title: Adaptive practices in heart failure care teams: implications for patient-centered care in the context of complexity.
abstract: BACKGROUND
  Heart failure (HF), one of the three leading causes of death, is a chronic, progressive, incurable disease. There is growing support for integration of palliative care's holistic approach to suffering, but insufficient understanding of how this would happen in the complex team context of HF care. This study examined how HF care teams, as defined by patients, work together to provide care to patients with advanced disease.
  
  
  METHODS
  Team members were identified by each participating patient, generating team sampling units (TSUs) for each patient. Drawn from five study sites in three Canadian provinces, our dataset consists of 209 interviews from 50 TSUs. Drawing on a theoretical framing of HF teams as complex adaptive systems (CAS), interviews were analyzed using the constant comparative method associated with constructivist grounded theory.
  
  
  RESULTS
  This paper centers on the dominant theme of system practices, how HF care delivery is reported to work organizationally, socially, and practically, and describes two subthemes: "the way things work around here", which were commonplace, routine ways of doing things, and "the way we make things work around here", which were more conscious, effortful adaptations to usual practice in response to emergent needs. An adaptive practice, often a small alteration to routine, could have amplified effects beyond those intended by the innovating team member and could extend to other settings.
  
  
  CONCLUSIONS
  Adaptive practices emerged unpredictably and were variably experienced by team members. Our study offers an empirically grounded explanation of how HF care teams self-organize and how adaptive practices emerge from nonlinear interdependencies among diverse agents. We use these insights to reframe the question of palliative care integration, to ask how best to foster palliative care-aligned adaptive practices in HF care. This work has implications for health care's growing challenge of providing care to those with chronic medical illness in complex, team-based settings.
authors: Department of Psychiatry and Division of Medical Education, Dalhousie University, Halifax, NS, Canada.
authors: Glendon R
authors: GR
authors: Tait
authors: Centre for Health Education Scholarship, Vancouver General Hospital, Vancouver, BC, Canada.
authors: Joanna
authors: J
authors: Bates
authors: Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, University Hospital, London, ON, Canada.
authors: Kori A
authors: KA
authors: LaDonna
authors: Palliative Care, London Health Sciences Centre, University Hospital, London, ON, Canada.
authors: Valerie N
authors: VN
authors: Schulz
authors: School of Nursing, McMaster University, Hamilton, ON, Canada.
authors: Patricia H
authors: PH
authors: Strachan
authors: Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, University Hospital, London, ON, Canada.
authors: Allan
authors: A
authors: McDougall
authors: Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, University Hospital, London, ON, Canada.
authors: Lorelei
authors: L
authors: Lingard
keywords: complex adaptive system; health care teams; multimorbidity; palliative care; qualitative