Making sense of complexity: A qualitative ‘Framework’ analysis of naturopathic case management and clinical reasoning

The clinical encounter is characteristically complex and lacking in certainty, despite the widespread incorporation of the evidence-based medicine model, clinical guidelines, and practice protocols; real life clinical practice is complex and non-linear [1]. As a whole complex system, the human organism does not always function in predictable and linear ways but instead exhibits emergence, fuzzy borders, sensitive dependence on starting conditions, and functional adaptation to internal and external change [2,3]. Contemporary health priorities include the prevention, resolution and management of chronic disease which tends to be complex and multifactorial [4,5]. The conditions which primarily contribute to disease burden across the life span are generally chronic, complex, and non-communicable [6]. Practitioners from different systems of medicine approach the clinical encounter in distinct ways, based on their epistemology and practice norms. The reductionist and positivist paradigm of biomedicine may inhibit practitioners from engaging with patients in a systems cognisant manner [[7], [8], [9]], while traditional medicine systems are commonly characterised by holistic foundations that work across multiple systems and symptoms and as such may offer insights into the clinical management of complexity. In this study, the perceptions of naturopathic practitioners regarding clinical reasoning and case management are explored in the context of understanding how complexity is managed within the naturopathic clinical encounter.

Naturopathy is a distinct traditional system of primary health care with diverse practices informed by its philosophy of holism and vitalism, seven practice guiding principles, and multiple theoretical premises [10] (Fig. 1). All aspects of naturopathic practice, from assessment to treatment, are person-centred [11], and a diverse range of practices and therapies are used by naturopathic practitioners in order to meet individualised treatment aims [12]. As well as treating patients with acute conditions or those requiring palliative care, naturopathy is clinically suited to preventing illness, wellbeing attainment, and treating chronic conditions [13] which often tend to be complex and multifactorial [5].

The therapeutic order, an embodiment of naturopathic philosophy (holism and vitalism) and naturopathic principles, prioritises the determinants of health as the foundation for maintaining and restoring vitality and health [18] (Fig. 2). The therapeutic order is a hierarchical intervention framework, which guides naturopathic practice and its application by acknowledging the innate healing capacity of an individual [15,19]. The objective of the naturopathic therapeutic order is to primarily support the natural healing processes of the body, and to graduate interventions to use the least possible force required to achieve the desired outcome [18,19] (see Fig. 3).

Chronic and systemic disease is generally more complex than acute disease [5]. A significant proportion of individuals with chronic illness use naturopathic services – 75% of naturopathy patients have a chronic illness [16,20] and one in 10 Australians with a chronic illness consult with a naturopath (McIntyre, Steel and Harnett cited in [21]). A review of 235 peer-reviewed articles reporting the outcomes of naturopathic clinical research found treatment effectiveness across a wide range of systemic presentations including cancer, complex immune conditions, cardiovascular conditions, endocrine conditions, gastrointestinal conditions, skin conditions, musculoskeletal conditions, and reproductive issues, encompassing 81 different patient populations [22]. The capacity of practitioners to manage complex and chronic illness might be impacted if a systems perspective is not applied [9]; it is possible that only through engagement with the whole organism that chronic, multifactorial, and complex conditions might be adequately managed or resolved [23].

A systems mindset is a relational, temporal, and holistic perspective which is attuned to complexity and focuses on the connections within an entity and between the entity and other systems [24]. In the context of primary health care, it pertains to encountering each patient as a complex system composed of and functioning within a vast number of interacting, self-regulating systems [25]; the interdependent and interacting connections within this fluctuating context give rise to emergent properties [26] such as health and wellbeing status. Through applying a complexity informed research method, Graham et al., [27,28] identified that naturopathic practice was characterised by a holistic case management approach, with naturopathic practitioners appraising patients’ integrated physiology and environmental context. Naturopathic practice is aligned with complexity science principles and encompasses systems thinking according to their holistic paradigm [27,28], which may offer insights into strategies for responding to complexity within the clinical encounter. Within the literature, there is limited focus on how naturopathic practitioners understand and engage with clinical complexity. In this study, the perceptions of naturopathic practitioners regarding their approach to, and management of, the complexity inherent to the naturopathic clinical encounter and patient care are explored.

Clinical reasoning is a core component of all health care disciplines [29] and is a key element in assessment and treatment decision making [30]; informed by each system of medicine's philosophies, principles, and theories. Clinical reasoning is the cognitive and meta-cognitive processes [31] used to assimilate, retrieve, evaluate and discard information arising within the clinical encounter [32]. While the therapeutic relationship and the care, compassion and empathy underpinning this might be considered the heart and soul of clinical practice, clinical reasoning could be seen as the intellect and brain. “The goal of clinical reasoning of all healthcare professionals is to identify and articulate patients' health needs and to use specialised knowledge and skills to work out ways to help patients achieve optimal health”, [33]. Clinical reasoning is a multilayered and multicomponent skillset that supports clinicians to make difficult assessments and decisions despite the inherent uncertainty and complexity of health care provision [34]. The model of clinical reasoning used in biomedical practice is based on a technical rational model [33], however this approach is not necessarily preferred across different health professions and paradigms. While clinical reasoning is increasingly being studied in a range of healthcare professions including biomedicine, nursing and physiotherapy [35], within the scientific literature there has been limited consideration of reasoning in the context of clinical complexity, and of naturopathic clinical reasoning. This study explores naturopathic practitioners' understanding of their clinical reasoning and case management response to clinical complexity and uncertainty.

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