Second, when individuals want to be in the majority group, the well-mixed model predicts that they will all form one big group. However, if individuals only react to their local neighborhood, many more small groups of identities can be stable in the population, and this number again increases for smaller neighborhoods. Thus, as individuals adjusted their social identities to larger and larger radii of social influences, populations became more and more homogeneous.
Finally, although the well-mixed model predicts that everyone will be dissatisfied in a less-than-optimally-distinct group, spatial organization, in which individuals react only to local neighborhoods or social networks, as an alternative interpretation , allows individuals to organize in a way such that their distinctiveness is very close to optimal. Error 5. Each time step, an agent chose a random SID from the original nine instead of the one that was most optimally distinct with a probability of 0. Simulations were run with error for time steps, after which error was turned off, allowing the population to stabilize for another time steps.
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In these cases, the population often went to a single, global SID. All of the other example runs, including spatial run 5 with its hexagonal layout, were replicated even in the presence of error. Figure Full analysis of the spatial model with error. For the first time steps of each run, agents selected a random SID with probability. SID decisions were once again deterministic for the final time steps. Discussion 6. Equilibrium is maintained by correcting for deviations from optimality. However, ODT has not previously accounted for the influence of many individuals each simultaneously attempting to optimize their distinctiveness.
Our model suggests that the individual-level decision strategy proposed by ODT is insufficient to generate an equilibrium in which all or even most individuals are optimally distinct if individuals have complete knowledge about the prevalence of all social identities in their populations. The model further suggests, however, that this decision strategy may be effective if knowledge about social identity prevalence is restricted to individuals' local social neighborhoods. If we like, we can consider agents as "happy" when their distinctiveness approaches their subjective optimal and "unhappy" when their distinctiveness differs from that optimal.
Agents using ODT as a decision rule in a well-mixed population are doomed to be unhappy. In other words, basing their decisions only on the individuals in their local neighborhoods allowed agents to be happy. These results were robust to errors in social decision making. Additionally, more social identities could be maintained in the population—i. Because individuals responded locally, everyone could be in a local majority, but local neighborhoods could also differ from one another, leading to local segregation of social groups rather than global conformity.
This result, however, was not very robust to error. The position of being in the majority for agents at the peripheries of group boundaries was precarious, and errors tended to disrupt group stability and lead to the emergence of a single, dominant SID. This did not always occur for very small r , however, as individual neighborhoods were too small and varied to spread effectively via a tipping phenomenon Schelling , Our results show that the heuristic of optimizing one's distinctiveness is actually a technique that has the best validity under conditions of limited, local information.
Here we have attempted to instantiate a simple act of social cognition in a multi-agent framework. Although it is a highly simplified view of the cognitive, behavioral, and environmental complexities of human interactions, our model is able to reveal key insights into the social identity dynamics implicit in optimal distinctiveness theory.
Limitations and future directions 6. The model's simplicity naturally excludes many features of real human actors and their environments. Future models should include some of these additional complexities. For example, individuals could be heterogeneous in their distinctiveness preferences and have the ability to create novel social identities. Also, we assumed that social identities were orthogonal, and that decisions to change social identities were complete and instantaneous.
Some social identities could be similar or antithetical, and changes to social identity could be modeled as more of a gradual process that might also be influenced by one's current social identity and the social identities of disliked members of one's social network enemies as well as friends. We also treated social identity as a single trait that was visible to everyone in an individual's social network.
In reality, individuals have many social identities and domains of social identities, some of which may be nested in others. For example, a person may be an academic, a psychologist, and a social psychologist. These are nested identities, and the most salient level will depend on the setting for social comparison. Additionally, someone who is a psychologist may also be an athlete, a musician, a parent, a Jew, a Southerner, etc. Multi-dimensional or nested trait profiles could be interesting additions to future models as long as their complexity does not obscure the model's inherent value, which lies in clarification through simplification.
Real social neighborhoods may have more complex structure. We also assumed that social networks were fixed. Strong social ties tend to persist McPherson et al. The role of both goal-directed and random movement in social and physical space can have important influences on population dynamics for a range of phenomena Schelling ; Beltran et al.
Because the decision rules and the ability to instantly switch SIDs are dramatic simplifications, the specific time scale of the model cannot directly correspond to a real-world time scale. At the same time, experimenters should look at the temporal stability of social identities in different settings. Conclusion 7. While social identity choices are often influenced by many factors, the extent to which they are based on the social identities of others typifies the class of social systems in which such multi-level models are appropriate.
Theories of social identity dynamics will never be sufficiently explanatory if they only focus on solitary decision makers reacting to a static social environment. Because individual choices affect the stimulus landscapes for other decision makers, social identity decisions must be understood in terms of population dynamics as well as individual cognition. Acknowledgements We thank Joshua Epstein, Elizabeth Matthews, and Jimmy Calanchini for valuable discussion in the development of ideas presented here.
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6| Models and Processes of Systemic Design
Editor who approved publication: Professor Russell Taichman. Leadership is considered pivotal for enabling the development and preservation of compassionate health care organizations. Strategies for developing compassionate health care leadership in the complex, fast-moving world of today will require a paradigm shift from the prevalent dehumanizing model of the organization as machine to one of the organizations as a living complex adaptive system.
It will also require the abandonment of individualistic, heroic models of leadership to one of shared, distributive, and adaptive leadership. It must be eschewed. Instead, leadership should be developed throughout the organization with collective holistic learning strategies combined with high levels of staff support and engagement. Culture and leadership are interdependent and synergistic; their codevelopment needs to be grounded in a sophisticated, scientifically based account of human nature held within a coherent philosophical framework reflected by modern organizational and leadership theories.
Developing leadership for compassionate care requires acknowledging and making provision for the difficulties and challenges of working in an anxiety-laden context. This means providing appropriate training and well-being programs, sustaining high levels of trust and mutually supportive interpersonal connections, and fostering the sharing of knowledge, skills, and workload across silos. It requires enabling people to experiment without fear of reprisal, to reflect on their work, and to view errors as opportunities for learning and improvement.
Tasks and relational care need to be integrated into a coherent unity, creating space for real dialog between patients, clinicians, and managers, so that together they can cocreate ways to flourish in the context of illness and dying. Keywords: servant leadership, compassion, complexity, adaptive, resilience, culture. In many countries, there is a deep concern that modern health care has lost its moral compass and is struggling to provide safe, timely, and compassionate care to its citizens. Changing demographics, greater demand, rapidly evolving technology, information overflow, and financial constraints present new challenges.
This is particularly evident in the UK, where recent high-profile scandals and condemnatory reports regarding health care provision have led to a great number of guidance documents, conferences, and articles on this theme. One survey showed that just over half of the patients and doctors believed that the health care system provided good compassionate care.
The responses to these shocking and disturbing reports have also highlighted the importance of leadership in fostering or subverting compassionate health care. But can services and institutions, in the context of a fast-paced, industrialized, and marketized modern health care, reliably respond with sensitivity and compassion to patients in their care, particularly of the frail and elderly? Furthermore, health care does not exist in a vacuum — demographic, political, and sociocultural contexts influence the moral climate and, in turn, the expectations and motivations of the public and those working in health care organizations.
In this article, I set out to integrate perspectives from neuroscience, psychology, and complexity science with modern leadership and organizational theories in an endeavor to arrive at a useful synthesis. I will clarify what is meant by compassion, consider its facilitators and barriers, explore the models of leadership that are relevant and appropriate to the modern health care context, and describe an integrative realistic vision of compassionate leadership with proposals for its development.
I shall also consider how changes in health care delivery — notably industrialization and marketization — in hospitals and primary care have prioritized or favored transactional care, measurable outcomes, and mechanistic solutions that have squeezed out relational care and the scope for compassionate practice. Compassionate care involves responding with kindness and sensitivity to the vulnerability and suffering of patients and their relatives , who may be experiencing frightening junctures in their lives, with the threat of losing their autonomy, dignity, control over their bodies, and the direction of their future lives.
They may be confronting death and lack resources to cope with dying. Patients wish to have their humanity and uniqueness acknowledged. What would compassionate health care look like? In a compassionate health care system, patients and staff would feel listened to, supported, and cared for. Staff would feel empowered to show attentive kindness, to be attuned to their own needs and those of their patients, and to be free to take appropriate actions to relieve suffering. Patients would have their physical, psychological, and spiritual needs attended to.
They would feel safe and their dignity restored or preserved. Care would reflect not just compassion but also competence and timeliness. There would be time to care and space to reflect and recharge. There is considerable confusion and divergence in the conceptualization of compassion. A recent review reveals that compassion arises out of distinct appraisal processes and has distinct behaviors, experiences, and physiological responses. Compassion refers to a deep awareness of the suffering of another coupled with the wish to relieve it […]. Although the process of arriving at compassion can be difficult or complex, showing compassion often flows naturally […].
Elsewhere I proposed that compassion is at the heart of medical ethics as it is essential for the relief of suffering, which is arguably the prime goal of medicine. It is complex and dynamic and resists quantitative measurements but is easy to recognize. Experiencing compassion makes people better able to show compassion to others, leading to a virtuous spiral.
Compassion is often conflated with empathy and most of the research in health care relates to empathy, not compassion , and empathy itself is multifaceted with two broad components: emotional empathy and cognitive empathy. But empathic distress can lead to individuals focusing on themselves and on alleviating their own distress. If they lack the psychological resources to cope, they may resort to aversive responses — suppression, denial, or avoidance of the person triggering the distress.
Compassion is a broader, more vigorous concept: empathic concern is coupled with motivation to relieve the suffering of another. Cognitive empathy helps to guide an appropriate response rather than an impulsive and potentially harmful one. Importantly, compassion unlike emotional empathy involves distress tolerance: having the resilience to avoid being overwhelmed by afflictive emotions and thereby becoming less capable of helping. Evidence suggests, however, that cognitive empathy is protective against burnout and promotes well-being.
In this model, there are broadly three emotion systems:. Importantly, the threat system inhibits the affiliative system. As already highlighted, medicine is intrinsically threatening and anxiety-laden. Another key finding in neuroscience research relevant to leadership development is the discovery that two large-scale cortical networks can antagonize each other. In contrast, the default mode network plays a central role in emotional self-awareness, social cognition, and ethical decision-making, as well as creativity and insightful problem solving.
Activity in the TPN inhibits activity in the default mode network. On the other hand, a highly relationship-orientated leader may have difficulties in focusing and executing the clearly defined goals. All tasks, however, have relational and analytical components, so that leadership will almost always require consideration of both. The crucial skill for leaders is to be able to toggle fluidly between the two, responding appropriately to situations as they arise. Training for this ability will be the key to compassionate and effective leadership.
This will involve training in two role-specific abilities — analytical and mechanical reasoning and making social—emotional connections crucial to relationship building. Compassion, albeit an innate human capability, is vulnerable to a variety of factors and can readily be eclipsed. Compassion cannot be coerced or turned on at will by some diktat or rule.
Indeed, attempts to do so will result in inauthentic compassion, a forced submissiveness that is likely to lead to depression and distress in the caregiver. Barriers to compassion, such as fear of death and dying, stress, depression, and burnout, have been identified in other studies. This is particularly evident in the nursing research literature.
If people are time pressured, too preoccupied, or distracted, they simply may not realize that people are suffering around them, as evidenced from staff reports and social psychology studies. Self-determination theory has stood the test of time and emphasizes the importance of intrinsic versus extrinsic motivation for flourishing and well-being. The majority of health professionals enter the profession with a high level of intrinsic motivation to help others and to be good at their work. Unfortunately, rigid and oppressive management, negative role models, and traumatizing experiences without the opportunity for supported reflection can extinguish the flame of compassion.
But where intrinsic motivation and staff engagement are nurtured, compassionate patient-centered care can flourish. Self-compassion is a key ingredient for resilience and the sustainability of compassion, yet theories of leadership neglect this. From this account, we can deduce that leadership for compassion should involve the creation of systems that can provide a healthy containment of anxiety, support for the individuals involved, and the modeling and harnessing of positive adaptive responses to challenges.
Leadership also needs to foster a culture of learning and openness, such that errors, mistakes, and hazards can be shared and discussed and new learning can evolve. A punitive regulatory approach will only make people hide their mistakes for fear of damaging their future careers or to avoid shame. Unfortunately, in the English National Health Service NHS , the evidence attests to a culture of fear and blame with whistle-blowers put at risk of damaging repercussions if they speak up.
A variety of conceptual frameworks for leadership have evolved over a number of years, accompanied by an abundance of definitions that fail to reach universal consensus. Furthermore, the ubiquity of suffering and anxiety in health care creates an imperative for compassionate leadership but paradoxically creates conditions that make such leadership challenging and difficult to sustain.
Defining leadership as dynamic, nonlinear, reciprocal processes and outcomes, available to everyone and not restricted to a formally designated person, signifies a renouncement of the theories that depict leadership as a collection of traits or characteristics residing within an individual. It also means that we abandon the heroic model of leadership and move to a model of collective or shared and distributive leadership. We can democratize leadership further and use the term partners rather than followers. Regrettably, reports and inquiries suggest that this form of leadership is still too prevalent in the health care context.
Even if we discard an individualized trait approach to leadership, a brief outline of leadership typologies is still useful in their application for the collective. Authentic leadership includes self-awareness, internalized moral perspective, balanced processing, and relational transparency. Servant leadership is characterized by a focus on the needs of others altruism and the setting aside of egoistic goals. Also far greater themes of connectedness and inclusiveness emerged than in the USA. Servant leadership differs from transformational leadership although there is a considerable overlap in that servant leaders focus on service and people rather than on organizational goals.
Furthermore, servant leaders have the belief that the organizational goals will be achieved by facilitating the growth, development, and well-being of those who work in the organization and by trusting them to undertake appropriate actions. They conclude as follows:.
If countless individuals transform into servant leaders, infinitely more people would benefit. Servant leadership offers the potential to positively revolutionize interpersonal work relations and organizational life. Finally, adaptive leadership is needed when organizations face new challenges, and the old systems no longer work.
These are common in health care, for example, obesity, drug abuse, violence, frailty, and so on. The picture that emerges from these inquiries is depressingly repetitive and resonates with the findings from the Francis Inquiry: financial difficulties, understaffing, poor leadership, low staff morale, a culture of bullying, and a fear of speaking up. And can compassionate leadership change this? Clearly, organizational change is urgently needed. Arguably, one of the biggest barriers to compassionate care is the persistent and uncritical deployment of the theory and metaphor of the organization as a machine with hierarchical command and control managerial leadership.
The market system also instrumentalizes people and human-to-human interactions by viewing them as monetizable and a means to an end eg, profitability. It also attempts to slice caregiving and the experience of illness into discrete, disjointed units. Medicine, however, is both an art and a science, involving high levels of unpredictability and emotional charge, and requiring many skills and responsive, trusting relationships.
Relational care is dynamic, iterative, and heterogeneous. Each interaction is unique and adaptive to the patient and the context. The organization as a living human system, like any ecosystem in nature, provides a coherent metaphor, which can accommodate human motivation and emotions.
Culture can be defined as the shared values, assumptions, and beliefs within occupational groups or organizations. These are translated into norms of practice reinforced by rituals, ceremonies, and shared narratives. Health care organizations need to nurture cultures that ensure the delivery of high-quality, safe, and compassionate health care. In a large multimethod study, the best performing organizations were those that gave priority to a vision and strategy for high-quality compassionate care.
Leadership is seen as the most influential factor in shaping organizational culture. But one could also argue that culture influences the emergence of different kinds of leadership and they are in a reciprocal, even synergistic, relationship. These focus on efficiency and use task systems dominated by technical cores, machine bureaucracy, and market or bureaucratic governance. In contrast, caring cultures ensure that staff members are engaged by being valued, respected, and supported.
Engaged staff are more likely to provide compassionate safer care and higher patient satisfaction. But cultural diversity and complexity can exist within a health service with multiple, often competing, subcultures. Kanov et al described three collective compassion subprocesses with examples that reflect the culture of the organization: collective noticing, feeling, and responding. The competing values framework provides a useful diagnostic tool for evaluating organizational culture.
Hierarchy control and stability should be applied only when strictly necessary, such as in crises or when procedures require a uniform and routinized approach. This is borne out by research which found that clan cultures in hospitals were associated with higher staff morale and fewer patient complaints. The opposite was true of market cultures. Hierarchical cultures were associated with poor outcomes and a climate of fear. General practitioners in the UK working with primary care professionals were able to function as relatively autonomous self-organizing teams, but imposed target-driven bureaucracy and industrialization have changed this and led to fragmentation and loss of personal holistic care.
In practice, a cultural shift toward adaptive, collaborative, and creative health care organizations means that much of the daily decision-making can be left to small self-organizing multidisciplinary teams. The management is primarily coaching and supportive. Professional barriers are overcome, and clinicians engage more with patients and work with them to bring about change and innovation, treating them as coproducers of health, not passive recipients of care.
Leadership development is underpinned by human adult development and is a dynamic process built on a foundation of trust and respect. Traditional leader-centric development programs by external providers in remote locations with tenuous links to organizational outcomes continue to dominate. People will need to learn to be adept at managing across boundaries and disciplines.
Managers will need to be trained in coaching skills to support staff. From the empirical evidence, it is clear that we need to nurture and cultivate facilitators, team builders, mentors, and coaches clan as well as individuals in large numbers who are creative, transformative, and adaptive ad-hocracy.
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Hard-driving competitive leadership market , characteristics of pacemakers, and bureaucratic and controlling leaders hierarchy need to be present in very small doses. Frost et al propose three lenses that serve as a blueprint for the development of compassion in organizations:. There will still be a need for some individualized senior leadership development, but the focus should be on developing servant and adaptive leadership attributes and practices.
Senior leaders will require the capacity to establish a collective vision to support the greater good, make connections and work across boundaries, tolerate uncertainty, collate multiple perspectives, and ensure that leadership is distributed. They will need to embody and model compassionate attitudes and behaviors and receive the support and training to develop and maintain self-compassion and emotional resilience.
Clinicians are exposed to high levels of negative emotions in stressful environments and need to be proficient in emotional regulation skills and adaptive strategies to cope. Training and education will no doubt help, but the environment has to be conducive to compassionate care. Nor can we expect compassionate leadership to be sustainable in the context of inadequate resources including staffing levels and insufficient support.
These show evidence of improving staff well-being and morale. It gives a core perception of capability and activates community building with extensive use of storytelling. It engages people in learning, planning, and innovation and focuses on best practices. Several medical schools and health care institutions report positive outcomes. Mindfulness meditation and compassionate mind training can increase responsiveness to suffering and psychological flexibility, enhance patient-centered value-directed care, and increase self-compassion and emotional resilience.
Coaching is also widespread and popular and can be tailored for compassionate leadership. In conclusion, to develop compassionate leadership in health care, we need a paradigm shift from an engineering hierarchical model of organizations with trait-based, top-down individualistic models of leadership toward a model of the organization as a complex living system and leadership as adaptive, shared, and distributed. This is in keeping with modern organizational and scientific theories and a great deal of empirical evidence. It is also philosophically coherent. The inevitable anxiety related to caring for the sick and dying needs to be recognized and contained in an adaptive and healthy way.
Development for compassionate leadership means fostering leaders, who embody and enact the qualities of servant leadership: altruism, integrity, humility, and wisdom combined with an appreciation and empowerment of others. Developing a compassionate and person-centered organization requires senior leaders to clearly articulate the core values and vision of the health service and to ensure that they resonate in all the self-organizing groups within the system. Leadership should support, engage, and enable staff and patients in a meaningful way.
Yet more regulation and bureaucracy will stifle innovation and impede the flow of compassion. Francis R. London: Stationery Office; London: The Stationery Office; Abraham A. Health Service Ombudsman. Care and Compassion? Department of Health. London: HSMC; Berwick D. An agenda for improving compassionate care: a survey shows about half of patients say such care is missing.
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