• change;
  • complexity;
  • health visiting;
  • organization;
  • primary care;
  • professional behaviour

Aim.  This paper uses the experiences of a programme designed to bring about change in performance of public health nurses (health visitors and school nurses) in an inner city primary care trust, to explore the issues of professional and organizational change in health care organizations.

Background.  The United Kingdom government has given increasing emphasis to programmes of modernization within the National Health Service. A central facet of this policy shift has been an expectation of behaviour and practice change by health care professionals.

Methods.  Change was brought about through use of a Complex Adaptive Systems approach. This enabled change to be seen as an inclusive, evolving and unpredictable process rather one which is linear and mechanistic. The paper examines in detail how the use of concepts and metaphors associated with Complex Adaptive Systems influenced the development of the programme, its implementation and outcomes.

Findings.  The programme resulted in extensive change in professional behaviour, service delivery and transformational change in the organizational structures and processes of the employing organization. This gave greater opportunities for experimentation and innovation, leading to new developments in service delivery, but also meant higher levels of uncertainty, responsibility, decision-making and risk management for practitioners.

Conclusion.  Using a Complex Adaptive Systems approach was helpful for developing alternative views of change and for understanding why and how some aspects of change were more successful than others. Its use encouraged the confrontation of some long-standing assumptions about change and service delivery patterns in the National Health Service, and the process exposed challenging tensions within the Service. The consequent destabilising of organizational and professional norms resulted in considerable emotional impacts for practitioners, an area which was found to be underplayed within the Complex Adaptive Systems literature. A Complex Adaptive Systems approach can support change, in particular a recognition and understanding of the emergence of unexpected structures, patterns and processes. The approach can support nurses to change their behaviour and innovate, but requires high levels of accountability, individual and professional creativity.