Unpredictable predictables : complexity theory and the construction of order in intensive care

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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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