Many wonder why there has been so little change in care quality, despite substantial quality improvement efforts. Questioning why current approaches are not making true changes draws attention to the organization as a source of answers. We bring together the case study method and complexity science to suggest new ways to study health care organizations. The case study provides a method for studying systems. Complexity theory suggests that keys to understanding the system are contained in patterns of relationships and interactions among the system's agents. We propose some of the "objects" of study that are implicated by complexity theory and discuss how studying these using case methods may provide useful maps of the system. We offer complexity theory, partnered with case study method, as a place to begin the daunting task of studying a system as an integrated whole. KeywordsCase study methods; research; complexity science; health care organizations Dr. Jane Russell, Family Physician, spoke at a luncheon with great zeal about the benefits of preventive medicine, transferring her enthusiasm to the audience of family health care providers. It was evident that the individuals in this group felt strongly about the value of prevention as a part of their medical practice. When we examined Dr. Russell's practice for the level of preventive services delivered, therefore, we were greatly surprised to find that, while most women in her practice were up-to-date with mammograms, in only 10% of her patients who smoked tobacco was there any documentation of their ever having been counseled to stop smoking.In order to understand and improve the complex contexts and interactions that lead to anomalies such as those presented by Dr. Russell, theoretical models and research methods are needed for understanding health care organizations. These models and methods need to address questions such as: "Why have we seen so little change in what is being done for clients despite substantial knowledge in the form of best practice guidelines?" "Why is it that a physician, NIH Public Access

Purpose:The relationship between job satisfaction of nurse aides and intent to leave and actual turnover after 1 year is examined. Design and Methods: Data came from a random sample of 72 nursing homes from 5 states (Colorado, Florida, Michigan, New York, and Oregon). From these nursing homes, we collected 1,779 surveys from nurse aides (a response rate of 62%). We used a job satisfaction instrument specifically developed for use with nurse aides, as well as previously validated measures of intent to leave and turnover. We used ordered logistic regression and logistic regression to examine the data. Results: High overall job satisfaction was associated with low scores on thinking about leaving, thinking about a job search, searching for a job, and turnover. In examining the association between the job satisfaction subscales and intent to leave and turnover, we found that high Work Schedule subscale scores, high Training subscale scores, and high Rewards subscale scores were associated with low scores on thinking about leaving, thinking about a job search, searching for a job, and turnover. High scores on the Quality of Care subscale were associated with low turnover after 1 year. Implications: These results are important in clearly showing the relationship between job satisfaction and intent to leave and turnover of nurse aides. Training, rewards, and workload are particularly important aspects of nurse aides' jobs.

This article examines the intersection of professionalism and complexity science as a source of new insights for improving the health care industry from both a clinical and business point of view. Viewing health care organizations as professional complex adaptive systems suggests eight leadership tasks for addressing the circumstances that engulf health care. Managers who adopt this view will be able to create new levers for positive movement in their organizations.

Complexity science was used to explain the results. The findings open the door to rethinking nursing home management practice. Practices that increase communication and interaction among people are needed for better resident outcomes.