• Competence –individuals "know" or "can do" in terms of knowledge skills and attitudes
  • Capability- the extent to which individuals can adapt to change, generate new knowledge and continue to improve their performance

Greenhalgh – "in the 21st Century we must aim not for change, improvement and response BUT changeability, improvability and responsiveness. (BMJ 2001;323:799-803 Coping with Complexity: educating for Capability)

As educators we are challenged to enable people not merely to be competent but capable.

Capability

  • can adapt to change
  • can generate new knowledge
  • can continue to improve on their performance

Adults chose to learn to learn because they want to change –things are not constant, individuals are independent, uncertainty is common (inherent in the system) and small changes can have big effects.

In the past we have had knowledge based courses and knowledge based assessments. Actual knowledge is not so important…..we are not custodians of information-we are awash with it.

We do not need to know everything but the ability (capability) to find out. Learning how things interconnect and are interconnected is more important that the pieces- a checklist curriculum is no longer valid for capability learning.

Problem solving is important-appraise the situation, find relevant information then integrate and generate a solution. Non linear and experiential learning is key:

  • Situational learning (shadowing, apprenticeship, rotational attachments)
  • Small group learning (case based, role play, problem solving peer support)
  • Problem based learning (how to find out, teamwork)
  • Self Directed (reflective practice, using patients learning log, networking informally)

Many of our primary care encounters deal with uncertainty – due to patient presentations, environmental unfamiliarity or the task can be unfamiliar. It is the norm in first contact medicine to have a degree of uncertainty and an awareness of the lack of general agreement about the diagnosis, interpretation, investigation and management-this is the zone of complexity.

Learning takes place in the zone of complexity. If it is supported learning with adequate experiential activity, self directed learning, small group learning and problem based learning it can be a potent influence for creating a CAPABLE cohort of primary care doctors that are enthused ,enabled and effective .

Capability and competence

Competence is a measure that can do.

Capability is the development of competencies, the generation of new knowledge and the adaptation to change. Shows and does do.

NOVICE becomes an EXPERT

TRANSACTIONS between EXPERT and EXPERT

EDUCATION needs SERVICE to produce CAPABILITY which is enhanced by MASTERY AND MODELLING

Benefits by SUPPORT or CHALLENGE at the right times not just through the year but day by day and even hour by hour

Act as a GUIDE and remember MASLOW

The area of competence is the safe area to the left and the areas of uncertainty and complexity is in the centre & where capability is needed. It benefits from experiential learning with feedback and reflection.

 

Complexity

The majority of clinical primary care scenarios are in the uncertainty and low level of agreement category. Similarly in our education work with groups & individuals we are in this zone... hence requirement for CAPABILITY. (When the task is unfamiliar & the environment is unfamiliar we also are in complexity if not chaotic zone.)

Many trainees think their trainers work with a very large competence zone because they are certain about things and have a clear understanding of what should be agreed. As a trainer dispel the myth and explore the complexity zone with learners and how we cope with life as a GP.

The Stacey matrix for complexity

Dr Shake Seigel, (with thanks to Brenda Zimmerman, Edgeware Aides, Toronto.)

I believe a useful map for navigating your way into the concepts and field of complexity is "The Stacey Matrix". It can help to guide you by offering a method to select the appropriate management actions in a complex adaptive system based on the degree of certainty and level of agreement on the issue in question.

The art of management and leadership is having an array of approaches and being aware of when to use which approach. Ralph Stacey proposed a matrix to help with this art by identifying management decisions on two dimensions: the degree of certainty and the level of agreement.

 

Possible applications:

  • Choosing between management or leadership approaches for a specific issue or decision.
  • Making sense of an array of decisions (or agenda for a group).
  • Communicating with others why a particular approach is appropriate.
  • When innovations and creative alternatives are needed, this matrix can be used to deliberately try to increase the uncertainty and disagreement to nudge the system to the edge of chaos.

Close to Certainty:

Issues or decisions are close to certainty when cause and effect linkages can be determined. This is usually the case when a very similar issue or decision has been made in the past. One can then extrapolate from past experience to predict the outcome of an action with a good degree of certainty.

Far from Certainty:

At the other end of the certainty continuum are decisions that are far from certainty. These situations are often unique or at least new to the decision makers. The cause and effect linkages are not clear. Extrapolating from past experience is not a good method to predict outcomes in the far from certainty range.

Agreement:

The vertical axis measures the level of agreement about an issue or decision within the group, team or organization. As you would expect, the management or leadership function varies depending on the level of agreement surrounding an issue.

 

The Edge of Chaos (The Zone of Complexity)

 

There is a large area on this diagram which lies between the anarchy region and regions of the traditional management approaches. Stacey calls this large center region the zone of complexity - others call it the edge of chaos. In the zone of complexity the traditional management approaches are not very effective but it is the zone of high creativity, innovation, and breaking with the past to create new modes of operating.

1. Technical Rational decision making: Much of the management literature and theory addresses the region on the matrix which is close to certainty and close to agreement. In this region, we use techniques which gather data from the past and use that to predict the future. We plan specific paths of action to achieve outcomes and monitor the actual behaviour by comparing it against these plans. This is sound management practice for issues and decisions that fall in this area. The goal is to repeat what works to improve efficiency and effectiveness.

2. Political decision making: Some issues have a great deal of certainty about how outcomes are created but high levels of disagreement about which outcomes are desirable. Neither plans nor shared mission are likely to work in this context. Instead, politics become more important. Coalition building, negotiation, and compromise are used to create the organization's agenda and direction.

3. Judgmental decision making. Some issues have a high level of agreement but not much certainty as to the cause and effect linkages to create the desired outcomes. In these cases, monitoring against a preset plan will not work. A strong sense of shared mission or vision may substitute for a plan in these cases. Comparisons are made not against plans but against the mission and vision for the organization. In this region, the goal is to head towards an agreed upon future state even though the specific paths cannot be predetermined.

4. Chaos: Situations where there are very high levels of uncertainty and disagreement often result in a breakdown or anarchy. The traditional methods of planning, visioning, and negotiation are insufficient in these contexts. One personal strategy to deal with such contexts is avoidance - avoiding the issues that are highly uncertain and where there is little disagreement. While this may be a protective strategy in the short run, it is disastrous in the long run. This is a region that organizations should avoid as much as possible.

5. Complexity zone: There is a large area on this diagram which lies between the anarchy region and regions of the traditional management approaches. Stacey calls this large centre region the zone of complexity - others call it the edge of chaos. In the zone of complexity the traditional management approaches are not very effective but it is the zone of high creativity, innovation, and breaking with the past to create new modes of operating. In management we spend much of our time teaching how to manage in areas (1), (2) and (3). In these regions, we can present models which extrapolate from past experience and thereby can be used to forecast the future. This is the hallmark of good science in the traditional mode. When we teach approaches, techniques and even merely a perspective in area (4) the models seem 'soft' and the lack of prediction seems problematic. We need to reinforce that managers and leaders of organizations need to have a diversity of approaches to deal with the diversity of contexts. Stacey's matrix honours what we already have learned but also urges us to move with more confidence into some of the areas which we understand intuitively but are hesitant to apply because they do not appear as 'solid.'

A Simplified version of the Stacey Matrix

Acknowledgement

Brenda Zimmerman,
 Schulich School of Business,
York University,
Toronto,
Canada