M.G. Guarinoni et al.
Ann Ig 2014; 26: 226-236 doi:10.7416/ai.2014.1981
226
Complexity of care: a concept analysis
M.G. Guarinoni*, P.C. Motta**, C. Petrucci*, L. Lancia*
Key words: Concept analysis, complexity of care, nursing, patient classification system
Parole chiave:Complessità assistenziale, analisi concettuale, infermieristica, sistema di classificazione dei pazienti
Abstract
Background: In spite of the high number of tools designed to measure the complexity of care, there is still
great diversity in the meaning of this concept.
Methods: The study was carried out using the concept analysis method as described by Beth Rodgers; 27
international papers were selected using PubMed, Web of Science and CINAHL data sets, without any time
constraints.
Results: A number of similar concepts relating to multiplicity, intensity of care and workload were selected.
The antecedents were classified according to personal and clinical features of patients, the characteristics
of care, the social and organizational features; the tools that emerged measure the risk of complexity of
care. Among the consequences, those that emerged were related to patients, operators and organization.
The two attributes of complexity of care are connected with measurement, on the one side, and uncertainly,
on the other.
Conclusions: As difficult as it is to define complexity of care, the analysis states that its classification should
be targeted at redefining hospital organization.
Background
Early attempts to classify patients by
complexity of care (Patient Classification
System) date back to the 1960s (1). The
study of care complexity measurement
methods still plays an important role in the
nursing discipline -more specifically, in its
organization.
A brief analysis of tools to measure care
complexity revealed that the many means
built for this purpose stem from the different
meanings attributed to this term and its
frequent use as a synonym for care intensity
or nursing workload.
Even though several attempts have been
made to define the differences among these
terms in order to obtain a unequivocal
meaning of care complexity (2-4), to date
this professional category does not seem to
have yet been assigned a single and clear
definition.
The aim of this work was to report an
analysis of the concept of complexity of
care.
In common parlance, ‘complexity’
refers to a being or an entity composed of
many elements that relate to and influence
one another. Consequently, it is usually
* Department of Health, Life and Environmental Sciences, University of L’Aquila, L’Aquila, Italy
** Department of Medical and Surgical Specialties, Radiological Science and Public Health, University of Brescia, Brescia,
Italy
Complexity of care
maintained that what is complex may not
be understood through an analytical and
reductionist approach. Indeed, contrary to
the claims of classical science, the whole
turns out to be radically different and/or
bigger than the mere sum of its parts (5).
Over the last decade, the study of complexity
has expanded remarkably, giving rise to what
is commonly defined as ‘complex systems
theory’, whereby a ‘complex system is an
open system, formed by several elements
that interact in a non-linear fashion and
constitute a single, organized and dynamic
entity, capable of evolving and adapting
to the environment’ (6). According to this
theory, complex systems are characterized
by 1) a large number of elements included
and 2) a large number of interconnections
between them, being non-linear, powerful,
and complex (e.g. the physiology of neurons
in the nervous system).
The term ‘care complexity’ has been
widely used in international healthcare
ever since attempts to define and quantify
the cost of disease and its treatment began.
In fact, it is quite clear that in order to
achieve an accurate economic assessment
of a hospital stay, it is necessary to
know the cost determinants and, more
specifically, the amount of resources the
patient has used during the hospitalization.
This is correlated with care complexity
(4, 7-10).
The term ‘care complexity’ has come
to be used quite frequently in the nursing
discipline as well, especially since the
recent past. The problem with defining
complexity of care in the nursing profession
arose halfway through the last century, when
the early tools for workload evaluation (the
New York method, John Hopkins method,
and Rhys Hearn method) were designed
to calculate the number of nursing staff
needed in each ward. Today, the purpose
of defining complexity of care is rather
wider than the above application. Several
Italian hospitals, for example, are currently
227
applying an organizational method based on
the complexity of care paradigm in which
patients are classified by means of different
measurement methods (11-14) within a
category defining the complexity level.
Accordingly, patients are no longer assigned
to wards based on the traditional medical
specialty rationale. This reorganization
effort is not merely targeted to human
resources optimization; rather, it pursues
the higher goal of providing better-quality
care.
As in Italy, tools for measuring
complexity of care (or those aimed at patient
classification) are increasing in number
internationally over time. This increase
leads to the question of why no single
method is in common use. Upon a close
examination of the issue, it becomes clear
that each of these tools varies according
to the definition of ‘complexity of care’.
Indeed, the term is often replaced by
‘intensity of care’, ‘intensity of treatment’,
‘workload’, ‘acute care’, etc. as though they
were synonyms.
Thus, the absence of a univocal meaning
attributed to the term ‘complexity of
care’ highlights the need for a conceptual
analysis to rigorously define its use and
clarify the concept.
Ordinary definitions of concepts are
found in the dictionary, but ordinary or
everyday concepts are not the same as
scientific concepts. Scientific concepts are a
different entity in that a degree of precision
is required in order for the conceptual label
to encompass a unit of meaning that is used
consistently within a scientific discipline
(15) so a concept analysis is necessary to
define the use into environment care.
Methods
The study was carried out using the
concept analysis method as described by
Beth Rodgers.
228
Evolutionary concept analysis according to
Beth Rodgers
Concept analysis is a technique used
to identify the attributes, properties, and
features of a subject; its purpose is to
increase the understanding of a concept
beyond the mere definition provided in a
dictionary (16) by means of an inductive
methodology.
Clarifying a concept is a necessary step
in developing useful knowledge and later
applying it to nursing science. Hence, many
authors recommend this type of analysis as
the first step in developing a theory that is
suitable to be used and tested (17, 18).
Nursing science has resorted to different
methods to analyse the concepts that are
most relevant for this discipline; the most
notable methods, among others, are Wilson,
1963 (19), Walker & Avant, 2005 (20), and
Rodgers 1989 (21).
Rodgers’ theory distances itself from
Walker & Avant’s, maintaining that concepts
are constantly developing and being
redefined. The meaning of a ‘concept’ is
strongly influenced by a number of factors
- both internal and external to the same
concept - which better define its meaning
and determine its continued development. A
concept is not a fixed, unchanging element
that is true per se, but rather something
strongly dependent on the context; it is in
its application that it changes and becomes
(21).
One of the strong points of Rodgers’
method is its systematic and clear approach
to its different phases (17).
The first phase consists of selecting
the subject of the analysis and collecting
the relevant material. This phase deserves
particular attention because the correct
selection of the sample guarantees the
completeness of the analysis (21).
The second phase is based on the actual
analysis. In this phase, every source is read,
first superficially and then with particular
M.G. Guarinoni et al.
focus on the following: the context of the
concept, similar terms (expressing the
concept idea with a different wording),
correlated terms (words that share common
features with the concept but do not show
exactly the same characteristics), antecedents
(events or phenomena that correlate as
antecedents to the concept), examples
(practical cases taken from hard data, which
are not found in all conceptual analyses),
consequences (the result of using a concept
in a practical situation), and attributes
(groups of features which constitute the true
definition of a concept). In Rodgers’ theory,
attributes constitute the heart of conceptual
analysis.
The product of each study is noted
separately at first and later compared,
highlighting similar and correlated traits,
antecedents, attributes, examples, and
consequences.
The data are considered saturated the
moment findings begin to repeat and
the subsequent data do yield no further
content.
In the last phase, the author provides
insights for developing questions and
hypotheses in light of subsequent studies.
Indeed, Rodgers believes that there is no
such thing as a final definition of a concept;
rather, it is precisely the purpose of every
study to stir interest in the direction of the
concept development process and to promote
the development of knowledge in the nursing
profession.
Research was carried out on the concept
of ‘complexity of care’ (‘complexity of care’,
‘care complexity’, and ‘nursing complexity’)
using PubMed, Web of Science, and
CINAHL, which were deemed to be sources
important to healthcare research and, more
specifically, the discipline of nursing.
This search produced a sample of 27
papers, to which two Italian book chapters
relating to ‘complexity of care’ measurement
tools were added. The material was chosen
after a quick scan of a larger number of
Complexity of care
articles, from which a sample was selected
based on the frequency (in numeric terms)
of appearance of the concept subject. We
stopped scanning the papers when similar and
correlated terms, antecedents, attributes, and
consequences started repeating themselves
quite frequently.
Even though our search was not limited
in terms of specific dates of publication, the
date of publication of the examined material
ranges from 1997 to 2012.
Results
Similar Concepts And Correlated Terms
Similar concepts are phrases used to
describe the concept of complexity of care
in other terms. In our review, we highlighted
similar concepts that referenced the idea of
multiplicity: diversity of care, co-morbidity
and multi-problematic status, case-mix,
and density of care. Other similar concepts
detected were severity, workload, and
intensity of care (Table 1).
229
Correlated terms are words or phrases
with something in common with the principle
of complexity of care and are found to be
associated with it, though they do not share
the same features. Terms referring to the
ideas of ‘difficult’ and ‘complex’ (complex
care, advanced operator competencies,
commitment, and treatment difficulty)
are often used in combination with the
complexity of care principle.
Length of stay (LOS) - which in turn
correlates with several variables - is in
many cases reported as the only indicator of
complexity, so much so that it is used as a
synonym for it. In other words, complexity
is considered to be determined exclusively
by the number of days the patient spends in
the hospital.
Antecedents
We identified antecedents that may be
grouped as follows (Table 2).
Patients’ personal characteristics:
personal demographic data, age (advanced
age appears in a remarkable number of
Table 1 - Similar concepts and correlated terms within the «complexity of care» concept
Similar or correlated concepts
References
Correlated terms referring to
Complex care, advanced operator O’Brien-Pallas 1997 (9), Hansen 2001 (22),
difficulty
competences, commitment, treatment de Jonge 2001 (A )(23), de Jonge 2001 (B)
difficulty
(24), de Jonge 2006 (25), Moiset 2009 (13),
Cologna 2010 (2), Lancia 2011 (3), Galimberti 2012 (26)
Similar concepts referring to
Diversity of care, co-morbidity and Goossen 1999 (8), de Jonge 2006 (25),
multiplicity
multi-problematic status, case-mix
Cavaliere 2006 (11), Welton 2006 (10),
Molleman 2008 (27), Moiset 2009 (13),
Galimberti 2012 (26)
LOS
LOS
Hansen 2001 (22), de Jonge 2001 (A) (23),
Kruizenga 2005 (28)
Care intensity/density
Care intensity/density
Hansen 2001 (22), de Jonge 2006 (25), Welton 2006 (10), Lobo 2007 (29), Moiset 2009
(13), Cologna 2010 (2), Bollini 2011 (14),
Lancia 2011 (3), Galimberti 2012 (26)
Workload
Workload
O’Brien-Pallas 1997 (9), Goossen 1999 (8),
Meloni Rosa 2006 (30), Moiset 2009
230
M.G. Guarinoni et al.
Table 2 - Antecedents of the «complexity of care» principle
Antecedents
References
Patients’ personal charac- Personal demographic data, age, lifestyle, Goossen 1999 (8), Molleman, 2008 (27),
teristics
personal ability and knowledge when it Bollini 2011 (14), de Jonge 2001 (B) (24),
comes to making independent choices
Pagliusco 2006 (31), Silvestro 2009 (12),
Lessard 2007 (32)
Clinical features
Medical diagnosis, diagnostic/therapeutic/ Goossen 1999(8), Hansen 2001 (22), de
care uncertainty, chronic status, physical Jonge 2001 (A) (23), de Jonge 2001 (B) (24),
function/disability, cognitive function, Kruizenga 2005 (28), Sieben-Hein 2005
malnutrition, illness severity, symptom (37), de Jonge 2006 (25), Cavaliere 2006
severity, diagnostic instability, complica- (11), Meloni Rosa 2006 (30), Pagliusco
tions, multiple-pathology picture, geriatric 2006 (31), Lobo 2007 (29), Koroukian 2007
syndromes, ICU/emergency hospitaliza- (33), Molleman 2008 (27), Silvestro 2009
tion, criticality
(12), van Langerberg 2010 (34), Hoogerduijn 2010 (35), Cologna 2010 (2), Bollini
2011 (14)
Characteristics of care
Diagnosis, interventions, nursing out- Goossen 1999 (8), Huyse 2001 (36), Kruicomes, single nursing activities intensity zenga 2005 (28), Sieben-Hein 2005 (37),
of care, commitment residence in nursing de Jonge 2006 (25), Cavaliere 2006 (11),
homes prior to hospitalization, or the provi- Koroukian 2007 (33), Moiset 2009 (13),
sion of residential services by the relevant Cologna 2010 (2), Bollini 2011 (14)
healthcare providers.
Social features
Social dysfunction, residential instability, Kruizenga 2005 (28), Benedict 2006 (7),
presence/absence of a support network or Pagliusco 2006 (31), Molleman 2008 (27),
care givers; but also socio cultural context Silvestro 2009 (12), Bollini 2011 (14)
in the living conditions, as well as the technology development progress and status
Organizational features
Healthcare setting and staff, need for care Goossen 1999 (8), Kruizenga 2005 (28),
coordination, level of technology, health- Welton 2006 (10), Pagliusco 2006 (31),
care service offering, average case-mix
Lobo 2008 (38), van Langenberg 2010
(34)
Tools for complexity of NMDSN, INTERMED, COMPRI
Goossen 1999 (8), Huyse 2001 (36), Kruicare risk measurement
zenga 2005 (28), Lobo 2008 (38)
papers), lifestyle, personal ability, and
knowledge regarding making independent
choices.
Clinical features: medical diagnosis,
diagnostic/therapeutic/care uncertainty,
chronic status, physical function/disability,
cognitive function, malnutrition, illness
severity, symptom severity, diagnostic
instability, complications, comorbidities,
geriatric syndromes, ICU/emergency
hospitalization, and criticality.
Characteristics of care: the need for
nursing care in terms of both quantity
and quality. Quantity includes diagnoses,
interventions, nursing outcomes, and single
nursing activities such as family support. It
also includes the intensity of care, commitment
to care, and expertise. Residence in nursing
homes prior to hospitalization and the
provision of residential services by relevant
healthcare providers are also frequently
mentioned antecedent characteristics.
Social features: elements associated
with the individual’s social status, including
social dysfunction, residential instability,
and the presence or absence of a support
Complexity of care
231
network or caregivers. This also includes
the sociocultural context of living conditions
as well as the progress and status of
technological development; it is quite
evident that technological advances cannot
but affect the complexity of care.
Organizational features: healthcare
setting and staff, need for care coordination,
level of technology, healthcare service
offering, and average case-mix.
Tools for complexity of care risk
measurement: NMDSN (Nursing Minimum
Data Set) (8), INTERMED (39), COMPRI
(Complexity Prediction Instrument) (36).
Attributes
The attributes that emerged from our
study may be essentially divided into two
groups: the first pertains to classification
variables such as measurement, objectivity,
predictability, and classification itself and the
second comprises the opposite, addressing
elements of change, including instability,
variability, uncertainty, subjectivity, and
perception (Table 3).
If complexity of care is, on the one hand,
objectively measurable and classifiable
(collecting variable data and, from them,
deriving a quantity that allows placement
of the individual in a group of subjects
sharing similar data values), on the other it
is something extremely variable, involving
continuous personal instability; hence, it is
extremely difficult to reliably quantify. In
this case, subjectivity and perception make
assigning a person to a stable class a difficult
exercise.
These two groups of attributes express
two antithetical characteristics within the
same concept and, consequently, complicate
its definition.
Consequences
Consequences are the result of
using a concept in a practical setting
(17). Consequences, like antecedents and
attributes, may also be divided into broad
groups (Table 4).
Patient-related: needs that derive from the
complexity of care, more specifically after
discharge; these may be medical, nursing
(physical, educational, relational), therapeutic,
or diagnostic. This also includes reduced
quality of life deriving from complexity of care
as well as Activities of Daily Living (ADL)
constraints, multi-dimension vulnerability,
anxiety, behavioural problems, requests for
care, and actual LOS.
Operator-related: conflict within
the medical team and with the patient,
Table 3 - Attributes of the «complexity of care» concept
Measurement-related
Uncertainty-related
Attributes
Measurement, objectivity,
predictability, classification
Instability, variability,
ncertainty, subjectivity,
perception.
References
Goossen 1999 (8), Hansen 2001 (22), de Jonge 2001 (A)
(23), Huyse 2001 (36), de Jonge 2001 (B) (24), LacourGayet 2004 (40), Kruizenga 2005 (28), de Jonge 2006
(25), Cavaliere 2006 (11), Pagliusco 2006 (31), Lobo
2007 (29), Lobo 2008 (38), Moiset 2009 (13), Cucolo
2010 (41), van Langerberg 2010 (34), Hoogerduijn 2010
(35), Cologna 2010 (2), Bollini 2011 (14), Galimberti
2012 (26)
De Jonge 2001 (A) (23), Huyse 2001 (36), Lacour-Gayet
2004 (40), Kruizenga 2005 (28), Sieben-Hein 2005 (37),
Lessard 2007 (32), Molleman 2008 (27), Galimberti 2012
(26)
M.G. Guarinoni et al.
232
Table 4 - Consequences of the «complexity of care» principle
Consequences
Medical, nursing (physical, educational, relational), therapeutic, and diagnostic, ADL
constraints, multi-dimension vulnerability,
anxiety, behavioural problems, requests for
care, actual hospital stay time (LOS)
Operator related
Conflict within the team and with the patient, complicated relations, burnout, and
communication barriers
Organization related Costs, resource allocation, benchmarking,
nursing workload, quality of care, multidisciplinary management, collaborations
and consulting, specific competences, care
planning, care timing, option of assigning
support staff some care activities, MAP,
PCS, LOS
Patient related
complicated relationships, burnout, and
communication barriers. When in the
presence of patients with high complexity of
care, operators tend to experience difficulties
in relation to increased demands for
teamwork, making the job more challenging
and demanding (37). Furthermore, patients
are often in a state of anxiety, which in turn
makes communication more difficult.
Organization-related: in most of the
literature we reviewed, these generally
included costs, resource allocation, and
benchmarking possibilities. Indeed,
complexity of care dictates a higher or
lower demand for resources both generally,
in economic terms, and specifically, in terms
of staff allocation. Moreover, complexity
is directly correlated with the nursing
workload, the variables that determine it,
and the quality of care, in addition to the
need for multi-disciplinary management
including collaboration and consulting.
Therefore, related competencies must be
increasingly specific: care planning, care
References
Goossen 1999 (8), Hansen 2001 (22), de Jonge
2001 (B) (24), Kruizenga 2005 (28), Pagliusco
2006 (31), Hoogerduijn 2010 (35), Galimberti
2012 (26)
de Jonge 2001 (B) (24), Sieben-Hein 2005
(37), Lessard 2007 (32), Molleman 2008 (27),
Moiset 2009 (13)
Goossen 1999(8), Hansen 2001 (22), de Jonge
2001 (A) (23), Huyse 2001 (36), de Jonge 2001
(B) (24), Kruizenga 2005 (28), Sieben-Hein
2005 (37), Meloni Rosa 2006 (30), Cavaliere
2006 (11), Welton 2006 (10), Benedict 2006
(7), Pagliusco 2006 (31), Lessard 2007 (32),
Lobo 2007 (29), Molleman 2008 (27), Lobo
2008 (38), Silvestro 2009 (12), Cucolo 2010
(41), van Langerberg 2010 (34), Chapman
2010 (42), Cologna 2010 (2), Lancia 2011 (3),
Galimberti 2012 (26)
timing, and the option to assign some care
activities to support staff according to the
Professionalizing Care Model (MAP). The
Patient Classification System (PCS) is one
of the consequences and, normally, one of
the aims of measuring complexity of care,
though another consequence is also the
uncertainty that derives from complexity of
care. Hence, given the intrinsic variability
of complexity (as previously described in
the Attributes), measurement must be ongoing. Among the consequences, LOS may
be considered an objective variable, which
is why it is listed among the antecedents
for determining complexity and not the
consequences.
Conclusion
The results of this study seem to confirm
the variability of the definitions of ‘complexity
of care’ currently found in the literature.
Therefore, it is reasonable to attribute this
Complexity of care
variability to the variability associated with the
methods of measurement and consequently,
their application. According to Rodgers’
evolutionary concept analysis method, the
meaning of a concept varies depending on
the context and the culture in which it has
developed and is located. Hence, this study
should have identified different meanings for
different disciplines. It is interesting to note
that this distinction did not surface in this
study. The identity of meaning across the
different disciplines ought to trace back to
the fact that the concept is multi-disciplinary
per se; as such, it should be linguistically
shared among the different professions that
regularly use similar terms. Complexity
itself, one could say, is a complex concept
given its scope of application to varied and
diverse areas of knowledge and conceptual
variability. Indeed, if complexity is defined
by a number of elements interconnecting
in a non-linear fashion, such a non-linear
quality emerges precisely in some of the
elements included in Rodgers’ analysis. As
proof of this principle, this study sheds light
on some terms that are used differently in
the analysed papers in the form of ‘similar
terms’, ‘attributes’, ‘antecedents’, or again,
‘consequences’. In any case, if ‘complexity
should be defined clearly, it would be evident
that the term would no longer be complex’, as
E. Morin quite pertinently noted (1993) (5).
Consider the LOS parameter: when used as
the sole indicator it appears as a synonym for
complexity of care, but it is also a measurable
attribute (22, 23) and a consequence (24, 25,
28, 29, 34, 38).
Among the similar concepts (words used
as an alternative to the term ‘complexity
of care’), there is an issue relating to the
complexity/intensity (10, 14, 22, 38) of the
terms. From a semantic standpoint, the term
‘complexity’ refers to not only a quantitative
but also a qualitative principle while the term
‘intensity’ has a strictly quantitative meaning.
In truth, the literature review shows that there
is not always a clear distinction; the terms are
233
often used to express the same idea within the
concept. This implies an idea relating to the
complexity concept in the form of something
that may be measured in simplistically
quantitative terms, exactly like intensity.
Regarding issues used for reference to
determine complexity of care, it is interesting
to note that for some authors, these derive
exclusively from the individual and his/her
general and clinical characteristics (23, 29,
37). For others, ‘external’ factors are more
important, such as those relating to the
context and the organizational choices (10).
Further, others believe that all the above
mentioned personal, clinical, social, and
organizational factors interact to determine
complexity of care (2, 12, 13, 28).
The attributes of complexity of care
(the features that form the definition of the
concept) show a very specific antithesis:
while complexity cannot be quantified
and reduced to an objective value, there is
measurability and, most importantly, the
possibility of classifying complexity of care
(18 out of 29 studies attribute objective terms
to complexity of care). The idea of classifying
complexity is all the more interesting
given its implications for organizational
challenge and the opportunity for improved
resource allocation, the tasks operators
must complete in a complex setting, and the
possibility of proper management. It should
be remembered, for these purposes, that
complexity of care is often connected with
organization, both in terms of antecedents
and consequences (Fig 1).
Through conceptual analysis, we confirm
the variability in the definition of ‘complexity
of care’ as presented in the literature. In this
situation, the main use of ‘complexity’ as
applied to healthcare seems to refer to the
quantitative measurement of contextual
elements (in which care operates) as well
as organizational variables: the analysis of
complexity as a tool targeted at improving
the economics and management of the
care process. Although our results confirm
234
M.G. Guarinoni et al.
Figure 1.
the importance of this application, they
also support the idea that the concept of
complexity should be used and developed
in other ways. Specifically, in its ability to
encapsulate the qualitative and non-linear
characteristics of phenomena, complexity
should first focus on the subjects of care
and their classification as a necessary and
logically antecedent passage of the strategic
definition of hospital reorganization tools.
This ‘complexity of the subjects of care’
should then precede any ‘organizational
complexity’.
Riassunto
La complessità assistenziale: un’analisi concettuale
Background: Sebbene in ambito sanitario e nella
disciplina infermieristica in particolare il termine di
complessità assistenziale sia utilizzato sin dalla metà
del secolo scorso e sebbene siano ormai molteplici gli
strumenti per la sua misurazione, si evidenzia una eterogeneità nel significato del concetto stesso che spesso
viene sostituito con termini che in realtà non sono propriamente sinonimi.
Metodi: È stata condotta una ricerca utilizzando
le banche dati PubMed, Web of Science e CINAHL,
senza alcun limite di tempo. Sono derivati 27 articoli
internazionali ai quali si sono aggiunti due capitoli di
testi italiani. Tutto il materiale è risultato temporalmente
compreso tra il 1997 e il 2012.
Risultati: Si sono evidenziati in particolare concetti
simili che richiamano la molteplicità, l’intensità assistenziale e il carico di lavoro. Gli antecedenti sono stati
classificati in base alle caratteristiche personali e cliniche
dei pazienti, alle caratteristiche assistenziali, a quelle
sociali e dell’organizzazione e sono emersi strumenti
che misurano il rischio di complessità assistenziale. Tra
le conseguenze sono emerse quelle legate al paziente,
agli operatori e all’organizzazione. I due attributi della
complessità assistenziale risultano essere connessi alla
misurazione da un lato e all’incertezza dall’altro.
Conclusioni: Pur nella difficoltà di una definizione di
complessità assistenziale l’analisi indica che la sua clas-
Complexity of care
235
sificazione dovrebbe trovare finalità nella ridefinizione
dell’organizzazione ospedaliera.
13.
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Corresponding author: Dott. Cristina Petrucci, Nursing Science University of L’Aquila, Department of Health, Life
and Environmental Sciences, Edificio Delta 6, Via San Salvatore, 67100 Coppito (L’Aquila) Italy
e-mail: [email protected]