By Saskia Gubler, Annemiek Uneken and Marleen van Dijk
Management in Healthcare is a BSc program in the Hanze University in Groningen, the Netherlands. In the first year, students learn to understand the world of care and well-being. During the second semester of this first-year students gain insight into how care was organized in the past, how it’s organized in the present and the dilemmas that this entails. Themes such as the welfare state, healthy aging and the participation society are discussed.
In addition, we take a look into the possible futures of healthcare. Also, students investigate how healthcare is organized abroad. One part of the study program is developed and lectured by honours students. In this part of the program students are linked to patients, their relatives, and direct caregivers. The aim of this part of the course is that students gain insight in the lives of patients, beyond their diagnosis.
This results in a portrait of ‘the person behind the patient’. In addition, students participate in learning workplaces where they practice state-of-the-art communication, and they attend colleges about customer-oriented organization.
From a first experiment with “learning in complexity” (=> see our article “It’s a wicked world”), the following learning questions remained:
How do we cope with the paradox between innovating in the system versus systems innovation?
How do we translate this paradox into our lessons and the whole curriculum? How do we ‘start with complexity’ with first year bachelor students?
How do we facilitate collective learning that goes beyond the classroom setting?
How do we offer sufficient guidance when learning in uncertainty, especially for first-year students?
Complexe maatschappelijke vraagstukken en deconsequenties voor leren en de leeromgeving
By Paul Beenen
Onze maatschappij staat voor een groot aantal urgente uitdagingen die zich tegelijkertijd manifesteren, elkaar onderling beïnvloeden en waar we veel te weinig vat op krijgen. Onder meer de klimaatverandering en een toenemend verschil in inkomen en gezondheid tussen bevolkingsgroepen legt druk op het brede welzijn van de bevolking en de gezondheid van de planeet. Door de manier waarop we onze samenleving ingericht en georganiseerd hebben zijn we niet goed in staat om deze uitdagingen aan te pakken. Hiervoor zijn duurzame maatschappelijke transities nodig:
The term sustainability transitions is increasingly used to refer to large scale societal changes, deemed necessary to solve “grand societal challenges.” They are large scale disruptive changes in societal systems that emerge over a long period of time (decades). (Loorbach, 2017)
Het duurzaam vormgeven van transities is een moreel alternatief voor het op zijn beloop laten van complexe vraagstukken en het afwachten van de nieuwe werkelijkheid die zich aandient. Met het aangaan van complexe vraagstukken anticiperen we op mogelijkheden en werken we toe naar een wenkend perspectief binnen de transities die feitelijk al gaande zijn.
A STORY ABOUT HOW TO LEARN IN SITUATIONS WHERE WE DO NOT KNOW WHAT TO EXPECT.
A reflection from Loes Damhof
This story is about how to learn in situations where we do not know what to expect. When our assumptions on what to prepare beforehand are being challenged and when the complexity seems overwhelming. When you don’t or can’t have the solution to a problem, but your surroundings expect it anyway. This story is about embracing complexity.
A beautiful metaphor for learning in complexity to me is wayfaring (Ingold, 2010): that learning is not moving over the ground, or on the ground but rather through the ground… that moving is knowing. Not by acquiring more carefully planted knowledge along the way, but sensing more, picking up clues in places that vary, that come just in time… ‘in histories of movement, and changing horizons along the way’.I like it because I like walking.
When I walk, I like to think that the surface I walk on moves with me. The wind interacts with my surroundings, giving it guidance and agency. The plants move, and breathe and follow my tread. My footprints leave a trail that becomes part of the ground too. I prepare myself for a hike putting on my boots and bringing a map, knowing that the journey ahead is never what it set out to be. The earth changes while I walk and I change through the elements that grow or are placed on the surface.
In this post I try to live up to this metaphor by applying the design principles (written in the download document in bold) of four courses that support learning in complexity in higher education, as described in ECOLAH, an Erasmus+ funded project that stands for Embracing Complexity Oriented Learning Approaches in Health. These principles are not set in stone but offer guidelines on how to facilitate this type of learning and how to embrace complexity. I did not however, apply these principles beforehand or with a predetermined plan in mind. I am reflecting on an experience in hindsight, to see how my wayfaring was guided or inspired (albeit loosely) by these principles.
This story might demonstrate the underpinning of these principles, or it might give the reader some comfort that design principles are maybe not meant to find our way, but to get lost instead.
It is hard to pinpoint complexity as a phenomenon, since it is in essence how all aspects of life connect and interact and in return respond to those interactions (Cohn, 2013). And yet we can find some underlying logic to the complex situations that we face. Complex systems are made of many (networks of) interacting components. They feed on disruption: when one component changes, new challenges and opportunities appear. A complex system cannot be controlled or solved. Simulating complex situations therefor undercut the purpose of learning in complexity, since simulations assume a design that is goal- or purpose oriented in itself. But it is the unexpected and unanticipated nature of complexity that should be experienced by being prepared to abandon the design when taking off and.. well… walk the walk instead.
Learning in complexity therefor requires the imbedding in real-life situations, where we can try to anticipate the dynamic nature of the content by sensing and trying to make sense of it.
Somewhere in October 2022 I found myself in such a situation: in an average sized town in the deep south of the United States, answering a call to facilitate a Futures Literacy Laboratory (FLLab) and training for a disadvantaged, mostly black community to help them transition towards energy justice. A FLLab is a learning-by-doing workshop that creates space to practice the capability of imaging multiple futures to see the present anew (Miller, 2018). The training offered a deep dive into the theory of anticipatory systems and processes and was meant to equip the community with the skills to continue their learning journey after the workshop.
The community had gone through a transformation in recent years: it had been dealing with unaffordable housing, lack of (fresh) food, financial instability and no access to sustainable energy sources. On top of decades of racism, power abuse and violence, its members had grown weary and skeptical. Hurt, too.
Attempting to be fully equipped for this task and to eliminate as much uncertainty as I could, I tried to prepare myself accordingly, so I could meet them where they were. Reading up on available documents, interviewing local experts, visiting the community… I tried to prepare myself as much as I could, knowing there was only so much I could do. After all, so many factors were unknown to me that could cause anything to emerge.
It was a diverse group that was assembled for the Futures Literacy Lab: community members, energy companies, local organizers… This was as unusual as it was promising, since learning in complexity asks to invest in making a community sustainable, one that includes all relevant stakeholders and fosters individual and collective learning in a participatory and co-creative way. Complex challenges need collective action and wisdom, since they are beyond the scope of any individual to respond to or engage with. Diversity, a sense of belonging, co-creative spirit and awareness of roles are all essential ingredients for a community to live up to the challenge. Still, I was fully aware of being the ‘white lady expert’ from Northern Europe, and the fear of dominating the space with my privileged voice had me worried.
“Whiteness believes itself to be separate from all else. A thing apart. Even white attempts to apologise for imperialism amount to reinstatements of this formulaic distance between things. But whiteness moves. Everything fades. We need white ladies, men, people. Unless we embrace each other, we’d continue this noxious myth that you are isolated and alone in a universe that is hostile to separation.”
It occurred to me I couldn’t be a bystander. I had to face the beast.
Feeding the compost
This meant stepping into the space and the present moment, but not just for that moment alone. Investing in a sustainable community means understanding that you, as a facilitator, are part of the learning journey as well, which requires a commitment that stretches beyond the moment. That commitment does not have to be a life long relationship, it can be the awareness that all of us add knowledge to the ‘learning compost’; knowing that what happens in that moment will leave a residue in the soil, and that the ground in return changes us too (Wall Kimmerer, 2013). Taking care of the quality of that compost, is an investment as well. The purpose is to create a sustainable, nurturing learning environment, that transcends the once in a lifetime experience. Hence the principle: learning in complexity is both short and long term thinking. It is celebrating seemingly small signs of impact of individual and collective learning, and be aware and act on the future consequences. Making a notable impact in the context of the local ecosystem, requires patience and long term thinking: trustthat whatever nutrient we add to the compost will find its way to something new. Besides trusting the impact the Lab would have in ways I couldn’t foresee, I also knew we had to build capacity by investing in the collective learning journey after the Lab had finished.
Wandering and wondering our way out of stuckness
The actual physical space of any learning compost is important: in my case it was a cultural center for African-American heritage and remembrance. Surrounded by the beautiful art-works of and by black artists and their historic reference, we geared up to travel to the future. I warmed up the crowd with a light hearted icebreaker, acknowledging the fact that I entered the space as an expert. The participants then started off by mapping the context of reality and historicity by navigating between the weight of the past, the push from the present and the pull form the future (Futures Triangle, Inayatullah). After an hour, they had made long lists with answers for each question: what is holding us back in order to establish energy justice? What trends we see in the future are pulling us in a certain direction? What situations in the present make it the way it is?
I asked them what they observed. “The lists are all the same!”, they responded.
What could that mean, I asked?
“That we are stuck in the same story”
It was from that realization, of the stuckness in our own narratives, that we were able to move into the future and back, trying to overcome ‘the poverty of imagination’ (Miller, 2018). Step by step, moving from the past, to the present, to desirable, probable and alternative futures, we managed to break free from existing thought patterns, moving from what is.. to what if? Although these steps were part of the original design, the images of these futures did not form a paved road ahead, but were rather small steppingstones, serving as temporary natural waymarks, cairns, to guide our wandering. It was hard, and only after participants were confronted with what they perceived as a ‘whimsical’ scenario that was neither probable nor desirable, they managed to envision something different. The result was not as much a new future of energy justice, but deep insights and new questions, fueled by a new sense of agency.
“For the first time I feel like I belong in a room like this”.
Can belonging be the beginning of getting unstuck?
I left this space after three challenging but nurturing days. Had I anticipated this experience? No I hadn’t. I almost had been paralyzed by the complexity of it all. But just in time, I had found the next waymark allowing me to step into the present moment and embrace it all.
You see, I believe Bayo was not only referring to ‘each other’ as humans, black or white… I believe he was referring to all of it, all things and non-things, human and non-humans. I believe this is the key to learning in complexity; to accept that everything moves and everything fades. It is not only our footprints that make the trail, the trail makes us too. Stepping into a complex environment or situation does not require only skills, equipment or a plan. On the contrary, this might get us more stuck. It requires the willingness to get lost, to step into the cracks. To get ‘unstuck’.Growingthis ‘complexity mindset’ is crucial when learning in complexity.
To me it meant accepting the premise of not knowing and challenging the way forward and the way backward.
Or to quote Bayo again: to go awkward instead; where the beasts are.
A LEARNING PATH IN COMPLEXITY AND FUTURES LITERACY.
By Paul Beenen and Loes Damhof
This blog is the summary of two key notes during the final conference of the HIPPA project in digital innovations at the Metropolia University in Helsinki, October 2022: We felt both key notes were complementary and an example of the necessity to fundamentally rethink our world view, our perception of knowledge and agency facing the great challenges around health and social care today. We will argue for this rethinking and for the capability of futures literacy as an essential asset in this process of learning.
As such, this blog also illustrates the underpinning of our project ECOLAH, that stands for Embracing a Complexity Orientated Learning Approach in Health. A European project that explores the consequences for learning when we take the underlying logics of complexity seriously. For more information, follow us on this website.
The care for health is crumbling fast
Health and social care are in general based on a diagnose-intervention thinking. Once a problem arises, we determine the problem (diagnose) and then find a remedy (intervention). This has shown to be an extremely successful mode of thinking resulting in increased longevity and the ability to “manage” a diversity of health problems. Although successful, the last decades have proven this is not enough. Healthy life years turn out to be the result of a web of factors constantly interacting with each other (figure 1; based upon Prah Ruger, 2010; Bellancasa, 2017).
All these factors such as the influence of socioeconomic status, a societal tendency towards unhealthy stress induced lifestyles and the continuous neglect of the health of our planet, impact the health of people massively. Most individual health problems are chronic and are increasingly impacting our lives, often impairing us along the way. We are basically waiting till we are sick enough to be diagnosed before the system allows us to do something about it. We define urgency in health only when the damage is done:when a health problem occurs, it is often too late for the majority of societal health issues. While dealing with one health issue, people are often deconditioned and become highly vulnerable for other chronic lifestyle induced problems. Being lonely for example, fosters an inactive lifestyle which in return can increase health risks.
To put it bluntly; health and social care systems are designed to take care of health problems but do not invoke the capacity to be and stay healthy. The way modern societies have developed in the last century and the associated health problems have received little attention. We often start to hear the call for urgency when a problem has developed over decades into a storm we can’t ignore any longer. These systems are financially unsustainable and unable to answer the demands of society. Moreover, challenges like the increasing demand of health workers under a high demographic pressure, the pandemic of Non-Communicable Diseases and a deteriorating planetary health have been known for decades, without any actionable result to speak of.
It is therefore not surprising that health systems are under tremendous pressure of being unable to deliver the necessary services while dealing with increasing costs. Optimising the current health systems will not suffice and won’t reach SDG 3;Ensure healthy lives and promote well-being for all at all ages. Policies to incrementally change this undesired and unsustainable situation doesn’t expedite these reforms (Christensen et al, 2017). An alternative is the fundamental change from solely problem oriented ‘health care’ towards the care for health.
Taking complexity of health seriously
Taking the care of health seriously necessitates the acknowledgement of the interweaving and dynamics of all factors as a complex system. Questions of circumstances, events, timing, history, personal and cultural preferences matter enormously in addressing the question ‘what needs to be done? (Tsoukis, 2017). However, as Greenhalgh points out; “It is fashionable to talk of complex interventions, complex systems, complex patients, wicked problems, and the like. However, with few exceptions, we embrace the theme of complexity in name only and fail to engage with its underlying logic” (Greenhalgh, 2018).
To understand better why we have so much difficulty navigating complex systems, we need to distinguish between complicated complex and complex issues. A problem that is complicated means outcomes and effects are predictable and effective actions can be planned and translated through guidelines into actions (e.g. a cookbook). The great attraction and success of this view is that we can predefine the outcomes, and thus control and audit processes and results. An example of a complicated issue is an open heart operation, a tough challenge but with the right manual, knowledge, and material you can exactly get what was envisioned (and thankfully so). Our diagnose -intervention based health care systems are fully built on this complicated world view. In complex phenomena, like raising a child, the outcomes can often not fully be (pre) defined from the beginning and the steps to follow are always situative, negotiated and follow non-linear patterns. Simply said ‘context matters’. This complexity could be defined as: “A dynamic and constantly emerging set of processes and objects that not only interact with each other, but come to be defined by those interactions” (Cohn, 2013).
Don’t make from a complex issue a complicated one
The practical consequence of dealing with complex issues is that we, (managers and controllers included), need to accept that we do not know everything, which leaves us with the need to constantly anticipate these ‘emerging sets of processes and objects’ with a certain amount of uncertainty. What is left is a humble learning process navigating complexity. This thinking feels counter-intuitive to a reductionist diagnose-intervention mindset: the first reflex is often to reduce this complexity to a complicated problem by focusing on one or more ‘determinants’. This explains why health professionals tend to reduce a whole, complex human being, into a patient as if it were a single identity (and then follow the guideline). This is why the global health community responded to the COVID pandemic with a sole focus on finding a vaccine, while largely neglecting the rest of the societal system.
Learning in complexity
Accepting the underlying logic of complexity offers an opportunity to think beyond linear causal problem solving. Complex systems have the property to self-organise and adapt to new situations. A hopeful example was the caring resilience of local communities during COVID and lockdown. Care emerged from local communities, neighbours were shopping for each other and alternative ways of social contact and physical activities popped up. Tapping into this adaptability is an explorative, creative ‘trial and error’ way of learning. It’s less controlled, sometimes downright messy, and highly dependent on the local situation. Do we still have the space and degrees of freedom to engage in such a journey, to experiment, to allow for mistakes? How do we integrate systems thinking in our approach towards the care of health, from patients to the whole health system?
A major support in (re-)learning to think with this complexity is to accept that our knowledge is not all static (objective) and can not be planned and controlled. In complexity, knowledge is often short lived and depending on the dynamics in the system. This is uncomfortable as it demands a constant monitoring and evaluative attitude towards what we consider knowledge of the situation. Learning in complexity is then wayfaring; negotiating or improvising a passage as we go along. Knowledge is then grown along the myriad paths we take as we make our ways through the world in the course of everyday activities, rather than assembled from information obtained from numerous fixed locations (Ingold, 2010). This is uncomfortable as it demands a constant monitoring and evaluative attitude towards our knowledge of the situation. It is even more uncomfortable because we can’t put our objective truths upon people and systems. Not without accommodating towards the woven web of what we call ‘context’ with all it’s historicity, dependencies and dynamics. Yet, this more humble position offers also a way to understand and respect much better the qualities of our interconnected world and to cherish its agency. The hardest nut to crack is to say farewell to our illusion we can plan and control, if not colonise, our future. For this it is important to invest in futures literacy.
Futures Literacy is the capability to imagine multiple futures to see the present anew. Fundamental to this capability is acknowledging that the future does not exist. It is the undefined later-than-now (Miller, 2018)and the only way the future takes shape in the present, is through imagination. The future is fiction, and yet it has a profound impact on what we do, how we think and act in the present. It is therefore time to think about how we think about the future.
Although the future does not exist, we use her every day: to plan our week ahead, to schedule appointments, to dream about that trip or to worry about our health or age. These are common ways to use the future, or in other words to anticipate: we might plan for something we see as preferable, or we prepare for something we deem necessary or plausible. We call these ways of using futures anticipatory systems (Miller, 2018). What they have in common is a certain idea of what the future might hold; a scenario, a dot on the horizon, a strategy or a dream. These ideas, scenarios or stories we tell ourselves are based on a variety of factors: upbringing, culture, films, books or education. Think of our assumptions of what a healthy person looks like, or what healthcare should entail in a modern society. These narratives are rooted in systems, worldviews, myths or metaphors, and can often be static or deterministic (Inayatullah, 2015). Many (digital) innovations in healthcare for example, albeit useful and life-changing, do not change the system or worldview that lies underneath. A new technical tool can solve problems in the short run, but does not change the way we see health in society. To put it bluntly: everybody wants change, but nobody wants TO change.
Challenging dominant narratives
To fundamentally change how we see care for health, or what it means to be healthy or to be able, we need to start with our shared narrative of the future. What is it that we fundamentally believe in? These visions of the future shape our decision making in the present: they offer guidance, or can stimulate our sense of agency. They can, however, be extremely limiting in our capacity to innovate, to be creative and open to uncertainty and novelty in the present. Without understanding what assumptions or static narratives we base our futures on, we fail to detect our blind spots, or to see different ways of doing. It’s when ‘how we respond to a problem, might become part of the problem” (Akomolafe, 2016). Think about the topic of the HIPPA conference Digital innovations for the future of housing seniors: based on what assumptions do we intend to foster these innovations? That the word ‘senior’ has the same meaning in the future as it has now? That we still live in houses ? That technology continues to develop the way it has? Controllable by mankind? To identify these anticipatory assumptions we need to engage in a different anticipatory system besides planning and preparation. We can use the future for exploration by thinking about the unthinkable, imagine the unimaginable, by exploring alternative scenarios that may seem whimsical or farfetched, but can help us stretch our imagination beyond the obvious and help us identify the gaps in our thinking. Reflective practices are key here, as is the collective intelligence when engaging in these sort of exercises. Listening to the different futures of others and their interpretations can push our imaginary boundaries even more. The future does not exist, but thinking about her does and by widening the pathways in front of us, we are able to see more in the present. It can help us to overcome the poverty of imagination.
Walking in two legs
The practice of exploring alternative futures to see the present differently is called anticipation for emergence (Miller, 2018). When able to navigate between the three anticipatory systems (planning, preparation and exploration) in different contexts and for different purposes while identifying anticipatory assumptions, one can be called futures literate. Miller calls this ‘walking on two legs’, as we need both, anticipation for the future and for emergence. This capability, as any capability, takes time to develop and while practising, one should resist the modern call for urgency or for acting on an impulse. Understanding the differences in these anticipatory systems can force us to challenge the status quo of the current health care and social systems, and can make space for a different kind of (shared) decision making. Less controlled, less focus on complicated problems but more personalised and appropriate for any given situation; an approach that demands learning in complexity.
Futures Literacy accepts the premise that the future cannot be foreseen, and that knowledge creation is dynamic and fluid. It allows for complexity to be appreciated, not to be solved, and for uncertainty to be embraced, not to be eliminated. It enhances our perception of the present: we sense more, but novelty also makes more sense. Lastly, it changes our sense of agency (Kazemier et al, 2021), as we make better informed decisions and become comfortable with different ways of being, thinking and doing.
We state in this article that we should take the care of health more seriously as a grand societal challenge. For this we need a worldview that embraces more the underlying logic of its complexity (ontology) and be consistent in how we get and value knowledge of this world (epistemology). Learning in complexity offers a nascent guideline on how to do. Its goal is to install a humble yet performative attitude of ‘wayfairing’, developing capabilities and supportive learning methods. Futures Literacy, named by UNESCO as the essential capability of the 21st century, can help us change the narrative from health care to care for health.