Making changes with a ‘Systems Thinking’ framework

I am examining a ‘systems thinking’ framework tool to use in the current implementation of a sepsis prevention and treatment demonstration project in two rural Bangladesh hospitals.

Dr Kitson, a nursing professor from Australia, explains that most theories about knowledge translation use a linear theory, with a cause and effect model (Rogers’ Diffusion of Innovations) which does not work for people and stake-holders involved in change processes. In both low and high resource country health systems, significant organizational and technological changes with their corresponding behavioural and practice changes are not dynamic, easy to implement processes. It is prudent to look for other frameworks and guided efforts to expedite and facilitate needed system changes. Kitson’s (2009) article describes one such framework.

‘Systems thinking’ involves shifting the cause and effect linear thinking to a more complex system of how organizational change occurs in health care settings. The author proposes that factors relating to social, organizational and economic contexts influence the adoption of new knowledge. The importance of inter-relationships between people in all levels and the context of the health care system is stressed. Shift to systems thinking is a change towards seeing inter-relationships and processes of change rather than concrete moments of change. An innovation systems thinking knowledge translation tool is enabled by an expert facilitator working with individuals and teams in the wider system to change factors needed to adopt new practices.

The author notes that the health system is a complex entity, but does not work like a machine. Knowledge translation on its own is not enough to make changes, but relies on local autonomy experienced by individuals, teams and the unit involved in the change. Key stakeholders need to be involved and individuals must understand the new piece of knowledge being introduced and accept it. They need to be able to make informed decisions about using the knowledge, and to negotiate relations with others in their system. Resources to sustain the changes or improvements in practice are an important part of the equation.

According to Graham et al (2006), Knowledge translation’s primary purpose is to address the gap between what is known from research and knowledge synthesis and how this is manifested in practice. This definition is the one primarily used in the Canadian Institutes of Health Research (2005) but it does not indicate how the system responds to new information, how the interaction occurs, or how the knowledge is moved from researcher to practitioner or user. Kitson (2009) explores how the concepts of ideas, people, relationships, context, outcomes and process differ in traditional KT and in ‘systems thinking’ innovation. The process of synthesizing and adopting information is complex and needs to be enacted at multiple levels. Using ‘systems thinking’ can give us a more realistic perspective of how organizational change occurs.

The author describes the introduction of innovation into systems that are under-developed, where the individuals feel that they are victims and do not have control over their environment, have fixed attitudes and beliefs, and exhibit apathy. While using this framework to implement changes in rural Bangladesh hospitals, mid-level providers must increase their autonomy and control over the environment, and the involvement of stakeholders must be promoted.

Canadian Institutes of Health Research.

Graham I, Logan J. Harrison M, Straus S, Tetroe J, Caswell W, Robinson N.(2006). Lost in Translation: Time for a Map? Journal of Continuing Education in the Health Professions. (26)13-24.

Kitson A. (2009). The need for systems change; reflections on knowledge translation and organizational change. Journal of Advanced Nursing.  65, 217-28. Doi:10.1111/j.1365-2648.2008.04864x

National Collaboration Center for Methods and Tools (2013). Integrating Knowledge translation and systems thinking for organizational change. Hamilton, On: McMaster University. Retrieved from:

Rogers, E. (1983) Diffusion of innovations. New York : Free Press ; London : Collier Macmillan.


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