Table 2.

Substantive theory for embracing complexity – challenges and corresponding actions required for successful evidence translation and improvement

Embrace complexity
Common challenges	Simple rules: strategies for overcoming challenges
Interventions do not work on their own – they need to fit with practices and processes of care  - Interventions need to be used by people and are dependent on other processes and practices  - Interventions interact with complex processes and established practices of professions and organisations	Understand practices and processes of care - Understand what is actually happening and identify interdependent practices and processes - Consider fit of new or modified interventions and use to inform intervention design, implementation activities, and ongoing learning and actions to drive improvement
There is rarely a single, standardised, way by which care is delivered  - Agents within the system are constantly interacting and responding to each other and to internal and external stimuli  - This results in inherent levels of variation within healthcare systems, even when standard processes exist  - People have to make decisions and take actions in real world (imperfect) conditions	Understand types and sources of variation - Natural variation needs to be understood to inform intervention design and implementation - Identify what variation is (un)acceptable and what improvements are required - Use data, observations and feedback on variations to learn and assess whether progress is being made
It cannot be assumed that dependent processes or systems are working well  - To achieve the original improvement goal other problems or related issues may need to take priority  - Practices and processes are often sub-optimal and may require improvement to support evidence implementation  - Systemic problems can be hard to overcome and may challenge assumptions or current practices and cultures  - Not all systemic problems can be addressed	Identify systemic issues - Be vigilant for systemic issues as learning emerges - Consider what is within the project team’s sphere of influence, and where additional support is needed - Use learning to influence planning and design, and where necessary how to function within system constraints
Any intervention will compete for attention and resources with other initiatives or requirements  - Attention and resources are limited and initiatives need to work within system constraints  - Initiatives will always ‘compete’ with other priorities and may fail without appropriate support and backing  - Managerial, financial, strategic and political decisions and motives may work in support or against an initiative	Seek political, strategic and financial alignment - Recognise system constraints and be realistic about what can be achieved given finite resource and competing priorities - Consider where improvement might have greatest impact - Understand negative or positive impacts of political, strategic or financial incentives on behaviours and use this to inform the design of interventions - Where possible, seek alignment and consider how to secure support and continued investment