Healthcare systems in the Netherlands and other Western countries are under increasing strain due to growing demand for care and a shrinking workforce. A critical challenge is understanding why nurses choose to remain in the profession, particularly in high-pressure settings such as hospital emergency departments. This thesis investigates how a systems science approach can contribute to understanding nurses’ workload and their intention to stay in the profession, using a case study of the Emergency Department at Erasmus MC.

Drawing on System Dynamics modeling and participatory Group Model Building with nurses, the study explores the complex relationships among perceived workload, job satisfaction, stress, and team dynamics. The research combines literature review, participatory modeling sessions, and simulation using Exploratory Modeling and Analysis to identify the conditions under which nurses are most likely to remain in the profession.

Findings show that perceived workload has a stronger influence on the intention to stay than objective measures such as patient-to-nurse ratios. A key insight is the concept of “shift balance,” which captures whether nurses experience more positive than negative shifts over time. This metric proved more meaningful than traditional workload indicators. The study also highlights the importance of eustress, a motivating form of stress, and the need to distinguish it from other stress types.

By applying systems science tools to a complex workforce issue, the thesis offers practical guidance for designing interventions that support nurses' long-term commitment to their profession. It has deepened the understanding of stress and workload dynamics around the nurses' intention to stay in the profession.

The Netherlands faces significant capacity challenges in healthcare due to staff shortages. Many healthcare positions remain unfilled, despite rising demand for medical services. This also impacts the Emergency Department (ED), as higher patient volumes lead to longer wait times and increased responsibilities for emergency physicians. The combination of these variables leads to an increase in personnel turnover, putting additional strain on capacity. These capacity difficulties may also be seen in Deventer Hospital's ED, highlighting the significance of effectively organising patient flows and addressing system dynamics.

Although Deventer Hospital has conducted analyses to improve capacity management, current approaches, both locally and in the broader literature, primarily focus on technical aspects, such as staffing planning within the ED. However, by focusing solely on technical factors, such analyses may fail to account for social factors that influence system performance, such as human behaviour, communication patterns, decision-making processes, and institutional constraints. To bridge this gap, this study adopts a socio-technical systems approach that incorporates both technical and social factors of capacity management in the ED.

The main question is:
How can Emergency Department capacity challenges be improved using a social-technical approach?

To answer this question, the current system at Deventer Hospital's ED was examined through a socio-technical systems framework. The IDEF0 model was used to map both the technical and social factors influencing capacity management. This model systematically represents workflow processes, resource dependencies, regulatory constraints, and the stakeholders involved. The system mapping was informed by multi-day observations, open interviews with ED physicians, document analysis, and a stakeholder analysis. The stakeholder analysis provided deeper insights into communication patterns, knowledge distribution, and power-interest relationships among the actors. Together, these methods resulted in a comprehensive and structured representation of the ED.

The system analysis revealed that ED capacity challenges involve both technical and social dynamics. These were categorized across three phases: inflow, throughput, and outflow. Specific issues included variability in triage processes, workforce shortages, delays in diagnostics, and asymmetric information exchange between departments. Furthermore, ED physicians noted that a proportion of patients could potentially have been treated elsewhere, affecting resource allocation and patient flow.

Based on these insights, potential interventions were developed to optimize patient redirection within the socio-technical landscape. A snapshot analysis estimated the proportion of patients who, according to ED physicians, could have been treated in alternative settings, such as by general practitioners or outpatient clinics. This analysis was complemented by interviews with ambulance personnel, GPs, and medical specialists, which provided deeper insight into barriers and opportunities for patient redistribution.

The findings indicate that while technical opportunities exist, particularly in redirecting patients to urgent outpatient clinics, success is dependent on effective capacity planning and accessibility in alternative care settings. Social factors play an equally critical role. Efficient patient diversion requires a robust communication framework among general practitioners, ambulance services, and specialists. In practice, however, such communication is not always optimal.

Additionally, a growing claims culture increasingly influences referral behavior. Concerns regarding legal liability and potential complaints compel healthcare providers to refer patients to the ED more frequently as a precaution, even when alternative care options could be more appropriate. This defensive referral behavior exacerbates ED workload and reflects a broader trend of risk aversion in healthcare decision-making.

To address these issues, both technical and social interventions are proposed. Technically, expanding urgent outpatient clinic capacity could offer potential, provided that accessibility and appointment scheduling are carefully managed. Socially, interventions such as structured feedback systems between EDs and referring providers, enhanced real-time communication channels, and targeted legal literacy training for healthcare professionals could reduce unnecessary referrals.

In conclusion, the socio-technical system analysis provided a more comprehensive understanding of ED capacity management by considering both technical and social dimensions. This approach revealed important dynamics that a purely technical analysis might have overlooked, such as communication gaps, coordination barriers, and organizational constraints. It led to the development of potential interventions that not only address logistical aspects of patient redirection but also promote social structural improvements within the healthcare system. By targeting both technical workflows and social coordination mechanisms, this socio-technical approach offers a more realistic pathway to optimizing Emergency Department capacity.

The aim of this research is to gain an understanding of the balance between guideline standardisation and professional autonomy. This includes its impact on the safety and quality of healthcare. These are crucial aspects of providing good care as they can contribute to an overall healthcare system that is effective, reliable, and patient-centered. The reason for performing this research is the difficulty of finding a balance between guideline standardisation and professional autonomy. While guideline standardisation is crucial to ensure a structured approach to uniform care of high quality, professional autonomy is necessary to individualise this care for each patient. At times, the tension between these aspects arises as medical practitioners feel limited in their professional autonomy, but healthcare organisations require a structural set-up of healthcare systems to provide equal care.

By performing interviews with guideline developers, doctors, and patients, this tension and possible contributing factors were explored through a technical, human, and organisational perspective. The identification of a need for the inclusion of the psychosocial elements, research regarding sensitivity around professional autonomy, and structural changes is beneficial to get to a point where it is possible to identify a balance between guideline standardisation and professional autonomy and its impact on the safety and quality of care. While multiple points for further research are indicated in this study, these three factors contribute to improving the situation of both the tension itself and the discussions around it.

Standardisation plays a crucial role in driving long-term productivity, competitive growth, and innovation in various industries. Its primary objective is to streamline processes by establishing consensus among different stakeholders, such as firms, users, academia and governments. Standards provide classifications such as quality, compatibility, safety, or measurements to ensure that products and procedures meet specific requirements and can be reliably used across different domains. In spite of the importance of standardisation, there is a lot to learn about the factors that influence standard success. As of now, literature in this field is mostly exploratory in nature. This study investigates the factors influencing the success of standardisation efforts, in particular, it examines the impact of technological diversity and geographical diversity within standard setting organisations (SSOs) or standards consortia on achieving standard success. Additionally, the study explores the role of the size of these SSOs or standards consortia in influencing the likelihood of standard success. Next to that, the influence of the definition of standard success is also examined, by providing three different theoretical definitions for standard success. This study adds on to the literature by providing larger scale qualitative research in an attempt to better understand the dynamics of standard success. In this study an original dataset was created of standards consortia in the context of Renewable Energy (RE) and Sustainability, Efficiency, and Green Initiatives (SEG). The chosen context is significant for addressing the global climate problem, a complex and multifaceted wicked problem that requires collaborative efforts. Therefore, the understanding of which factors influence the success of standards is essential to tackle climate change's adverse impacts. Standards are important in providing universal guidelines, products and protocols that are needed to combat climate change. The results indicate the presence of a U-shaped relationship between technological diversity and standards success, this result has not yet been found earlier and implies that instead of an optimum range of diversity, managers should to be at either extreme end of the technological diversity spectrum. Moreover, we observe a positive relationship between consortium size and standard success, meaning that whenever possible, managers should aim to increase consortium size. This study provides a better understanding of how the characteristics of standards consortia influence standard success which can also aid managers in making well-educated choices when setting up standards consortia.

The first registered infection with the COVID-19 virus occurred in China at the end of 2019. The virus spread all over the world, turning a single infection into a pandemic. Most countries implemented policies to limit the spread of the virus. In general, these policies can be divided into pharmaceutical and non-pharmaceutical interventions. Vaccines are pharmaceutical interventions. Examples of nonpharmaceutical interventions are temporary closure of restaurants and bars or a limit to the number of people that are allowed to gather for social events. Although, these non-pharmaceutical interventions were effective in slowing down the spread of the COVID-19 virus, they also severely affected people’s social and economic life. For example, freelancers who worked in restaurants and bars lost their income and students experienced a decrease in mental health due to the lack of social engagement. These societal impacts of COVID-19 policy gradually reduced the public support and adherence to these COVID-19 measures over the course of different pandemic waves. Measuring how people weigh the societal impacts of COVID-19 policy during these waves, provides interesting insights that can improve the effectiveness of pandemic policies for a future pandemic. A way to measure how people weigh the societal impacts of COVID-19 policy during different waves of the pandemic is by conducting Discrete Choice Experiments (DCE). These DCEs are often analyzed with Multinomial Logit (MNL) models. The MNL model is able to quantify the relative importance of different societal impacts for the population as a whole. However, there also exist other models, such as the Mixed Logit (ML) model and Latent Class (LC) model, and different types of DCEs, such as the labeled and unlabeled DCE, that have their own advantages and disadvantages in eliciting the relative importance of societal
impacts during different phases of the pandemic. For instance, ML models are able to elicit how preference heterogeneity is distributed among individuals and the LC model is able to divide people into different classes with their own preferences. Also, the labeled DCE is able to measure how people weigh societal impacts when the COVID-19 measures that cause these impacts are explicitly mentioned. Unlabeled DCEs do not explicitly mention these measures, but only weigh the societal impacts.
Over the course of the end of 2022 and the beginning of 2023, the pandemic transitioned into an endemic. Therefore, this study will not only evaluate the advantages and disadvantages of using these models and DCEs during the pandemic, but also during the endemic, by asking the following question: What are the (dis)-advantages of using ML and LC models over MNL models to analyze (un)-labeled DCEs that weigh societal impacts of COVID-19 policy during the pandemic and endemic? The eventual goal of this study is to find out where the added value lies of ML and LC models compared to MNL models and labeled compared to unlabeled DCEs in informing future pandemic policy makers during different pandemic waves and the endemic. To answer the main research question, this study formulated three subresearch questions. The first subresearch question is defined as follows: What are the differences in using ML, LC and MNL models to analyze (un)-labeled DCEs that weigh societal impacts of COVID-19 policy during the pandemic according to the literature? To answer this question, the study conducted a literature review on the results obtained from labeled and unlabeled DCEs with MNL, ML and LC models in different waves of the pandemic. In the second part of the study, the following subresearch question is addressed: What are the differences between the results produced by ML, LC and MNL models obtained from (un)-labeled DCEs that weigh societal impacts of COVID-19 policy during the endemic? This question is answered by conducting a labeled and unlabeled Discrete Choice Experiment during the endemic. The third and last sub research question asks: What are the (dis)-advantages of using ML, LC and MNL models to analyze (un)-labeled DCEs that weigh societal impacts of COVID-19 policy during the pandemic and endemic according to experts? To answer this question, three expert interviews were conducted.
The results of this study show that the main advantage of the ML model is its ability to test for the existence of preference heterogeneity among individuals in a sample. This can help to check the reliability of the estimates produced by the MNL model. The reason for this is that the existence of preference heterogeneity means that the estimates of the MNL model do not adequately represent the majority of the sample, if the heterogeneity is high. Additionally, the existence of preference heterogeneity is a reason for further research into the origins of this heterogeneity. In this case, the LC model is able to estimate different classes with different preferences and characteristics that represent different subgroups in society. Providing such a classification is the main advantage of the LC model. The main disadvantage of the ML model is that it is time consuming to estimate the model.
For the LC model the main disadvantage is its sensitivity to changes in covariates and initial values. With regards to the DCEs, the study shows that the main advantage of the labeled DCE is its ability to measure the effect of COVID-19 measures on how respondents weigh societal impacts. For the unlabeled DCE, the main advantage is its ability to measure how people view different societal impacts without explicitly mentioning the COVID-19 measures that caused these impacts. With regards to the added value of DCEs for informing future pandemic policy in different waves of a pandemic and in an endemic, the study shows that unlabeled DCEs are most suitable to give a baseline estimation of the preference for societal impacts at the beginning of a pandemic. So that, these insights can be taken into consideration when the first pandemic policy package is created. Further, the study shows that labeled DCEs should be applied during and in between pandemic waves to evaluate and adjust implemented pandemic policy. Finally, a labeled DCE can be implemented during the endemic, that follows the pandemic, to evaluate the impact of COVID-19 measures. The insights obtained from this can help to inform a future pandemic. With regards to the added value of the ML and LC model in informing future pandemic policy in different waves of the pandemic and the endemic, the study shows that the ML model can be used to test the reliability of the mean coefficients of important societal impact attributes. This helps to verify if a specific societal impact attribute is a good target for mitigation with generic pandemic policy during pandemic waves. In between pandemic waves, the LC model can be used to elicit the origin of preference heterogeneity among people in the sample for different societal impact attributes. These insights can be used to create customized pandemic policy with increased public support and adherence for when a next pandemic wave hits.
The most important limitation of this research is the lack of unlabeled DCEs from both the pandemic and endemic and the lack of labeled DCEs from the endemic that are included in the literature review. A drawback of the included DCEs is that these experiments do not include exactly the same societal impact attributes and that these experiments are conducted during different waves of the pandemic in different countries. These factors make it difficult to compare the results of the studies. Also, this thesis recommends that future studies conduct further research on the societal impacts of COVID-19 measures with models that are extensions of the models that are used in this study, such as the logit or probit model and the LC model with distributed preference coefficients. Furthermore, it would be valuable to analyze the societal impacts of COVID-19 measures with models outside the domain of choice modeling, such as data driven models. Furthermore, this study emphasizes that a lot of research can be done into how and by whom the insights of this research should be implemented in the pandemic policy decision making process. For instance, questions for future research could be, should the insights of this study function as advice for the creation of pandemic policy or as directive? And does the government or the National Institute of Public Health decide upon this?

The Netherlands is experiencing a significant increase in its aging population. Multi morbidity and a rapidly growing shortage of healthcare personnel are putting pressure on the healthcare system, leading to capacity issues. The capacity problems of care have medical, safety, social, and economic consequences. Policy measures are needed to address these challenges and improve the transfer care system. Therefore, the research question is: On which factors should policy interventions by the Ministry of Health, Welfare, and Sport be aimed, to improve the performance of the Dutch transfer care system? This study uses qualitative System Dynamics (SD), a method that uses causal loop diagrams, to analyze the relationships between factors that influence the transfer care system performance, such as the demographic changes and workforce shortage. The goal is to find strategies and solutions for a sustainable healthcare system. A visual SD model is used to highlight the complexity of the transfer care system and to reveal inter dependencies, interactions, and feedback loops, aiming to understand system dynamics. A literature review, multiple interviews and case studies have revealed factors and interactions that are modeled in a causal loop diagram. This qualitative System Dynamics analysis revealed both unidirectional (+ or -) and different polarity (+/-) interactions/feedback loops between/among the indicators, which implicates that certain policy interventions (mentioned in Dutch policy notes and other publications) may not achieve the intended results. Based on the interactions found, the Ministry of Health, Welfare and Sport can start using a bundle of interventions aiming on reducing workload/number of admissions and simultaneously keeping availability of aftercare constant. Additionally, the Ministry can improve other indicators, when keeping workload constant. However, to determine how many additional interventions are needed to keep workload and availability aftercare constant and to determine the net total effect of interactions with different polarities, quantitative System Dynamics is needed. In addition, quantitative System Dynamics is needed to be able to prioritize policy interventions, because qualitative System Dynamics is not able to determine the net effect of feedback loops. However, this qualitative System Dynamics study provides a solid foundation with which researchers (and the Ministry of Health, Welfare and Sport) can proceed to construct a quantitative model.

A pressure ulcer (PU) is defined as localised damage to the skin and/or underlying tissue, as a result of pressure or pressure in combination with shear. Despite the fact that pressure ulcers have received a lot of attention recently in hospitals and long-term care homes, they still form a major issue. The ErasmusMC is one of the hospitals with concerns regarding pressure ulcerations. Currently, there is a need to know why the implementation of measures for the improvement of preventing pressure ulcers resulted in disappointing results within the hospital. Within a literature review, it was found that the concept of systems thinking and the application of this concept is lacking in the selected studies. Therefore, the research question of this thesis was: Why are the current measures for the prevention of pressure ulcers not working as expected and intended within the ErasmusMC hospital?

A case study approach with a single-case (holistic) design was chosen. From the concept of systems thinking (the dynamic interaction, synchronisation, and integration of people, processes, and technology), the multi-level perspective of Geels was applied to this case study. With the use of the six common sources of Yin, 22 recorded and summarised semi-structured interviews, 4 informal interviews, several observational moments whilst accompanying operational staff or participating in meetings, and countless informal conversations were collected. Furthermore, PowerPoint presentations, documents, and dashboard results of the ‘prevalentiemeting’ within the ErasmusMC were collected.

When applying the dynamic multi-level perspective on system innovations to the situation of preventing pressure ulcers within the ErasmusMC, it was found that the landscape developments represented the urgency of the policymakers of the hospital to lower the occurrence of pressure ulcers, the technological niches were the measures (or system innovations) created for preventing pressure ulcers, and the socio-technical regime could be described as the socio-technical system for preventing pressure ulcers within the ErasmusMC. Combining the hypothesis of the multi-level perspective and the findings of the theoretical reasons within the literature review, it was stated that a nested hierarchy (where regimes are embedded within landscapes and niches within regimes) was missing. The analysis of the collected data resulted in the practical socio-technical system of preventing pressure ulcer within the ErasmusMC, where the 10 system elements were filled in with overarching themes found within the qualitative data. Next to this, it was found that the system elements of the socio-technical were interconnected and these interconnections could be interpreted as the key leverage points for building resilience within the practical system. The key leverage points found within the interconnections of the practical socio-technical system for preventing pressure ulcers within the ErasmusMC are the following: communication, implementation, opinions of prevention measures, policy steps, doubts about measures, and responsibility.

By using the mutli-level perspective theory of Geels and applying it to a healthcare setting, this thesis showed why the current measures for preventing pressure ulcers are not working as expected and intended within the ErasmusMC. This research made a contribution to the generic actor-related patterns found within the dynamic multi-level perspective on system innovations by introducing the information related patterns. It is shown that this new pattern can be described by the crucial role of information and the flow of information within an organisation for the accelerations and slowing down in diffusion and breakthrough of new technologies.