/certainty to frontline practice is as
a central driver to managing change and complexity. Therefore it should be positively
revalued by health services researchers, policy makers and clinicians alike.
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