Studying the clinical encounter with the Adaptive Leadership framework

Understanding Adaptive Leadership in the Context of Nursing Homes

Rapidly growing populations of older adults rely heavily on formal long-term care services such as those provided in nursing homes. Nursing home staff are confronted with complex challenges. We explored how staff (N = 88), particularly care aides, interpreted challenges and responded to them by taking adaptive leadership roles, and engaging in technical and adaptive work in nursing homes. We conducted analysis of the ethnographic case studies. In long-term care settings, staff face complex challenges in improving resident care due to contextual barriers. These include demanding work conditions and inadequate resources. Additionally, top-down communications, despite being well-intentioned, often lead to misinterpretation and a lack of staff motivation. Nonetheless, we found that certain staff managed to overcome these contextual barriers and effectively execute change initiatives by assuming adaptive leadership roles. Formal leaders have a vital role in empowering staff, including care aides, and facilitating their adaptive leadership behaviors.

Adaptive leadership in clinical encounters with women living with HIV

BACKGROUND

Women living with HIV (WLWH) report low engagement in health care, missed office visits, and less engagement in the clinical encounter. Strengthening the clinical encounter for WLWH may improve health outcomes and quality of life. The Adaptive Leadership Framework for Chronic Illness offers specific adaptive leadership strategies for providers to improve patient-provider interactions. The purpose of this study was to examine adaptive leadership behaviors that contribute to the development of effective patient-provider communication from the perspectives of WLWH.

METHODS

The descriptive, cross-sectional and qualitative study conducted interviews with 22 WLWH to assess perceptions of the clinical encounter related to HIV-related stigma, engagement in care, medical distrust, and experiences with discrimination and quality of life. Members of the study team using a set of a priori codes analyzed data using NVivo 12.0.

RESULTS

Participants described two primary themes and subthemes of each for adaptive leadership behaviors. The primary theme for adaptive leadership of providers was "my provider cares about me"; subthemes were communication, trust building takes time, and supportive providers are trusted. The primary theme for adaptive leadership of WLWH themselves was "I care about me; subthemes were self-advocacy and self-empowerment.

CONCLUSIONS

Providers can use adaptive leadership behaviors during clinical encounters to support WLWH, improve patient-provider communication, enhance trust, and improve patient outcomes.

BRAVE: A Point of Care Adaptive Leadership Approach to Providing Patient-Centric Care in the Emergency Department

The practice of emergency medicine has reached its cross roads. Emergency physicians (EPs) are managing many more time-dependent conditions, initiating complex treatments in the emergency department (ED), handling ethical and end of life care discussions upfront, and even performing procedures which used to be done only in critical care settings, in the resuscitation room. EPs manage a wide spectrum of patients, 24 h a day, which reflects the community and society they practice in. Besides the medical and “technical” issues to handle, they have to learn how to resolve confounding elements which their patients can present with. These may include social, financial, cultural, ethical, relationship, and even employment matters. EPs cannot overlook these, in order to provide holistic care. More and more emphasis is also now given to the social determinants of health. We, from the emergency medicine fraternity, are proposing a unique “BRAVE model,” as a mnemonic to assist in the provision of point of care, adaptive leadership at the bedside in the ED. This represents another useful tool for use in the current climate of the ED, where patients have higher expectations, need more patient-centric resolution and handling of their issues, looming against the background of a more complex society and world.

Missed nursing care and complexity theory: a conceptual paper

Background

Missed nursing care is a complex healthcare problem. Extant literature in this area identifies several interventions that can be used in acute hospital settings to minimise the impact of missed nursing care. However, controversy still exists as to the effectiveness of these interventions on reducing the occurrence of missed nursing care.

Aim

This theoretical paper aimed to provide a conceptual understanding of missed nursing care using complexity theory.

Methods

The method utilised for this paper is based on a literature review on missed care and complexity theory in healthcare.

Results

We found that the key virtues of complexity theory relevant to the missed nursing care phenomenon were adaptation and self-organisation, non-linear interactions and history. It is suggested that the complex adaptive systems approach may be more useful for nurse managers to inform and prepare nurses to meet uncertain encounters in their everyday clinical practice and therefore reduce instances of missed care.

Conclusions

This paper envisions that it is time that methods used to explore missed care changed. Strategies proposed in this paper may have an important impact on the ability of nursing staff to provide quality and innovative healthcare in the modern healthcare system.

Applying the principles of adaptive leadership to person-centred care for people with complex care needs: Considerations for care providers, patients, caregivers and organizations

Background

Health systems in many countries see person‐centred care as a critical component of high‐quality care but many struggle to operationalize it in practice. We argue that models such as adaptive leadership can be a critical lever to support person‐centred care, particularly for people who have multiple complex care needs.

Objective

To reflect on two concepts: person‐centred care and adaptive leadership and share how adaptive leadership can advance person‐centred care at the front‐line care delivery level and the organizational level.

Findings

The defining feature of adaptive leadership is the separation of technical solutions (ie applying existing knowledge and techniques to problems) from adaptive solutions (ie requiring shifts in how people work together, not just what they do). Addressing adaptive challenges requires identifying key assumptions that may limit motivations for change and the behaviours influenced by these assumptions. Thus, effective care for patients, particularly those with multiple complex care needs, often entails helping care providers and patients to examine their relationships and behaviours not just identifying technical solutions. Addressing adaptive challenges also requires a supportive and enabling organizational context. We provide illustrative examples of how adaptive leadership principles can be applied at both the front line of care and the organization level in advancing person‐centred care delivery.

Conclusions

Advancing person‐centred care at both the clinical and organizational levels requires a growth mindset, a willingness to try (and fail) and try again, comfort in being uncomfortable and a commitment to figure things out, in partnership, in iterative ways. Patients, caregivers, care providers and organizational leaders all need to be adaptive leaders in this endeavour.

Patient loyalty to HIV care in an HIV facility in Eldoret, Kenya: A mediated mediation

Patient loyalty is the continuous commitment and engagement in care where patients can improve and sustain quality of life through continuous use of medical care. Identifying strengths and weaknesses in providing excellent quality care is a key measure of success of healthcare professionals and hospital management. However, few studies have examined patient loyalty from a strategic leadership perspective within HIV health care systems. The purpose of this study is to determine how patient loyalty to HIV care is influenced by multiple factors in a healthcare system environment. The study employs a mixed-methods approach guided by the complexity theory and the theory of planned behavior. A total of 444 surveys with (50 healthcare providers and 394 adult HIV-infected patients) currently on antiretroviral drugs, as well as 22 in-depth interviews with healthcare providers will be conducted. The study will be done at AMPATH Eldoret Kenya. We will use stratified proportionate and census sampling methods to select study participants for the survey while purposive and convenient sampling techniques will be used for in-depth interviews. Structured questionnaires and interviewer guides will guide data collection. Quantitative data analysis will entail hierarchical regression to test direct effects while multiple regression will test the mediation effects using the Hayes PROCESS Model No.6 in SPSS. Qualitative data analysis will be conducted using a thematic analytical method.

Supporting staff as change leaders in consumer engagement in aged care: Learnings from action research

AIM

The aim of this paper is to explore the process of staff leading change in consumer engagement practice in aged care.

BACKGROUND

Shifting expectations make engagement practice increasingly complex for service providers. This requires adaptive change within organisations. Organisations need to empower and support staff to critically assess practice, identify issues and pursue opportunities for innovation.

METHOD

Data were collected as part of an action research project addressing client engagement practice in Australian aged care. Staff worked together to identify issues for practice, generate solutions and create change within their organisations.

RESULTS

Staff identified innovative ways of generating change, demonstrating leadership. However, a range of technical, practical, systemic and philosophical factors impacted their progress.

CONCLUSIONS

Staff are effective, proactive change agents who can provide valuable insights into directions for their organisations and can lead practice improvement in engagement. However, they require support through the organisational environment.

IMPLICATIONS FOR NURSING MANAGEMENT

Staff in all roles can demonstrate adaptive leadership in changing engagement practice. However, those in traditional roles of authority need to recognize their own roles in showing leadership and supporting adaptive change. This provides a new insight into how managers can support practice change in consumer engagement.

Pressure Injury Prevention: Outcomes and Challenges to Use of Resident Monitoring Technology in a Nursing Home

PURPOSE:

We examined the usability, user perceptions, and nursing occupational subculture associated with introduction of a patient monitoring system to facilitate nursing staff implementation of standard care for pressure ulcer/injury prevention in the nursing home setting.

DESIGN:

Mixed methods, pre-/posttest design.

SUBJECTS AND SETTING:

Resident (n = 44) and staff (n = 38) participants were recruited from a 120-bed nursing home in the Southeast United States.

METHODS:

Digital data on frequency and position of residents were transmitted wirelessly from sensors worn on each resident's anterior chest to estimate nursing staff compliance with repositioning standard of care before and after visual monitors were activated to cue staff. The validated Nursing Culture Assessment Tool was used to determine changes in nursing culture. Benefits and challenges of implementation were assessed by 2 focus groups composed of 8 and 5 female members of the nursing staff (RN, LPN, CNA), respectively, and led by the three authors. Descriptive statistics were used for all quantitative variables, and inferential statistics were applied to categorical variables (χ² test or Fisher exact test) and continuous variables (analyses of variance or equivalent nonparametric tests), respectively, where a 2-sided P value of <.05 was considered statistically significant.

RESULTS:

System use significantly (P = .0003) improved compliance with every 2-hour repositioning standards. The nursing culture normative ranking percentage increased from 30.9% to 58.2%; this difference was not statistically significant. Focus groups expressed satisfaction with the monitoring system and recommended improvements to support adaptation and use of technology.

CONCLUSIONS:

Study findings support the usability of the patient monitoring system to facilitate repositioning. Implementation of multiple strategies for training, supplies, and communication may enhance uptake and effectiveness.

Enhancing Diabetes Self-Management Through Collection and Visualization of Data From Multiple Mobile Health Technologies: Protocol for a Development and Feasibility Trial

Background

Self-management is integral for control of type 2 diabetes mellitus (T2DM). Patient self-management is improved when they receive real-time information on their health status and behaviors and ongoing facilitation from health professionals. However, timely information for these behaviors is notably absent in the health care system. Providing real-time data could help improve patient understanding of the dynamics of their illness and assist clinicians in developing targeted approaches to improve health outcomes and in delivering personalized care when and where it is most needed. Mobile technologies (eg, wearables, apps, and connected scales) have the potential to make these patient-provider interactions a reality. What strategies might best help patients overcome self-management challenges using self-generated diabetes-related data? How might clinicians effectively guide patient self-management with the advantage of real-time data?

Objective

This study aims to describe the protocol for an ongoing study (June 2016-May 2019) that examines trajectories of symptoms, health behaviors, and associated challenges among individuals with T2DM utilizing multiple mobile technologies, including a wireless body scale, wireless glucometer, and a wrist-worn accelerometer over a 6-month period.

Methods

We are conducting an explanatory sequential mixed methods study of 60 patients with T2DM recruited from a primary care clinic. Patients were asked to track relevant clinical data for 6 months using a wireless body scale, wireless glucometer, a wrist-worn accelerometer, and a medication adherence text message (short message service, SMS) survey. Data generated from the devices were then analyzed and visualized. A subset of patients is currently being interviewed to discuss their challenges and successes in diabetes self-management, and they are being shown visualizations of their own data. Following the data collection period, we will conduct interviews with study clinicians to explore ways in which they might collaborate with patients.

Results

This study has received regulatory approval. Patient enrollment ongoing with a sample size of 60 patients is complete, and up to 20 clinicians will be enrolled. At the patient level, data collection is complete, but data analysis is pending. At the clinician level, data collection is currently ongoing.

Conclusions

This study seeks to expand the use of mobile technologies to generate real-time data to enhance self-management strategies. It also seeks to obtain both patient and provider perspectives on using real-time data to develop algorithms for software that will facilitate real-time self-management strategies. We expect that the findings of this study will offer important insight into how to support patients and providers using real-time data to manage a complex chronic illness.

International Registered Report Identifier (IRRID)

DERR1-10.2196/13517

Clinical Encounters and Treatment Initiation for Chronic Hepatitis C Patients: Applications of Adaptive Leadership Framework for Chronic Illness

Chronic Hepatitis C (CHC) is the most common blood-borne infection in the U. S. Patients with CHC undergoing treatment face many challenges including adherence to medications and management of symptoms; health care practitioners are well positioned to facilitate patients' ability to address these challenges. We used the Adaptive Leadership for Chronic Illness Framework to investigate the difficulties inherent in affecting behavior change in patients undergoing treatment. We enrolled 11 patient participants and 10 provider participants. We used data from the first clinical encounter between patients and providers during which treatment was discussed. We found examples of adaptive leadership and categorized these behaviors into three themes: support for medication, coping with family/ home life, and strategizing to manage employment. We also saw examples of what we termed missed opportunities for adaptive leadership. This study illustrates the contributions of adaptive leadership behaviors by healthcare providers and the potential risk to patients in their absence.

Working together to learn new oral hygiene techniques: Pilot of a carepartner-assisted intervention for persons with cognitive impairment

We pilot tested a carepartner-assisted intervention to improve oral hygiene in persons with cognitive impairment (participants) and help carepartners become leaders who can adapt approaches that foster participants' ability to develop new skills for oral hygiene care. Following the intervention, we conducted interviews with participants and carepartners to understand their challenges in working together to learn new oral hygiene skills. Participants reported challenges such as frustration using the electric toothbrush correctly, lack of desire to change, uncertainty about correctness of technique, and difficulty sustaining two minutes of toothbrushing. Carepartners reported challenges such as learning a new way of toothbrushing, learning new communication techniques, switching from instructing to working together, learning to balance leading with being too bossy, and being mindful of word choices. Findings suggested that despite challenges, participants were able to learn adaptive strategies to support new oral hygiene behaviors with support of the carepartner as the adaptive leader.

Person-directed care planning in nursing homes: A scoping review

AIM

Federal regulations require nursing homes in the United States to support residents in directing their own care rather than having their care plans developed for them without their engagement, but knowledge of person-directed approaches to care planning in nursing homes is limited. The purpose of this study was to advance understanding of person-directed care planning (PDCP).

METHODS

A multidisciplinary research team conducted a scoping review on individual and family involvement in care planning, including literature from a variety of care contexts. Search results were systematically screened to identify literature that addressed individual or family involvement in care planning as a primary concern, and then analysed using thematic content analysis.

RESULTS

Several themes were identified, including definitions of the concept of PDCP, essential elements of PDCP, barriers, facilitators and outcomes. The concept of PDCP is informed by multiple disciplines, including humanist philosophy, disability rights and end-of-life care. Essential elements of PDCP include knowing the person, integrating the person's goals in care planning and updating care plans as individuals' needs or preferences change. Limited time for care planning in nursing homes hinders PDCP. Facilitators include regulatory mandates and humanist social trends. Outcomes of PDCP were found to be positive (e.g., increased independence), but were inconsistently assessed across studies.

CONCLUSION

This study offers pragmatic information that can support PDCP within nursing homes and insights for policy reform that may more effectively support PDCP.

IMPLICATIONS FOR PRACTICE

These findings can be used to guide implementation of PDCP.

Complex Leadership in Healthcare: A Scoping Review

BACKGROUND

Nowadays, health systems are generally acknowledged to be complex social systems. Consequently, scholars, academics, practitioners, and policy-makers are exploring how to adopt a complexity perspective in health policy and system research. While leadership and complexity has been studied extensively outside health, the implications of complexity theories for the study of leadership in healthcare have received limited attention. We carried out a scoping review of complex leadership (CL) in healthcare to investigate how CL in healthcare has been defined, theorised and conceptualised and to explore how 'CL' has been applied in healthcare settings.

METHODS

We followed the methodological steps proposed by (Arksey and O'Malley, 2005): (1) specifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, (5) collating and summarizing the findings, and (6) reporting the results. We searched using Medline, Psychinfo, Wiley online library, and Google Scholar. Our inclusion criteria were: publication type (peer reviewed articles, theses, and book chapters); phenomenon of interest: complex leadership; context: healthcare and period of publication: between 2000 and 2016.

RESULTS

Our search and selection resulted in 37 papers (16 conceptual papers, 14 empirical studies and 7 advocacy papers). We note that empirical studies on CL are few and almost all research reported by these papers was carried out in the North (mainly in USA and UK). We found that there is some variation in definitions of CL. Furthermore, the research papers adopt mostly an explorative or explanatory approach and do not focus on assessing effectiveness of CL approaches. Finally, we found that the majority of researchers seem to adhere to the mathematical complexity perspective.

CONCLUSION

Complexity concepts derived from natural sciences may not automatically fit management of health services. Further research into how social complexity theories may offer researchers useful grounds to empirically test CL theories in health settings is warranted. Specific attention should be paid to the multi-layered nature of leadership.

Communicative Accessibility in Aphasia: An Investigation of the Interactional Context of Long-Term Care Facilities

PURPOSE

The purpose of this study was to examine the ability of persons with aphasia to access interaction and be included in social encounters in long-term care facilities (LTCFs).

METHOD

Four persons with aphasia were the focus of this investigation. A qualitative research approach using ethnographic methods was used to conduct participant observation, semistructured interviews, and artifact analysis. Expanded field notes from observations, transcribed interviews, and artifacts were then coded to identify patterns in the data.

RESULTS

The interactional context of LTCFs negatively influenced the ability of persons with aphasia to communicate with others and develop meaningful relationships. Three major themes emerged from the data detailing the contextual elements leading to communication accessibility and inclusion: (a) lack of support, (b) social hierarchy, and (c) focus on performance.

CONCLUSIONS

Findings highlighted several barriers in LTCFs that worked to discourage persons with aphasia from living social and expressive lives. Specific obstacles included a misunderstanding of aphasia and its influence on communicative exchanges and performance-oriented environment that overlooked psychosocial needs. Speech-language pathologists have an important role for advocacy in LTCFs. Clinical implications for assessment and treatment in institutions are discussed.

Pilot Study to Describe the Trajectory of Symptoms and Adaptive Strategies of Adults Living with Low-grade Glioma

OBJECTIVES

To describe the adaptability to the patterns in symptoms and quality of life (QoL) during 6 months post low-grade glioma diagnosis by valid and reliable tools; to identify through qualitative interviews patient/provider adaptive techniques and strategies; and to assess associations among patient characteristics, symptoms and QoL, and adaptive techniques or strategies.

DATA SOURCES

Demographic, clinical and pathologic data from medical records. Validated instruments that assess QoL, fatigue, depression, and distress were completed at 2, 4, and 6 months post diagnosis. Qualitative interviews identifying the symptoms, challenges, adaptive techniques and strategies were conducted at 4 and 6 months.

CONCLUSION

The most frequently used adaptive strategies included: obtaining community support (87%), managing expectations (73%) and support systems (67%), and seeking out knowledge about physical (67%) and behavioral symptoms (53%). Seizures were reported with IDH1^mut (11%) but not IDH1^wildtype. Patients with either IDH1^mut or TERT^mut consistently reported lower QoL and higher distress, depression, and fatigue scores. IDH1/TERT^mut may be related to lower QoL because of IDH1^mut-related seizures.

IMPLICATIONS FOR NURSING PRACTICE

Findings provide a list of adaptive strategies and characteristics to address the problems and symptoms that may improve overall QoL in patients with low-grade glioma.

Quality of care to nursing home residents with incontinence

Quality of care for residents with urinary incontinence (UI) living in nursing facilities was analyzed using data collected from 815 facilities for the Nursing Facility Quality Review in Texas. Overall, of the 1,560 residents, 48.4% (n = 755) experienced UI. The risk of developing UI over a ten-year-period in a nursing facility was 6%. Only 54% of residents with UI had a care plan for their incontinence. For those with a UI plan in their chart, 143 (35%) had a person entered UI plan developed based on that resident's voiding pattern and needs. Further, the creation of a UI plan of care by a RN for a person with UI was associated with a higher perceived level of health after controlling for gender, and age. Finally, the more satisfied the resident was with the response to their calls for help with voiding the more satisfied with the nursing facility.

Neurosurgical Subspecialty Bedside Guide Improves Nursing Confidence

Familiarity with a neurosurgical nursing guide had a positive impact on the confidence of medical-surgical nurses caring for neurosurgical patients and helped improve patient care skills.

Adaptive Challenges Rising from the Life Context of African-American Caregiving Grandmothers with Diabetes: A Pilot Study

To understand the challenges arising from the context within which diabetic African-American caregiving grandmothers self-manage their diabetes we used the Adaptive Leadership Framework. Additionally, challenges to retaining this population in a longitudinal study were examined. In this exploratory, longitudinal, qualitative pilot study, data were collected at five time-points over 18 months. We coded the data using content analysis and conducted the within-case and cross-case analyses using data matrices. Lack of awareness of available resources, represented a technical challenge within the life context of these grandmothers and the remaining three themes: family upheaval; priority setting (with subthemes of difficulty meeting basic needs and competing demands); and self-silencing and self-sacrifice represented adaptive challenges. The context of African-American grandmothers’ lives created primarily adaptive challenges that were complex and without immediate solutions. Research is needed to develop culturally and contextually appropriate interventions to help this vulnerable group develop capacity for adaptive work.

Adaptive leadership framework for chronic illness: framing a research agenda for transforming care delivery

We propose the Adaptive Leadership Framework for Chronic Illness as a novel framework for conceptualizing, studying, and providing care. This framework is an application of the Adaptive Leadership Framework developed by Heifetz and colleagues for business. Our framework views health care as a complex adaptive system and addresses the intersection at which people with chronic illness interface with the care system. We shift focus from symptoms to symptoms and the challenges they pose for patients/families. We describe how providers and patients/families might collaborate to create shared meaning of symptoms and challenges to coproduce appropriate approaches to care.

Implementing Culture Change in Nursing Homes: An Adaptive Leadership Framework

PURPOSE OF THE STUDY

To describe key adaptive challenges and leadership behaviors to implement culture change for person-directed care.

DESIGN AND METHODS

The study design was a qualitative, observational study of nursing home staff perceptions of the implementation of culture change in each of 3 nursing homes. We conducted 7 focus groups of licensed and unlicensed nursing staff, medical care providers, and administrators. Questions explored perceptions of facilitators and barriers to culture change. Using a template organizing style of analysis with immersion/crystallization, themes of barriers and facilitators were coded for adaptive challenges and leadership.

RESULTS

Six key themes emerged, including relationships, standards and expectations, motivation and vision, workload, respect of personhood, and physical environment. Within each theme, participants identified barriers that were adaptive challenges and facilitators that were examples of adaptive leadership. Commonly identified challenges were how to provide person-directed care in the context of extant rules or policies or how to develop staff motivated to provide person-directed care.

IMPLICATIONS

Implementing culture change requires the recognition of adaptive challenges for which there are no technical solutions, but which require reframing of norms and expectations, and the development of novel and flexible solutions. Managers and administrators seeking to implement person-directed care will need to consider the role of adaptive leadership to address these adaptive challenges.

Communication about life-sustaining therapy: insights from the Adaptive Leadership Framework

OBJECTIVE

Effective provider and caregiver communication is central to quality care during treatment for life-threatening illnesses. The study aim was to analyze communication patterns between providers and a parent of an infant with a life-threatening disease using the Adaptive Leadership Framework, which is an activity that involves mobilizing others to adapt to a difficult situation.

METHOD

A secondary analysis was conducted on one case using 23 interviews with providers and mother of an infant diagnosed with Hurler's syndrome. The interviews focused on decision-making challenges in regard to the infant's treatment and were conducted over a 1-year period (pre-transplant, study entry, monthly, after a life-threatening event or substantial change in treatment and at 1-year post enrollment). Content analysis was used to identify and categorize communication patterns using concepts from the Adaptive Leadership Framework.

RESULTS

Infant illness events and parent-provider caregiving were chronicled across a 1-year trajectory. Despite the life-threatening nature of Hurler's disease, the parent and providers did not discuss palliative care or end-of-life. The parent sought direction and answers from the providers. The Adaptive Leadership Framework suggested how communication approaches were often mismatched with the needs of the parent.

DISCUSSION

The results of the study accentuate the need to improve communication between provider and parents about end-of-life for their child. Adaptive Leadership illuminates how providers can influence a parent's behavior when facing a challenging situation. This study suggests that Adaptive Leadership is a useful framework to guide research about healthcare communication in dealing with challenging issues.

Finding your way through EOL challenges in the ICU using Adaptive Leadership behaviours: A qualitative descriptive case study

OBJECTIVE

Using the Adaptive Leadership framework, we describe behaviours that providers used while interacting with family members facing the challenges of recognising that their loved one was dying in the ICU.

RESEARCH METHODOLOGY

In this prospective pilot case study, we selected one ICU patient with end-stage illness who lacked decision-making capacity. Participants included four family members, one nurse and two physicians. The principle investigator observed and recorded three family conferences and conducted one in-depth interview with the family. Three members of the research team independently coded the transcripts using a priori codes to describe the Adaptive Leadership behaviours that providers used to facilitate the family's adaptive work, met to compare and discuss the codes and resolved all discrepancies.

FINDINGS

We identified behaviours used by nurses and physicians that facilitated the family's ability to adapt to the impending death of a loved one. Examples of these behaviours include defining the adaptive challenges for families and foreshadowing a poor prognosis.

CONCLUSIONS

Nurse and physician Adaptive Leadership behaviours can facilitate the transition from curative to palliative care by helping family members do the adaptive work of letting go. Further research is warranted to create knowledge for providers to help family members adapt.

Commentary on "Health care organizations as complex systems: new perspectives on design and management" by Reuben R. McDaniel, Dean J. Driebe, and Holly Jordan Lanham

In this commentary, I highlight a few of the assertions made by McDaniel et al. (2013) about the importance of complexity science guided management practices, and extend these ideas specifically to how we might think about reducing seemingly intractable problems in health care such as patient safety, patient falls, hospital acquired infection, and the rise of chronic illness and obesity. I suggest that such changes will require managers and providers to view health care organizations and patients as complex adaptive systems and include patients as full participants in co-producing their health care.