problem solving strategies healthcare

Fresh Perspectives

Want to Solve Problems in Public Health? Here's How

I have many loves in family medicine. I love delivering a newborn directly into a mother's arms. I love excisional biopsies of funny looking moles. I love giving someone hope after a chronic disease diagnosis.  

What I love most, however, is community-based preventive medicine. As such, I wrangled a contract directly out of residency that is 20 percent population medicine. (Lesson No. 1: Ask for what you want. You might actually get it).

As part of this endeavor, I am pursuing a master's degree in public health. I hope to use this training to make connections in the world of public health policy; to learn how to create, implement, message and evaluate programming; and perhaps to eventually break into creation of, or participation in, policy. I will have some required coursework in, for example, biostatistics and epidemiology, but I will also have myriad electives on topics like environmental public health and behavioral economics.

Throughout the course of my program, I hope to distill the most useful-to-the-family-medicine-doc public health pearls from my classes and pass them along. This post is the first in this series. Thus far, I have taken courses on problem-solving in public health and intro to persuasive communication.

The course on problem-solving in public health taught me two things: a remarkably egalitarian way to run a meeting and a systematic approach to solving problems.

The Nominal Group Technique (NGT)

In this setup for running a meeting, start by imagining a group of eight people. During each session, one of them is the moderator, one a notetaker and one a timekeeper. The moderator's job is to decide how long each part of the session ought to take, and the timekeeper's job is to cut people off once time is reached. The notetaker … takes notes.

Each meeting uses the following series of steps, and as participants get used to the process, they get faster and more efficient.

• Clarify the purpose and goals. The moderator reminds everyone about the specific question or questions for the session, reviews time limits for each ensuing step and allows for adjustments on each of these points.
• Brainstorm solutions. Group members brainstorm answers to the session's central question, a step that can take place before the meeting.
• Share ideas in a round robin. Going around in a circle, each person briefly shares one idea, adding more brief ideas -- avoiding duplicates -- when the circle comes back around until time runs out or all ideas have been voiced. In this manner, no one dominates the discussion and everyone is heard.
• Discuss as a group. Here the group focuses on clarifying, not debating. The goal is to add salient details or reasons for a certain suggestion. This is a time to ask questions rather than make arguments. Some time can also be spent discussing criteria for voting in the next step.
• Rank the suggestions. Each group member ranks the options based on the set criteria -- perhaps voting for their three favorites, using two votes however they want, or casting one vote each -- and the group ends up with two or three leading suggestions.
• Wrap up with conclusions and assignments. Participants are assigned roles or tasks to complete before the next meeting, and a new moderator, timekeeper and notetaker are assigned.

The NGT is delightfully efficient and focused. Moreover, it imposes a thoughtful, respectful and inclusive methodology to traditionally explosive or at least controversial topics. By using this technique, you can assure all members of the group that each of their voices will be heard with equal weight, as will also be the case in the problem-solving process below.

The Problem-solving Process

Usually applied to public health problems, this series of steps offers a framework through which one can approach just about any problem that involves groups of people. Whether your problem is developing a group visit program or decreasing smoking in pregnant women, you can approach the problem with success in this way. Notably, this process works well in combination with the NGT.

• Define the problem. A good problem definition has a specific group, timeframe and outcome of interest. For example, the definition could be, "Childhood obesity rates in the United States among school-aged children have been rising since the 1970s."
• Identify indicators of the problem. If your problem is childhood obesity, your direct indicators would be things like body mass index, waist circumference or waist-to-hip ratio. Indirect indicators -- things that give you a clue your endpoint might be happening -- would be rates of childhood hypertension, diabetes or obesity-related sleep apnea. Using the NGT would lead your group to brainstorm as many direct and indirect indicators as possible, then you vote on which ones to track and change.
• Find data for the indicators. Without data, you will have a hard time convincing others to do what you want.
• Identify stakeholders. Find out who cares about the outcome. A meeting held in the NGT style would come out of brainstorming and round robin with a diverse, inclusive and thorough list of potential stakeholders. For childhood obesity, the stakeholders could be parents, students, educators, elected officials, etc. The ranking step would narrow the list to the stakeholders that your group wants to work with.
• Identify key determinants. These are the things that might make the outcome of interest more or less likely. For childhood obesity, these factors might be diet, exercise, dangerous neighborhoods that prevent exercise, food deserts, genes, obesity in parents, television watching, school lunches and poverty.
• Identify intervention strategies. Here is when you brainstorm actions to change the outcome. Some of the group's ideas might be school lunch programs, educational programs for parents, active recess or adjusting food aid programs. All ideas are welcome for discussion and ranking. At the end of the meeting, your group will have decided on an intervention strategy to pursue.
• Identify implementation strategies. It is all well and good to have an intervention, but the next step is to figure out how to get it off the ground. You need to use all the resources you have -- friends in high places, friends in low places, grants, national organizations, local fundraising, city council meetings and more.
• Evaluate. All good interventions need to be evaluated. Be sure to figure out how to do so. Is it working? Is it costing too much? Does it have any unintended benefits or consequences?

I already have used each of these techniques to great effect. By addressing problems in this step-by-step fashion, I find myself suddenly more organized, and you know what that means: more time for more projects!

Just kidding. I get to read books for fun these days and go on long runs. It is amazing.

Stewart Decker, M.D., is a family physician practicing in southern Oregon. He focuses on the intersection of public health and primary care. You can follow him on Twitter at @drstewartdecker.

The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our  Terms of Use .

Copyright © 2024 American Academy of Family Physicians. All Rights Reserved.

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Cultivating Critical Thinking in Healthcare

Published: 06 January 2019

Critical thinking skills have been linked to improved patient outcomes, better quality patient care and improved safety outcomes in healthcare (Jacob et al. 2017).

Given this, it's necessary for educators in healthcare to stimulate and lead further dialogue about how these skills are taught , assessed and integrated into the design and development of staff and nurse education and training programs (Papp et al. 2014).

So, what exactly is critical thinking and how can healthcare educators cultivate it amongst their staff?

What is Critical Thinking?

In general terms, ‘ critical thinking ’ is often used, and perhaps confused, with problem-solving and clinical decision-making skills .

In practice, however, problem-solving tends to focus on the identification and resolution of a problem, whilst critical thinking goes beyond this to incorporate asking skilled questions and critiquing solutions .

Several formal definitions of critical thinking can be found in literature, but in the view of Kahlke and Eva (2018), most of these definitions have limitations. That said, Papp et al. (2014) offer a useful starting point, suggesting that critical thinking is:

‘The ability to apply higher order cognitive skills and the disposition to be deliberate about thinking that leads to action that is logical and appropriate.’

The Foundation for Critical Thinking (2017) expands on this and suggests that:

‘Critical thinking is that mode of thinking, about any subject, content, or problem, in which the thinker improves the quality of his or her thinking by skillfully analysing, assessing, and reconstructing it.’

They go on to suggest that critical thinking is:

• Self-directed
• Self-disciplined
• Self-monitored
• Self-corrective.

Key Qualities and Characteristics of a Critical Thinker

Given that critical thinking is a process that encompasses conceptualisation , application , analysis , synthesis , evaluation and reflection , what qualities should be expected from a critical thinker?

In answering this question, Fortepiani (2018) suggests that critical thinkers should be able to:

• Formulate clear and precise questions
• Gather, assess and interpret relevant information
• Reach relevant well-reasoned conclusions and solutions
• Think open-mindedly, recognising their own assumptions
• Communicate effectively with others on solutions to complex problems.

All of these qualities are important, however, good communication skills are generally considered to be the bedrock of critical thinking. Why? Because they help to create a dialogue that invites questions, reflections and an open-minded approach, as well as generating a positive learning environment needed to support all forms of communication.

Lippincott Solutions (2018) outlines a broad spectrum of characteristics attributed to strong critical thinkers. They include:

• Inquisitiveness with regard to a wide range of issues
• A concern to become and remain well-informed
• Alertness to opportunities to use critical thinking
• Self-confidence in one’s own abilities to reason
• Open mindedness regarding divergent world views
• Flexibility in considering alternatives and opinions
• Understanding the opinions of other people
• Fair-mindedness in appraising reasoning
• Honesty in facing one’s own biases, prejudices, stereotypes or egocentric tendencies
• A willingness to reconsider and revise views where honest reflection suggests that change is warranted.

Papp et al. (2014) also helpfully suggest that the following five milestones can be used as a guide to help develop competency in critical thinking:

Stage 1: Unreflective Thinker

At this stage, the unreflective thinker can’t examine their own actions and cognitive processes and is unaware of different approaches to thinking.

Stage 2: Beginning Critical Thinker

Here, the learner begins to think critically and starts to recognise cognitive differences in other people. However, external motivation  is needed to sustain reflection on the learners’ own thought processes.

Stage 3: Practicing Critical Thinker

By now, the learner is familiar with their own thinking processes and makes a conscious effort to practice critical thinking.

Stage 4: Advanced Critical Thinker

As an advanced critical thinker, the learner is able to identify different cognitive processes and consciously uses critical thinking skills.

Stage 5: Accomplished Critical Thinker

At this stage, the skilled critical thinker can take charge of their thinking and habitually monitors, revises and rethinks approaches for continual improvement of their cognitive strategies.

Facilitating Critical Thinking in Healthcare

A common challenge for many educators and facilitators in healthcare is encouraging students to move away from passive learning towards active learning situations that require critical thinking skills.

Just as there are similarities among the definitions of critical thinking across subject areas and levels, there are also several generally recognised hallmarks of teaching for critical thinking . These include:

• Promoting interaction among students as they learn
• Asking open ended questions that do not assume one right answer
• Allowing sufficient time to reflect on the questions asked or problems posed
• Teaching for transfer - helping learners to see how a newly acquired skill can apply to other situations and experiences.

(Lippincott Solutions 2018)

Snyder and Snyder (2008) also make the point that it’s helpful for educators and facilitators to be aware of any initial resistance that learners may have and try to guide them through the process. They should aim to create a learning environment where learners can feel comfortable thinking through an answer rather than simply having an answer given to them.

Examples include using peer coaching techniques , mentoring or preceptorship to engage students in active learning and critical thinking skills, or integrating project-based learning activities that require students to apply their knowledge in a realistic healthcare environment.

Carvalhoa et al. (2017) also advocate problem-based learning as a widely used and successful way of stimulating critical thinking skills in the learner. This view is echoed by Tsui-Mei (2015), who notes that critical thinking, systematic analysis and curiosity significantly improve after practice-based learning .

Integrating Critical Thinking Skills Into Curriculum Design

Most educators agree that critical thinking can’t easily be developed if the program curriculum is not designed to support it. This means that a deep understanding of the nature and value of critical thinking skills needs to be present from the outset of the curriculum design process , and not just bolted on as an afterthought.

In the view of Fortepiani (2018), critical thinking skills can be summarised by the statement that 'thinking is driven by questions', which means that teaching materials need to be designed in such a way as to encourage students to expand their learning by asking questions that generate further questions and stimulate the thinking process. Ideal questions are those that:

• Embrace complexity
• Challenge assumptions and points of view
• Question the source of information
• Explore variable interpretations and potential implications of information.

To put it another way, asking questions with limiting, thought-stopping answers inhibits the development of critical thinking. This means that educators must ideally be critical thinkers themselves .

Drawing these threads together, The Foundation for Critical Thinking (2017) offers us a simple reminder that even though it’s human nature to be ‘thinking’ most of the time, most thoughts, if not guided and structured, tend to be biased, distorted, partial, uninformed or even prejudiced.

They also note that the quality of work depends precisely on the quality of the practitioners’ thought processes. Given that practitioners are being asked to meet the challenge of ever more complex care, the importance of cultivating critical thinking skills, alongside advanced problem-solving skills , seems to be taking on new importance.

Additional Resources

• The Emotionally Intelligent Nurse | Ausmed Article
• Refining Competency-Based Assessment | Ausmed Article
• Socratic Questioning in Healthcare | Ausmed Article
• Carvalhoa, D P S R P et al. 2017, 'Strategies Used for the Promotion of Critical Thinking in Nursing Undergraduate Education: A Systematic Review', Nurse Education Today , vol. 57, pp. 103-10, viewed 7 December 2018, https://www.sciencedirect.com/science/article/abs/pii/S0260691717301715
• Fortepiani, L A 2017, 'Critical Thinking or Traditional Teaching For Health Professionals', PECOP Blog , 16 January, viewed 7 December 2018, https://blog.lifescitrc.org/pecop/2017/01/16/critical-thinking-or-traditional-teaching-for-health-professions/
• Jacob, E, Duffield, C & Jacob, D 2017, 'A Protocol For the Development of a Critical Thinking Assessment Tool for Nurses Using a Delphi Technique', Journal of Advanced Nursing, vol. 73, no. 8, pp. 1982-1988, viewed 7 December 2018, https://onlinelibrary.wiley.com/doi/10.1111/jan.13306
• Kahlke, R & Eva, K 2018, 'Constructing Critical Thinking in Health Professional Education', Perspectives on Medical Education , vol. 7, no. 3, pp. 156-165, viewed 7 December 2018, https://link.springer.com/article/10.1007/s40037-018-0415-z
• Lippincott Solutions 2018, 'Turning New Nurses Into Critical Thinkers', Lippincott Solutions , viewed 10 December 2018, https://www.wolterskluwer.com/en/expert-insights/turning-new-nurses-into-critical-thinkers
• Papp, K K 2014, 'Milestones of Critical Thinking: A Developmental Model for Medicine and Nursing', Academic Medicine , vol. 89, no. 5, pp. 715-720, https://journals.lww.com/academicmedicine/Fulltext/2014/05000/Milestones_of_Critical_Thinking___A_Developmental.14.aspx
• Snyder, L G & Snyder, M J 2008, 'Teaching Critical Thinking and Problem Solving Skills', The Delta Pi Epsilon Journal , vol. L, no. 2, pp. 90-99, viewed 7 December 2018, https://dme.childrenshospital.org/wp-content/uploads/2019/02/Optional-_Teaching-Critical-Thinking-and-Problem-Solving-Skills.pdf
• The Foundation for Critical Thinking 2017, Defining Critical Thinking , The Foundation for Critical Thinking, viewed 7 December 2018, https://www.criticalthinking.org/pages/our-conception-of-critical-thinking/411
• Tsui-Mei, H, Lee-Chun, H & Chen-Ju MSN, K 2015, 'How Mental Health Nurses Improve Their Critical Thinking Through Problem-Based Learning', Journal for Nurses in Professional Development , vol. 31, no. 3, pp. 170-175, viewed 7 December 2018, https://journals.lww.com/jnsdonline/Abstract/2015/05000/How_Mental_Health_Nurses_Improve_Their_Critical.8.aspx

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About this content

A problem can be defined as a gap in performance (actual vs. expected). Problem solving is therefore the act of identifying the possible causes of that “gap” and implementing countermeasures that aim at mitigating or eliminating them, so that the performance can meet expectations.

In life as well as in the work we do, we are frequently faced with problems, sometimes daily. Not all problems are equal and not all of them can benefit from the same approach to problem solving. This is why it’s helpful identify early on what approach to problem solving would be best fit for the problem at hand:

• Plan-Do-Study-Act (PDSA)
• Complex Problem Solving
• Innovation (or research)

How it works

When faced with a problem, ask the following questions to identify what approach is best suited for the type of problem you are addressing:

• Are you addressing a self-evident process with a simple solution?
• Are you making a change and want to track the before/after improvement results?
• Are you solving a problem that appears to have multiple causes?
• Are you implementing a new process or service?

Follow the respective clue to learn more about the best approach for each type of questions problem resolution.

What approach should I use?

When to use it

• Quick action is preferred or necessary
• The cause of the problem is self-evident
• Proposed solution is small, easily testable, and not risky
• The change is easily reversible

How to use it

• Ask: how can I improve the process? How can I make the process better, faster, cheaper?
• Use visual management to make a process clearer
• Simplify a process to make it more efficient
• Use less costly supplies or methods to save costs

Examples of when to use Just do it

• Implementing a policy or revising an outdated policy
• Switching to a vastly cheaper and better technology or supply
• Implementing a previously non-existent checklist
• Eliminating a redundant or non-value added step

Just Do It worksheet: Click here to download

• Application of the scientific method in testing a change
• Use of pre and post change to measure success of intervention
• Focus on continuous improvement in the process

Plan: What change are you going to make?

• Who is going to do what and by when?
• Have a clear objective, a goal (often called AIM statement)

Do: How are you going to make it?

• What resources will you need?
• What method of improvement will you use?

Study: Did you see an improvement?

• How long will you observe the change?
• Did you achieve the set objectives?

Act: Adopt the change, revise the plan, discard

Examples of when to use PDSA

• Testing the cost effectiveness and impact on quality of a new surgical implant compared to the currently used one
• Confirming the before and after financial impact of adding one more service line

PDSA worksheet: Click here to download

• The cause of the problem is unknown
• The countermeasures are difficult to adopt
• Disciplined approach to problem solving is preferred
• Multiple stakeholders or departments needs to be involved
• Use a structured approach to problem solving such as A3, DMAIC, 8D, etc.
• Usually they follow similar steps identified below:

Examples of when to use complex problem solving

• Length of stay in a unit is higher than national average
• Staff reports feeling of burnout and lack engagement that results in high turnover

A3 Problem Solving worksheet: Click here to download

• A new way to deliver a product or service or a new product or service to address a need
• New knowledge on how to treat disease or improve patient care that requires IRB approval
• Data and statistical analysis are necessary
• Funded by internal or external research grants
• Innovate with the intended customer in mind
• Think in terms of minimum viable product (MVP)
• Leverage Agile development principles

Examples of when to innovate

• Implementing Covid-19 testing sites in the community
• Transition employees from on site working to work from home, with minimal disruption

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Making Decisions and Solving Problems

CHAPTER 6 Making Decisions and Solving Problems Rose Aguilar Welch This chapter describes the key concepts related to problem solving and decision making. The primary steps of the problem-solving and decision-making processes, as well as analytical tools used for these processes, are explored. Moreover, strategies for individual or group problem solving and decision making are presented. Objectives •  Apply a decision-making format to list options to solve a problem, identify the pros and cons of each option, rank the options, and select the best option. •  Evaluate the effect of faulty information gathering on a decision-making experience. •  Analyze the decision-making style of a nurse leader/manager. •  Critique resources on the Internet that focus on critical thinking, problem solving, and decision making. Terms to Know autocratic creativity critical thinking decision making democratic optimizing decision participative problem solving satisficing decision The Challenge Vickie Lemmon RN, MSN Director of Clinical Strategies and Operations, WellPoint, Inc., Ventura, California Healthcare managers today are faced with numerous and complex issues that pertain to providing quality services for patients within a resource-scarce environment. Stress levels among staff can escalate when problems are not resolved, leading to a decrease in morale, productivity, and quality service. This was the situation I encountered in my previous job as administrator for California Children Services (CCS). When I began my tenure as the new CCS administrator, staff expressed frustration and dissatisfaction with staffing, workload, and team communications. This was evidenced by high staff turnover, lack of teamwork, customer complaints, unmet deadlines for referral and enrollment cycle times, and poor documentation. The team was in crisis, characterized by in-fighting, blaming, lack of respectful communication, and lack of commitment to program goals and objectives. I had not worked as a case manager in this program. It was hard for me to determine how to address the problems the staff presented to me. I wanted to be fair but thought that I did not have enough information to make immediate changes. My challenge was to lead this team to greater compliance with state-mandated performance measures. What do you think you would do if you were this nurse? Introduction Problem solving and decision making are essential skills for effective nursing practice. Carol Huston (2008) identified “expert decision-making skills” as one of the eight vital leadership competencies for 2020. These processes not only are involved in managing and delivering care but also are essential for engaging in planned change. Myriad technologic, social, political, and economic changes have dramatically affected health care and nursing. Increased patient acuity, shorter hospital stays, shortage of healthcare providers, increased technology, greater emphasis on quality and patient safety, and the continuing shift from inpatient to ambulatory and home health care are some of the changes that require nurses to make rational and valid decisions. Moreover, increased diversity in patient populations, employment settings, and types of healthcare providers demands efficient and effective decision making and problem solving. More emphasis is now placed on involving patients in decision making and problem solving and using multidisciplinary teams to achieve results. Nurses must possess the basic knowledge and skills required for effective problem solving and decision making. These competencies are especially important for nurses with leadership and management responsibilities. Definitions Problem solving and decision making are not synonymous terms. However, the processes for engaging in both processes are similar. Both skills require critical thinking, which is a high-level cognitive process, and both can be improved with practice. Decision making is a purposeful and goal-directed effort that uses a systematic process to choose among options. Not all decision making begins with a problem situation. Instead, the hallmark of decision making is the identification and selection of options or alternatives. Problem solving, which includes a decision-making step, is focused on trying to solve an immediate problem, which can be viewed as a gap between “what is” and “what should be.” Effective problem solving and decision making are predicated on an individual’s ability to think critically. Although critical thinking has been defined in numerous ways, Scriven and Paul (2007) refer to it as “ the intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action.” Effective critical thinkers are self-aware individuals who strive to improve their reasoning abilities by asking “why,” “what,” or “how.” A nurse who questions why a patient is restless is thinking critically. Compare the analytical abilities of a nurse who assumes a patient is restless because of anxiety related to an upcoming procedure with those of a nurse who asks if there could be another explanation and proceeds to investigate possible causes. It is important for nurse leaders and managers to assess staff members’ ability to think critically and enhance their knowledge and skills through staff-development programs, coaching, and role modeling. Establishing a positive and motivating work environment can enhance attitudes and dispositions to think critically. Creativity is essential for the generation of options or solutions. Creative individuals can conceptualize new and innovative approaches to a problem or issue by being more flexible and independent in their thinking. It takes just one person to plant a seed for new ideas to generate . The model depicted in Figure 6-1 demonstrates the relationship among related concepts such as professional judgment, decision making, problem solving, creativity, and critical thinking. Sound clinical judgment requires critical or reflective thinking. Critical thinking is the concept that interweaves and links the others. An individual, through the application of critical-thinking skills, engages in problem solving and decision making in an environment that can promote or inhibit these skills. It is the nurse leader’s and manager’s task to model these skills and promote them in others. FiGURE 6-1 Problem-solving and decision-making model. Decision Making This section presents an overview of concepts related to decision models, decision-making styles, factors affecting decision making, group decision making (advantages and challenges), and strategies and tools. The phases of the decision-making process include defining objectives, generating options, identifying advantages and disadvantages of each option, ranking the options, selecting the option most likely to achieve the predefined objectives, implementing the option, and evaluating the result. Box 6-1 contains a form that can be used to complete these steps. BOX 6-1    Decision-Making Format Objective: _____________________________________ Options Advantages Disadvantages Ranking                                 Add more rows as necessary. Rank priority of options, with “1” being most preferred. Select the best option. Implementation plan: ______________________________________________________________________________ Evaluation plan: __________________________________________________________________________________ A poor-quality decision is likely if the objectives are not clearly identified or if they are inconsistent with the values of the individual or organization. Lewis Carroll illustrates the essential step of defining the goal, purpose, or objectives in the following excerpt from Alice’s Adventures in Wonderland: One day Alice came to a fork in the road and saw a Cheshire Cat in a tree. “Which road do I take?” she asked. His response was a question: “Where do you want to go?” “I don’t know,” Alice answered. “Then,” said the cat, “it doesn’t matter.” Decision Models The decision model that a nurse uses depends on the circumstances. Is the situation routine and predictable or complex and uncertain? Is the goal of the decision to make a decision conservatively that is just good enough or one that is optimal? If the situation is fairly routine, nurse leaders and managers can use a normative or prescriptive approach. Agency policy, standard procedures, and analytical tools can be applied to situations that are structured and in which options are known. If the situation is subjective, non-routine, and unstructured or if outcomes are unknown or unpredictable, the nurse leader and manager may need to take a different approach. In this case, a descriptive or behavioral approach is required. More information will need to be gathered to address the situation effectively. Creativity, experience, and group process are useful in dealing with the unknown. In the business world, Camillus described complex problems that are difficult to describe or resolve as “wicked” (as cited in Huston, 2008 ). This term is apt in describing the issues that nurse leaders face. In these situations, it is especially important for nurse leaders to seek expert opinion and involve key stakeholders. Another strategy is satisficing. In this approach, the decision maker selects the solution that minimally meets the objective or standard for a decision. It allows for quick decisions and may be the most appropriate when time is an issue. Optimizing is a decision style in which the decision maker selects the option that is best, based on an analysis of the pros and cons associated with each option. A better decision is more likely using this approach, although it does take longer to arrive at a decision. For example, a nursing student approaching graduation is contemplating seeking employment in one of three acute care hospitals located within a 40-mile radius of home. The choices are a medium-size, not-for-profit community hospital; a large, corporate-owned hospital; and a county facility. A satisficing decision might result if the student nurse picked the hospital that offered a decent salary and benefit packet or the one closest to home. However, an optimizing decision is more likely to occur if the student nurse lists the pros and cons of each acute care hospital being considered such as salary, benefits, opportunities for advancement, staff development, and mentorship programs. Decision-Making Styles The decision-making style of a nurse manager is similar to the leadership style that the manager is likely to use. A manager who leans toward an autocratic style may choose to make decisions independent of the input or participation of others. This has been referred to as the “decide and announce” approach, an authoritative style. On the other hand, a manager who uses a democratic or participative approach to management involves the appropriate personnel in the decision-making process. It is imperative for managers to involve nursing personnel in making decisions that affect patient care. One mechanism for doing so is by seeking nursing representation on various committees or task forces. Participative management has been shown to increase work performance and productivity, decrease employee turnover, and enhance employee satisfaction. Any decision style can be used appropriately or inappropriately. Like the tenets of situational leadership theory, the situation and circumstances should dictate which decision-making style is most appropriate. A Code Blue is not the time for managers to democratically solicit volunteers for chest compressions! The autocratic method results in more rapid decision making and is appropriate in crisis situations or when groups are likely to accept this type of decision style. However, followers are generally more supportive of consultative and group approaches. Although these approaches take more time, they are more appropriate when conflict is likely to occur, when the problem is unstructured, or when the manager does not have the knowledge or skills to solve the problem. Exercise 6-1 Interview colleagues about their most preferred decision-making model and style. What barriers or obstacles to effective decision making have your colleagues encountered? What strategies are used to increase the effectiveness of the decisions made? Based on your interview, is the style effective? Why or why not? Factors Affecting Decision Making Numerous factors affect individuals and groups in the decision-making process. Tanner (2006) conducted an extensive review of the literature to develop a Clinical Judgment Model. Out of the research, she concluded that five principle factors influence decision making. (See the Literature Perspective below.) Literature Perspective Resource: Tanner, C. A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45 (6), 204-211. Tanner engaged in an extensive review of 200 studies focusing on clinical judgment and clinical decision making to derive a model of clinical judgment that can be used as a framework for instruction. The first review summarized 120 articles and was published in 1998. The 2006 article reviewed an additional 71 studies published since 1998. Based on an analysis of the entire set of articles, Tanner proposed five conclusions which are listed below. The reader is referred to the article for detailed explanation of each of the five conclusions. The author considers clinical judgment as a “problem-solving activity.” She notes that the terms “clinical judgment,” “problem solving,” “decision making,” and “critical thinking” are often used interchangeably. For the purpose of aiding in the development of the model, Tanner defined clinical judgment as actions taken based on the assessment of the patient’s needs. Clinical reasoning is the process by which nurses make their judgments (e.g., the decision-making process of selecting the most appropriate option) ( Tanner, 2006 , p. 204): 1.  Clinical judgments are more influenced by what nurses bring to the situation than the objective data about the situation at hand. 2.  Sound clinical judgment rests to some degree on knowing the patient and his or her typical pattern of responses, as well as an engagement with the patient and his or her concerns. 3.  Clinical judgments are influenced by the context in which the situation occurs and the culture of the nursing care unit. 4.  Nurses use a variety of reasoning patterns alone or in combination. 5.  Reflection on practice is often triggered by a breakdown in clinical judgment and is critical for the development of clinical knowledge and improvement in clinical reasoning. The Clinical Judgment Model developed through the review of the literature involves four steps that are similar to problem-solving and decision-making steps described in this chapter. The model starts with a phase called “Noticing.” In this phase, the nurse comes to expect certain responses resulting from knowledge gleaned from similar patient situations, experiences, and knowledge. External factors influence nurses in this phase such as the complexity of the environment and values and typical practices within the unit culture. The second phase of the model is “Interpreting,” during which the nurse understands the situation that requires a response. The nurse employs various reasoning patterns to make sense of the issue and to derive an appropriate action plan. The third phase is “Responding,” during which the nurse decides on the best option for handling the situation. This is followed by the fourth phase, “Reflecting,” during which the nurse assesses the patient’s responses to the actions taken. Tanner emphasized that “reflection-in-action” and “reflection-on-action” are major processes required in the model. Reflection-in-action is real-time reflection on the patient’s responses to nursing action with modifications to the plan based on the ongoing assessment. On the other hand, reflection-on-action is a review of the experience, which promotes learning for future similar experiences. Nurse educators and managers can employ this model with new and experienced nurses to aid in understanding thought processes involved in decision making. As Tanner (2006) so eloquently concludes, “If we, as nurse educators, help our students understand and develop as moral agents, advance their clinical knowledge through expert guidance and coaching, and become habitual in reflection-on-practice, they will have learned to think like a nurse” ( p. 210 ). Implications for Practice Nurse educators and managers can employ this model with new and experienced nurses to aid in understanding thought processes involved in decision making. For example, students and practicing nurses can be encouraged to maintain reflective journals to record observations and impressions from clinical experiences. In clinical post-conferences or staff development meetings, the nurse educator and manager can engage them in applying to their lived experiences the five conclusions Tanner proposed. The ultimate goal of analyzing their decisions and decision-making processes is to improve clinical judgment, problem-solving, decision-making, and critical-thinking skills. Internal and external factors can influence how the situation is perceived. Internal factors include variables such as the decision maker’s physical and emotional state, personal philosophy, biases, values, interests, experience, knowledge, attitudes, and risk-seeking or risk-avoiding behaviors. External factors include environmental conditions, time, and resources. Decision-making options are externally limited when time is short or when the environment is characterized by a “we’ve always done it this way” attitude. Values affect all aspects of decision making, from the statement of the problem/issue through the evaluation. Values, determined by one’s cultural, social, and philosophical background, provide the foundation for one’s ethical stance. The steps for engaging in ethical decision making are similar to the steps described earlier; however, alternatives or options identified in the decision-making process are evaluated with the use of ethical resources. Resources that can facilitate ethical decision making include institutional policy; principles such as autonomy, nonmaleficence, beneficence, veracity, paternalism, respect, justice, and fidelity; personal judgment; trusted co-workers; institutional ethics committees; and legal precedent. Certain personality factors, such as self-esteem and self-confidence, affect whether one is willing to take risks in solving problems or making decisions. Keynes (2008) asserts that individuals may be influenced based on social pressures. For example, are you inclined to make decisions to satisfy people to whom you are accountable or from whom you feel social pressure? Characteristics of an effective decision maker include courage, a willingness to take risks, self-awareness, energy, creativity, sensitivity, and flexibility. Ask yourself, “Do I prefer to let others make the decisions? Am I more comfortable in the role of ‘follower’ than leader? If so, why?” Exercise 6-2 Identify a current or past situation that involved resource allocation, end-of-life issues, conflict among healthcare providers or patient/family/significant others, or some other ethical dilemma. Describe how the internal and external factors previously described influenced the decision options, the option selected, and the outcome. Group Decision Making There are two primary criteria for effective decision making. First, the decision must be of a high quality; that is, it achieves the predefined goals, objectives, and outcomes. Second, those who are responsible for its implementation must accept the decision. Higher-quality decisions are more likely to result if groups are involved in the problem-solving and decision-making process. In reality, with the increased focus on quality and safety, decisions cannot be made alone. When individuals are allowed input into the process, they tend to function more productively and the quality of the decision is generally superior. Taking ownership of the process and outcome provides a smoother transition. Multidisciplinary teams should be used in the decision-making process, especially if the issue, options, or outcome involves other disciplines. Research findings suggest that groups are more likely to be effective if members are actively involved, the group is cohesive, communication is encouraged, and members demonstrate some understanding of the group process. In deciding to use the group process for decision making, it is important to consider group size and composition. If the group is too small, a limited number of options will be generated and fewer points of view expressed. Conversely, if the group is too large, it may lack structure, and consensus becomes more difficult. Homogeneous groups may be more compatible; however, heterogeneous groups may be more successful in problem solving. Research has demonstrated that the most productive groups are those that are moderately cohesive. In other words, divergent thinking is useful to create the best decision. For groups to be able to work effectively, the group facilitator or leader should carefully select members on the basis of their knowledge and skills in decision making and problem solving. Individuals who are aggressive, are authoritarian, or manifest self-oriented behaviors tend to decrease the effectiveness of groups. The nurse leader or manager should provide a nonthreatening and positive environment in which group members are encouraged to participate actively. Using tact and diplomacy, the facilitator can control aggressive individuals who tend to monopolize the discussion and can encourage more passive individuals to contribute by asking direct, open-ended questions. Providing positive feedback such as “You raised a good point,” protecting members and their suggestions from attack, and keeping the group focused on the task are strategies that create an environment conducive to problem solving. Advantages of Group Decision Making The advantages of group decision making are numerous. The adage “two heads are better than one” illustrates that when individuals with different knowledge, skills, and resources collaborate to solve a problem or make a decision, the likelihood of a quality outcome is increased. More ideas can be generated by groups than by individuals functioning alone. In addition, when followers are directly involved in this process, they are more apt to accept the decision, because they have an increased sense of ownership or commitment to the decision. Implementing solutions becomes easier when individuals have been actively involved in the decision-making process. Involvement can be enhanced by making information readily available to the appropriate personnel, requesting input, establishing committees and task forces with broad representation, and using group decision-making techniques. The group leader must establish with the participants what decision rule will be followed. Will the group strive to achieve consensus, or will the majority rule? In determining which decision rule to use, the group leader should consider the necessity for quality and acceptance of the decision. Achieving both a high-quality and an acceptable decision is possible, but it requires more involvement and approval from individuals affected by the decision. Groups will be more committed to an idea if it is derived by consensus rather than as an outcome of individual decision making or majority rule. Consensus requires that all participants agree to go along with the decision. Although achieving consensus requires considerable time, it results in both high-quality and high-acceptance decisions and reduces the risk of sabotage. Majority rule can be used to compromise when 100% agreement cannot be achieved. This method saves time, but the solution may only partially achieve the goals of quality and acceptance. In addition, majority rule carries certain risks. First, if the informal group leaders happen to fall in the minority opinion, they may not support the decision of the majority. Certain members may go so far as to build coalitions to gain support for their position and block the majority choice. After all, the majority may represent only 51% of the group. In addition, group members may support the position of the formal leader, although they do not agree with the decision, because they fear reprisal or they wish to obtain the leader’s approval. In general, as the importance of the decision increases, so does the percentage of group members required to approve it. To secure the support of the group, the leader should maintain open communication with those affected by the decision and be honest about the advantages and disadvantages of the decision. The leader should also demonstrate how the advantages outweigh the disadvantages, suggest ways the unwanted outcomes can be minimized, and be available to assist when necessary.

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Problem-Solving Strategies and Obstacles

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Sean is a fact-checker and researcher with experience in sociology, field research, and data analytics.

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• Application
• Improvement

From deciding what to eat for dinner to considering whether it's the right time to buy a house, problem-solving is a large part of our daily lives. Learn some of the problem-solving strategies that exist and how to use them in real life, along with ways to overcome obstacles that are making it harder to resolve the issues you face.

What Is Problem-Solving?

In cognitive psychology , the term 'problem-solving' refers to the mental process that people go through to discover, analyze, and solve problems.

A problem exists when there is a goal that we want to achieve but the process by which we will achieve it is not obvious to us. Put another way, there is something that we want to occur in our life, yet we are not immediately certain how to make it happen.

Maybe you want a better relationship with your spouse or another family member but you're not sure how to improve it. Or you want to start a business but are unsure what steps to take. Problem-solving helps you figure out how to achieve these desires.

The problem-solving process involves:

• Discovery of the problem
• Deciding to tackle the issue
• Seeking to understand the problem more fully
• Researching available options or solutions
• Taking action to resolve the issue

Before problem-solving can occur, it is important to first understand the exact nature of the problem itself. If your understanding of the issue is faulty, your attempts to resolve it will also be incorrect or flawed.

Problem-Solving Mental Processes

Several mental processes are at work during problem-solving. Among them are:

• Perceptually recognizing the problem
• Representing the problem in memory
• Considering relevant information that applies to the problem
• Identifying different aspects of the problem
• Labeling and describing the problem

Problem-Solving Strategies

There are many ways to go about solving a problem. Some of these strategies might be used on their own, or you may decide to employ multiple approaches when working to figure out and fix a problem.

An algorithm is a step-by-step procedure that, by following certain "rules" produces a solution. Algorithms are commonly used in mathematics to solve division or multiplication problems. But they can be used in other fields as well.

In psychology, algorithms can be used to help identify individuals with a greater risk of mental health issues. For instance, research suggests that certain algorithms might help us recognize children with an elevated risk of suicide or self-harm.

One benefit of algorithms is that they guarantee an accurate answer. However, they aren't always the best approach to problem-solving, in part because detecting patterns can be incredibly time-consuming.

There are also concerns when machine learning is involved—also known as artificial intelligence (AI)—such as whether they can accurately predict human behaviors.

Heuristics are shortcut strategies that people can use to solve a problem at hand. These "rule of thumb" approaches allow you to simplify complex problems, reducing the total number of possible solutions to a more manageable set.

If you find yourself sitting in a traffic jam, for example, you may quickly consider other routes, taking one to get moving once again. When shopping for a new car, you might think back to a prior experience when negotiating got you a lower price, then employ the same tactics.

While heuristics may be helpful when facing smaller issues, major decisions shouldn't necessarily be made using a shortcut approach. Heuristics also don't guarantee an effective solution, such as when trying to drive around a traffic jam only to find yourself on an equally crowded route.

Trial and Error

A trial-and-error approach to problem-solving involves trying a number of potential solutions to a particular issue, then ruling out those that do not work. If you're not sure whether to buy a shirt in blue or green, for instance, you may try on each before deciding which one to purchase.

This can be a good strategy to use if you have a limited number of solutions available. But if there are many different choices available, narrowing down the possible options using another problem-solving technique can be helpful before attempting trial and error.

In some cases, the solution to a problem can appear as a sudden insight. You are facing an issue in a relationship or your career when, out of nowhere, the solution appears in your mind and you know exactly what to do.

Insight can occur when the problem in front of you is similar to an issue that you've dealt with in the past. Although, you may not recognize what is occurring since the underlying mental processes that lead to insight often happen outside of conscious awareness .

Research indicates that insight is most likely to occur during times when you are alone—such as when going on a walk by yourself, when you're in the shower, or when lying in bed after waking up.

How to Apply Problem-Solving Strategies in Real Life

If you're facing a problem, you can implement one or more of these strategies to find a potential solution. Here's how to use them in real life:

• Create a flow chart . If you have time, you can take advantage of the algorithm approach to problem-solving by sitting down and making a flow chart of each potential solution, its consequences, and what happens next.
• Recall your past experiences . When a problem needs to be solved fairly quickly, heuristics may be a better approach. Think back to when you faced a similar issue, then use your knowledge and experience to choose the best option possible.
• Start trying potential solutions . If your options are limited, start trying them one by one to see which solution is best for achieving your desired goal. If a particular solution doesn't work, move on to the next.
• Take some time alone . Since insight is often achieved when you're alone, carve out time to be by yourself for a while. The answer to your problem may come to you, seemingly out of the blue, if you spend some time away from others.

Obstacles to Problem-Solving

Problem-solving is not a flawless process as there are a number of obstacles that can interfere with our ability to solve a problem quickly and efficiently. These obstacles include:

• Assumptions: When dealing with a problem, people can make assumptions about the constraints and obstacles that prevent certain solutions. Thus, they may not even try some potential options.
• Functional fixedness : This term refers to the tendency to view problems only in their customary manner. Functional fixedness prevents people from fully seeing all of the different options that might be available to find a solution.
• Irrelevant or misleading information: When trying to solve a problem, it's important to distinguish between information that is relevant to the issue and irrelevant data that can lead to faulty solutions. The more complex the problem, the easier it is to focus on misleading or irrelevant information.
• Mental set: A mental set is a tendency to only use solutions that have worked in the past rather than looking for alternative ideas. A mental set can work as a heuristic, making it a useful problem-solving tool. However, mental sets can also lead to inflexibility, making it more difficult to find effective solutions.

How to Improve Your Problem-Solving Skills

In the end, if your goal is to become a better problem-solver, it's helpful to remember that this is a process. Thus, if you want to improve your problem-solving skills, following these steps can help lead you to your solution:

• Recognize that a problem exists . If you are facing a problem, there are generally signs. For instance, if you have a mental illness , you may experience excessive fear or sadness, mood changes, and changes in sleeping or eating habits. Recognizing these signs can help you realize that an issue exists.
• Decide to solve the problem . Make a conscious decision to solve the issue at hand. Commit to yourself that you will go through the steps necessary to find a solution.
• Seek to fully understand the issue . Analyze the problem you face, looking at it from all sides. If your problem is relationship-related, for instance, ask yourself how the other person may be interpreting the issue. You might also consider how your actions might be contributing to the situation.
• Research potential options . Using the problem-solving strategies mentioned, research potential solutions. Make a list of options, then consider each one individually. What are some pros and cons of taking the available routes? What would you need to do to make them happen?
• Take action . Select the best solution possible and take action. Action is one of the steps required for change . So, go through the motions needed to resolve the issue.
• Try another option, if needed . If the solution you chose didn't work, don't give up. Either go through the problem-solving process again or simply try another option.

You can find a way to solve your problems as long as you keep working toward this goal—even if the best solution is simply to let go because no other good solution exists.

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Stewart SL, Celebre A, Hirdes JP, Poss JW. Risk of suicide and self-harm in kids: The development of an algorithm to identify high-risk individuals within the children's mental health system . Child Psychiat Human Develop . 2020;51:913-924. doi:10.1007/s10578-020-00968-9

Rosenbusch H, Soldner F, Evans AM, Zeelenberg M. Supervised machine learning methods in psychology: A practical introduction with annotated R code . Soc Personal Psychol Compass . 2021;15(2):e12579. doi:10.1111/spc3.12579

Mishra S. Decision-making under risk: Integrating perspectives from biology, economics, and psychology . Personal Soc Psychol Rev . 2014;18(3):280-307. doi:10.1177/1088868314530517

Csikszentmihalyi M, Sawyer K. Creative insight: The social dimension of a solitary moment . In: The Systems Model of Creativity . 2015:73-98. doi:10.1007/978-94-017-9085-7_7

Chrysikou EG, Motyka K, Nigro C, Yang SI, Thompson-Schill SL. Functional fixedness in creative thinking tasks depends on stimulus modality .  Psychol Aesthet Creat Arts . 2016;10(4):425‐435. doi:10.1037/aca0000050

Huang F, Tang S, Hu Z. Unconditional perseveration of the short-term mental set in chunk decomposition .  Front Psychol . 2018;9:2568. doi:10.3389/fpsyg.2018.02568

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By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Creative Problem Solving in Healthcare

CREATIVE PROBLEM SOLVING IN THE HEALTHCARE SETTING

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There are 5 primary strategies to use when looking for creative ways to solve problems in healthcare:

• Brainstorming
• Thinking hats
• Problem reversal
• Role-playing

We all have to deal with problems, not only at work, but also in our personal lives. Planning a wedding or a party, finding child care, paying bills, trying to arrange transportation for family members to get where they need to go…all of these are frequent problems that we have to deal with.

As a healthcare worker, your workplace is always changing. It is full of challenges and new clients. You must monitor your client’s condition and perform prescribed treatments. You must know when to inform health professionals about your client’s condition. You must help your clients to make decisions.

Problems can quickly arise and you will have to solve these problems. You need to know what to do and when to do it. Some of these problems will require creative solutions. Being able to creatively problem-solve is an important skill for today’s healthcare workers. Knowing the types of problems that can arise and planning for them in case they do happen will help you to deal with problems effectively.

ABOUT PROBLEM SOLVING

Problem-solving requires critical thinking skills and creativity. What is a problem? What does creativity mean? What is critical thinking?

A problem is a gap or difference in what the situation now is and what you would like it to be.

Creativity is basically the production of order out of chaos. Creativity is developing new, flexible, open-minded approaches or solutions to a problem.

Critical thinking is examining and reflecting on ideas and thinking. Then judgments are made and a course of action decided upon. By combining critical thinking and problem solving, the problem is identified, information is gathered, beliefs and ideas are challenged, and different options are examined creatively. Asking questions is the way to build critical thinking into problem solving.

CREATIVE PROBLEM-SOLVING STRATEGIES

Several strategies that you can use to solve problems creatively are brainstorming, thinking hats, problem reversal, S.W.O.T., and role playing.

Brainstorming Brainstorming is often used by groups, but can also be used by you alone. It is used to create as many possible solutions to a problem as possible. To be effective, the ideas must not be judged or evaluated in any way as they are being developed, no matter how bizarre they seem. Wild ideas are welcomed. Ideas can build on other ideas. New ideas can be created by changing ideas already mentioned.

The more solutions that can be created, the more likely you are to find an effective one. Also, the more variety there is in the solutions, the more likely you are to find an effective one. Once all possible ideas have been created, they are considered for possible consequences. A solution is then selected.

Consider for a moment Divide a square into 4 equal parts. How many possible ways can you think of to divide a square into 4 equal parts?

Below are 4 of the possible answers to this exercise. There are actually many different ways to divide a square into 4 equal parts. This exercise helps to develop your creative thinking skills. It also shows that there is often more than one right answer to a problem.

Thinking hats Thinking hats can also be used in groups, or by you alone. It was originally designed by Edward de Bono. It uses six colored (imaginary) hats. Each hat stands for a different way of thinking about a problem or issue. Using all of the hats will help you to consider the problem more creatively. You will be able to think about the problem from a different viewpoint than you usually take. If it is being used with a group, all members have on the same colored hat at the same time.

1. The white hat is neutral. Facts, figures, and information are examined. It helps to decide if more information is needed.

2. The red hat is for feelings, hunches, and intuition. There is no need to explain your feelings.

3. The yellow hat is for optimism and a logical, positive view of things. It looks at the benefits. It also helps during the evaluation of ideas.

4. The black hat is the logical negative. It uses caution and judgement. It does not encourage creativity. It helps during the evaluation of ideas. It is usually better to use the yellow hat before the black one, to look at the benefits first.

5. The green hat is for creative thinking and new ideas.

6. The blue hat is used to think about the problem-solving process. It ensures the process is being followed. It helps to decide what should be done next.

Problem reversal Sometimes, you will get a different view of a problem if you look at it from the opposite direction. State the problem in reverse. Change a positive statement into a negative one. For example, if there is a problem with a co-worker and you want to improve the situation, consider what would make the situation worse.

S.W.O.T. Analyzing the strengths, weaknesses, opportunities, and threats (S.W.O.T.) is another way of evaluating a problem. It can also be used when evaluating the solutions. What are the possible benefits? What strengths are present? What are the weaknesses? What new opportunities or situations can be created? How can we take advantage of these opportunities? What is the possible harm in the problem? What is the possible harm in the solution?

TIPS TO HELP WITH PROBLEM-SOLVING

1. Think before acting. Use a problem-solving process.

2. Think clearly – stay open-minded. Recognize the effects your emotions can have on your thinking. Separate facts from opinions. Look for errors in reasoning. Consider the evidence (information) – do not jump to conclusions. Don’t try to make the facts fit the solution you want to use.

3. Ask as many questions as you can. Make sure you are asking the right questions to find out what the problem really is. Find out all you can about the problem.

4. Get good ideas from everyone and from everywhere. Edward Land was taking photographs of his family on vacation. His daughter asked him, “Why do we have to wait to see the pictures?” Land thought about this and came up with the idea of instant photography and the Polaroid Camera.

5. Be selective. You cannot solve every problem. Make sure the problem is yours to solve.

6. If a problem seems to be overwhelming, break it into parts.

7. Make the best use of what you have. People often waste a lot of time and energy on “if only.” When you are solving problems, focus on what you have available and what you can change or fix. Spending time on “if only” will just waste time. Spending time and energy saying, “It wouldn’t be a problem if only we had twice as much money for equipment” does not solve the problem – especially if you know you are not going to get twice as much money. Gather the facts as they exist and develop realistic solutions.

8. Look for the opportunity in the problem. Developing creative solutions takes advantage of the opportunity in the problem. For example, a long-term institution for the elderly is looking at the possibility of having to lay-off employees. At the same time, there is a community need for daycare services for the elderly. Perhaps a creative solution would be to develop a daycare program for the elderly instead of laying the employees off.

9. Don’t wait for a problem to occur. If you can take action before a situation turns into a problem, do so.

10. Plan for problems before they occur.

11. Negotiate. Negotiation means that those involved have some of their needs met. This is usually a good strategy in problem-solving. Everybody gets something.

12. Ensure the solution fits the problem. Once the solution has been put into action, it is important to evaluate the plan to ensure the problem has actually been solved and not just hidden for a while.

13. Expect success. Believe in your ability. Work towards realistic goals rather than trying to save the world. Use your skills, time, and energy wisely.

14. Look forward, not backward. Don’t always count on strategies that worked in the past. Be curious. Have the self-confidence to try new things.

15. Although we would like to have all of our problems solved quickly, don’t expect to be able to solve every problem, especially with the first strategy used.

16. Keep your sense of humor.

17. Avoid judging during the gathering of information and development of ideas. The most important question in the creative process is “How might we…?” “We can’t because …” is a barrier to creative problem solving.

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I look upon the “Herb Interaction” book as a “quickie” for my pharmacy team, no need to get bogged down on the computer.

The book on “foot ulcers” spoke to me, I now understand the importance of foot care.

We forget sometimes the power of the patient for healing through compliance and self care habits. We should provide understandable information.

The Dr’ Guide books were a great door opener and relationship builder with the allergy medical team. Our reps loved them.

We had the highest BRC (business Reply Card) return rate of all time – it built up great customer goodwill and easier repeat calls.

The distribution of the Dr. Guide books was the most cost effective, most quickly integrated and best ROI program I have had in years – no committee development meetings, no sky high “creative” costs and so appropriate for our product / treatment messages.

Implementation Strategies for Frontline Healthcare Professionals: People, Process Mapping, and Problem Solving

Affiliations.

• 1 San Francisco Veterans Affairs Health Care System, San Francisco, USA. [email protected].
• 2 Department of Medicine, University of California San Francisco, San Francisco, USA. [email protected].
• 3 San Francisco Veterans Affairs Health Care System, San Francisco, USA.
• 4 Department of Medicine, University of California San Francisco, San Francisco, USA.
• 5 Office of Rural Health, Veterans Health Administration, Washington, DC, USA.
• 6 Quality Enhancement Research Initiative, Veterans Health Administration, U.S. Department of Veterans Affairs, Washington, DC, USA.
• 7 Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, USA.
• PMID: 32918200
• PMCID: PMC7878661
• DOI: 10.1007/s11606-020-06169-3

Implementation science is focused on developing and evaluating methods to reduce gaps between research and practice. As healthcare organizations become increasingly accountable for equity, quality, and value, attention has been directed to identifying specific implementation strategies that can accelerate the adoption of evidence-based therapies into clinical practice. In this perspective, we offer three simple, practical strategies that can be used by frontline healthcare providers who are involved in on-the-ground implementation: people (stakeholder) engagement, process mapping, and problem solving. As a use case example, we describe the iterative application of these strategies to the implementation of a new home sleep apnea testing program for patients in the Veterans Health Administration (VA) healthcare system.

Publication types

• Research Support, U.S. Gov't, Non-P.H.S.
• Delivery of Health Care
• Health Personnel*
• Implementation Science
• Problem Solving*

Grants and funding

• P30 DK092926/DK/NIDDK NIH HHS/United States

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How do you help patients who show up in the ER 100 times a year?

Leslie Walker

Dan Gorenstein

The hope was that bringing many other services to people with high needs would stabilize their health problems. While the strategy has succeeded sometimes, it hasn't saved money. Douglas Sacha/Getty Images hide caption

The hope was that bringing many other services to people with high needs would stabilize their health problems. While the strategy has succeeded sometimes, it hasn't saved money.

Larry Moore, of Camden, N.J, defied the odds — he snatched his life back from a spiral of destruction. The question is: how?

For more than two years straight, Moore was sick, homeless and close-to-death drunk — on mouthwash, cologne, anything with alcohol, he says. He landed in the hospital 70 times between the fall of 2014 and the summer of 2017.

"I lived in the emergency room," the 56-year-old remembers. "They knew my name." Things got so bad, Moore would wait for the ER nurses to turn their backs so he could grab their hand sanitizer and drink it in the hospital bathroom.

"That's addiction," he says.

Then, in early 2018, something clicked, and turned Moore around. Today, he's more than five-years sober with his own apartment, and he has only needed the ER a handful of times since 2020. He's active in his church and building new relationships with his family.

Moore largely credits the Camden Coalition , a team of nurses, social workers and care coordinators for his transformation. The nonprofit organization seeks out health care's toughest patients — people whose medical and social problems combine to land them in the ER dozens of times a year — and wraps them in a quilt of medical care and social services. For Moore, that meant getting him medical attention, addiction treatment and — this was key for him — a permanent place to live.

"The Camden Coalition, they came and found me because I was really lost," Moore says. "They saved my life."

For two decades, hospitals, health insurers and state Medicaid programs across the country have yearned for a way to transform the health of people like Moore as reliably as a pill lowers cholesterol or an inhaler clears the lungs. In theory, regularly preventing even a few $10,000-hospital-stays a year for these costly repeat customers could both improve the health of marginalized people and save big dollars.

Larry Moore (left) in 2020 with staff members from the Camden Coalition. The housing and addiction treatment the organization helped him get has been life saving. Dan Gorenstein/Tradeoffs hide caption

Larry Moore (left) in 2020 with staff members from the Camden Coalition. The housing and addiction treatment the organization helped him get has been life saving.

But breaking this expensive cycle — particularly for patients whose lives are complicated by social problems like poverty and homelessness — has proved much harder than many health care leaders had hoped. For example, a pair of influential studies published in 2020 and 2023 found that the Coalition's pioneering approach of marrying medical and social services failed to reduce either ER visits or hospital readmissions . Larry Moore is the outlier, not the rule.

"The idea that someone should go to the emergency room 100 times in a year is a sign of deep, deep system dysfunction," says Jeff Brenner, the primary care physician who founded and led the Camden Coalition from 2002 until 2017. "It should be fixable. We're clearly still struggling."

Yet, Brenner and others on the frontlines of one of health care's toughest, priciest problems say they know a lot more today about what works and what misses the mark. Here are four lessons they've learned:

Lesson 1: Each patient needs a tailored, sustained plan. Not a quick fix

The Camden Coalition originally believed that just a few months of extra medical and social support would be enough to reduce the cycle of expensive hospital readmissions. But a 2020 study published in the New England Journal of Medicine found that patients who got about 90 days of help from the Coalition were just as likely to end up back in the hospital as those who did not.

That's because, frontline organizations now realize, in some cases this wraparound approach takes more time to work than early pioneers expected.

"That 80th ER visit may be the moment at which the person feels like they can finally trust us, and they're ready to engage," says Amy Boutwell, president of Collaborative Healthcare Strategies , a firm that helps health systems reduce hospital readmissions. "We do not give up."

Frontline groups have also learned their services must be more targeted, says Allison Hamblin , who heads the nonprofit Center for Health Care Strategies, which helps state Medicaid agencies implement new programs. Organizations have begun to tailor their playbooks so the person with uncontrolled schizophrenia and the person battling addiction receive different sets of services.

Larry Moore, for example, has done fine with a light touch from the Coalition after they helped him secure stable housing. But other clients, like 41-year-old Arthur Brown, who struggles to stay on top of his Type 1 diabetes, need more sustained support. After several years, Coalition community health worker Dottie Scott still attends doctor's visits with Brown and regularly reminds him to take his medications and eat healthy meals.

Aaron Truchil, the Coalition's senior analytics director, likens this shift in treatment to the evolution of cancer care, when researchers realized that what looked like one disease was actually many and each required an individualized treatment.

"We don't yet have treatments for every segment of patient," Truchil says. "But that's where the work ahead lies."

Lesson 2: Invest more in the social safety net

Another expensive truth that this field has helped highlight: America's social safety net is frayed, at best.

The Coalition's original model hinged on the theory that navigating people to existing resources like primary care clinics and shelters would be enough to improve a person's health and simultaneously drive down health spending.

Over the years, some studies have found this kind of coordination can improve people's access to medical care , but fails to stabilize their lives enough to keep them out of the hospital. One reason: People frequently admitted to the hospital often have profound, urgent needs for an array of social services that outstrip local resources.

As a result of this early work, Hamblin says, state and federal officials — and even private insurers — now see social issues like a lack of housing as health problems, and are stepping in to fix them. Health care giants like insurers UnitedHealthcare and Aetna have committed hundreds of millions of dollars to build affordable housing, and private Medicare plans have boosted social services , too. Meanwhile, some states, including New York and California, are earmarking billions of Medicaid dollars to improve their members' social situations, from removing mold in apartments to delivering meals and paying people's rent .

Researchers caution that the evidence so far on the health returns of more socially focused investments is mixed — further proof, they say, that more studies are needed and there's no single solution that works for every patient.

Some health care experts also still question whether doctors and insurers are best positioned to lead these investments, or if policymakers and the social service sector should drive this work instead.

Lesson 3: Recent boom in new programs demands better coordination

This spike in spending has led to a wave of new organizations clamoring to serve this small but complex population, which Hamblin says can create waste in the system and confusion for patients.

"All of these barriers to entry and handoffs don't work for traumatized people," former Coalition CEO Brenner says. "They're now having to form new, trusting relationships with multiple different groups of people."

Streamlining more services under a single organization's roof is one possible solution. Evidence of that trend can be seen in the nationwide growth of clinics called Certified Community Behavioral Health Clinics, These clinics deliver mental health care, addiction treatment and even some primary care in one place.

Brenner, who now serves as CEO of the Jewish Board, a large New York City-based social service agency with a budget of more than $200 million a year, is embracing this integration trend. He says his agency is building out four of that newer type of behavioral health clinic, and offering clients housing on top of addiction treatment and mental health care.

Other groups, including the Camden Coalition, say simply getting neighboring care providers to talk to one another can make all the difference. Coalition head Kathleen Noonan estimates the organization now spends just 25% of its time on direct service work and the rest on quarterbacking, helping to coordinate and improve what she calls the "local ecosystem" of providers.

Lesson 4: Rethink your definition of success, and keep going

Twenty years ago, the goal of the Camden Coalition was to help their medically complex patients stay out of the E.R. and out of the hospital — provide better health care for less cost. Noonan, who took over from Jeff Brenner as CEO of the Coalition, says they've made progress in providing better care, at least in some cases — and that's a success. Saving money has been tougher.

"We certainly don't have quick dollars to save," Noonan says. "We still believe that there's tons of waste and use of the [E.R.] that could be reduced ... but it's going to take a lot longer."

Still, she and others in her field do see a path forward. As they focus on improving their patients' mental and physical health by developing and delivering the right mix of interventions in "the right dose," they believe the cost savings may ultimately follow, as they did in Larry Moore's case.

The stakes are high. Today, homelessness and addiction combined cost the U.S. health care system north of $20 billion a year, wreaking havoc on millions of Americans. As health care delivery has evolved in the last two decades, the question is no longer whether to address people's social needs, but how best to do that.

This story comes from the health policy podcast Tradeoffs . Dan Gorenstein is Tradeoffs' executive editor, and Leslie Walker is a senior reporter/producer for the show, where a version of this story first appeared. Tradeoffs' weekly newsletter brings more reporting on health care in America to your inbox.

• Camden, N.J.
• health costs
• Emergency Room
• emergency room frequent flier

Do you feel bad for seeking therapy? It’s called ‘thriver’s guilt.’

Many of my second-generation immigrant patients are first-time therapy-goers who feel their problems don’t matter because their parents or family abroad have had it worse.

Guilt can be especially magnified in children of immigrants — like myself and my therapy patients — whose hopes, dreams and goals may differ from familial values.

As the first in my family to be born in the West, go to therapy, and marry outside my race, religion and culture, I have always had to navigate my feelings of guilt and have painful and difficult conversations with my immigrant parents about the choices I am making that are different from their expectations.

This guilt can be because of constant adaptation between two cultural influences, a phenomenon known as bicultural straddling . The collectivist cultural influence encourages second-generation immigrants to prioritize family and community, sometimes at their expense. The individualistic cultural influence suggests they prioritize themselves, sometimes at the expense of others.

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When they do follow their own path, second-generation immigrants can feel guilt for, among other things, being what their families may consider to be too individualistic or seeming ungrateful. I call this “thriver’s guilt” — what children of immigrants feel for having access to more resources, opportunities and choices than their parents.

Many of my patients are first-time therapy goers who feel bad for even seeking mental health care. They feel as though their problems don’t matter because their parents or family abroad have had it worse. I often have to remind them that pain and suffering are not a competition.

This kind of guilt may be imposed on them or internalized. Some immigrant parents may use their sacrifices in moving to the United States to guilt their children into obedience, leading to increased emotional distress.

Internalizing such high expectations and standards — and constantly feeling like they are falling short — is exhausting.

Guilt motivates behavior that strengthens social bonds and can be tied to empathy; it’s a useful emotion. However, chronic, intensified guilt is associated with mental health struggles such as anxiety and depression .

Many children of immigrants are not taught to question, examine or parse this guilt. But chronic or unhelpful guilt needs to be understood and navigated for better mental health.

To address this guilt and other issues faced by adult children of immigrants, I’ve spent the past five years building a wellness community for them called Brown Girl Therapy . I also have collected their stories, and shared my own, along with research and prescriptive tools in my upcoming book, “ But What Will People Say? Navigating Mental Health, Identity, Love and Family Between Cultures .”

Here are some ways I suggest to manage guilt.

Guilt does not always equal a wrong

Almost all of my second-generation immigrant patients have conflated feeling guilty with doing something wrong.

Like others from collectivist cultures , they will then engage in reparative behaviors to maintain group harmony. To some of them, guilt feels like a neon sign screaming, “TURN AROUND!” They will revert to a previous path, back to the comfort of social and parental expectations. Unfortunately, this reinforces internalized beliefs, which perpetuates the cycle.

Many of my patients have struggled to share their desires with their immigrant parents for fear that they won’t support them. One told her mother that she didn’t want to come home for several weeks over the holidays and instead only wanted to do one week. While this may sound like a reasonable decision for many, she was guilt-tripped by her mother and made to feel like she doesn’t want to spend time with the family. Since my patient wasn’t sure how to manage the guilt, she changed her plans to make her mother happy.

She believed the guilt was telling her that she’s a bad daughter and must make amends to stop feeling that way.

Parse helpful guilt from unhelpful guilt

In her book, “Codependent No More,” author Melody Beattie talks about how to differentiate between helpful and unhelpful guilt.

Helpful guilt propels change. For instance, if guilt arises from causing harm, take steps to repair it.

Unhelpful guilt causes pain and anxiety, and can turn into shame and self-punishment. When you embody guilt as part of your self-concept, much like my patient did, you go from feeling bad to believing that you are bad.

Learn to manage your feelings

Catch this cycle as it’s happening and disrupt it.

Reflect on what you are feeling, especially if you are overwhelmed with guilt. Sit in the feelings, identify and name them, and invite them in as visitors. Often, the feelings associated with guilt — anger , frustration, sadness , shame — are rooted in something deeper, such as people pleasing, codependency or a resentment at a lack of boundaries .

Be clear about your values

Pause, reflect and ask, “What is wrong with what I am doing? Why does it feel wrong? What expectations, values or morals are being crossed?”

Many children of immigrants grow up in households with standards, values and norms different from those they encounter outside the home or develop internally. But they seldom interrogate if they themselves subscribe to familial norms.

One of my patients identifies as a gay man and has had to reconcile with how his sexual identity is at odds with his Korean parents’ expectations that he marry a woman and have children. To his parents, being gay is not morally accepted, and they are convinced this is a result of living in America and wouldn’t have happened if they didn’t move here.

As the only child, he feels immense guilt for not being able to fulfill his parents’ desires, and culturally conflicted, as though he is less Korean for being gay. I often have to remind him that he is not doing anything morally wrong by being true to his identity.

Questioning whether our guilt is in line with our values helps us to step into our own values-driven truth.

Practice self-compassion

You can do something that disappoints your family or someone else, and it can be the best thing for you. Black-and-white thinking perpetuates the false idea that only one person can be right. Even more, it can reinforce negative self-talk and self-criticism . Challenge this.

Instead of using words such as, “I should,” which can fortify feelings of guilt, reframe to “I can,” which can open up the possibility of something different to be true.

Emotional reasoning, as it’s called, refers to feeling something so strongly that we equate that feeling with objective truth. Just because we feel guilty does not mean we did something bad.

Our feelings, including guilt, are impermanent, and taking time to sit with them, reflect on them and process them can allow us to get clarity on what is actually happening in our realities.

Over the years, it became obvious that my parents’ desire for control was rooted in fear — that I won’t attain security or stability in my entrepreneurial career choice, and that of cultural erasure for being with a non-Indian, non-Sikh partner. These choices have been right for me, and slowly, I have been able to bridge the gap between what I want with my parents wanting me to be happy.

Sahaj Kaur Kohli, LGPC, is a practicing therapist, author of “ But What Will People Say? Navigating Mental Health, Identity, Love, and Family Between Cultures ,” and founder of Brown Girl Therapy .

We welcome your comments on this column at [email protected] .

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