Hot off the press is our recent endeavor to apply systems thinking towards understating the injury and injury prevention context. We undertook this qualitative study within an international circus company—Cirque du Soleil—to explore the narrative of artists and the artistic team in regards to injuries and their prevention and to describe the prevention of injuries from a systems thinking lens. The outcomes show the need for a broader view on preventive interventions, and as we speak we are validating this in elite and professional sports as well (stay tuned for those outcomes).
Focus groups (FG) with artists and semistructured individual interviews with the artistic team were conducted in six selected shows. The structure of the interviews and FGs concerned the themes: ‘injury’, ‘injury-related factors’ and ‘injury prevention’. Data were analysed through comparative data analysis based on Grounded Theory. Concept mapping and systems thinking approaches were used to design a map of participants’ views on how to prevent injuries.
A multilevel system map with factors, strategies and stakeholders in relation to injury and their prevention. Starting at the centre of the map (ie, the athlete) and moving distally; (A) entails artists-related intrinsic injury factors; (B) presents external injury factors; (C) describes the main preventive strategies (eg, load management, safety and preparation) which are driven by the factors from the inner two circles; (D) represents the stakeholders in the system as well as how they connect to the strategies and factors across the multiple levels.
Injury was mainly described based on performance limitation. The factors mostly mentioned to be related to injury occurrence were physical load factors. Many of these factors were said to be connected and to influence each other. Injury prevention was mapped as a multilevel system, composed by artist-related factors (eg, technique and life style) and extrinsic factors (eg, touring conditions and equipment) that integrate different strategies and stakeholders.
This study reinforces the importance of multilevel injury prevention approaches with shared responsibility and open communication among stakeholders.
What are the new findings?
Systems thinking and qualitative research can be applied to understand injury prevention as a complex system.
A system map can illustrate injury prevention as a multilevel system and identify the stakeholders directly and indirectly related to the injury prevention and their interconnections.
Injury prevention as a complex system requires an effort of multiple stakeholders working together and sharing the responsibility to prevent injuries.
How might it impact on clinical practice in the near future?
Injury prevention is not restricted to stakeholders that deal directly with artists, and multiple departments can influence injury prevention due to the interconnection between elements of the system.
The injury prevention in an organisation like Cirque du Soleil can be compared with other sports settings, and our approach can be applied to understand sports contexts.
Bolling C, Mellette J, Pasman HR, van Mechelen W, Verhagen E. From the safety net to the injury prevention web: applying systems thinking to unravel injury prevention challenges and opportunities in Cirque du Soleil. BMJ Open Sport & Exercise Medicine 2019;5:e000492. doi:10.1136/bmjsem-2018-000492