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FRONT-LINE PROBLEM SOLVING:

THE RESPONSES OF HOSPITAL NURSES TO WORK SYSTEM FAILURES

ANITA L. TUCKER
AMY C. EDMONDSON
STEVEN SPEAR
Harvard Business School
Morgan T-80
Soldiers Field
Boston, MA 02163

ABSTRACT

This paper investigates how front line workers respond to internal supply chain failures and how
this affects organizational learning. We spent 197 hours observing 22 nurses at eight hospitals.
We categorize problem-solving behavior into two types, one that sought to remove root causes
and one that did not, and report that the latter was most prevalent. We also identify implicit
heuristics governing problem-solving behaviors and speculate about organizational factors that
reinforce their use.
INTRODUCTION

It was 6:41 P.M. when Kristy1 a nurse at "Lakeview Hospital," encountered her first internal
supply chain problem of the night. A post-operative patients nasogastric (NG) tube was not
suctioning out any stomach fluids, a condition which can cause vomiting if left uncorrected for
one to two hours. Despite considerable effort, the nurse was unable to get the gauge functioning.
After three unsuccessful attempts to replace the gauge with ones taken from other patients
rooms, she changed her approach and attached the tube to the adjacent patient beds suction unit.
This unit worked and the tube began suctioning out fluids. In total, Kristy spent fifteen minutes
getting the NG tube functioning and 23 minutes had elapsed since she first noticed the difficulty.

This episode illustrates the focus of our research: problem solving by front-line workers (FLWs).
These valuable employees, who provide services or products purchased by clients, occupy the
critical intersection between organizations and consumerscritical because their actions can
have a direct impact on employee productivity and client satisfaction. We investigated internal
supply chain (ISC) exceptions, which occur when necessary information, materials, or resources
are unavailable or incorrect thereby compromising an employee's performance or the system's
output quality. Following Argyris and Schons (1978) classification of single loop and double
loop learning, we distinguish between first order and second order problem solving. First order
problem solving is characterized by attempts to remove the exception so that a FLW can
continue producing the good or service. Kristys effort to get suction in the tube was first order
problem solving. Second order problem solving involves effort to remove the root cause of the
problem so the exception does not reoccur in the future. In this particular instance, despite
observing throughout the shift, we did not observe the nurse engaging in any second order
problem solving about the broken suction device. She neither called nor spoke to anyone about
the malfunctioning unit. Understandably, her first priority was to meet the patients immediate
need quickly, and she could do this most expediently through first order problem solving.
However, by taking gauges from other rooms or using the wall suction unit that belonged to the

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patients future roommate, she increased (rather than reduced) the chances that another nurse
would also face an ISC exception.

A MODEL OF FRONT-LINE PROBLEM SOLVING

We sought to better understand the nature of problem solving behavior (PSB) at the pressured
front line of work, first by seeking patterns of problem solving activity and second by exploring
possible antecedents of these patterns. There is little debate about the existence of daily
headaches and breakdowns in internal supply chains. How workers respond to these problems
and the impact of these responses on organizations is less well understood, however. Hackman
and Wageman (1995) suggest that humans have a large capacity to adapt to the many problems
that they encounter. Workers can become satisfied with the current condition and learn to "make
do" with a work system that is far from ideal (Hackman and Wageman, 1995). Both front-line
workers and managers tend to downplay problems and errors, a behavior that can lead to a
gradual decline in organizational performance (Keating et al., 1999, Wruck and Jensen, 1994).
We propose that the pattern of FLWs responses to exceptions is influenced by organizational
factors that affect their ability to recognize exceptions as opportunities for organizational
learning and to act upon these opportunities. Starting with the premise that solution quality
increases when root causes of discrepancies are removed (Ishikawa, 1985), we argue that if
workers engage in second-order problem solving in addition to first-order problem solving the
reoccurrence of similar problems will decrease.

A rich literature on FLW behavior, starting with the famous Hawthorne plant studies conducted
from 1927 1932, has identified organizational culture, group norms and structures, and
problem solving processes as three factors affecting workers attitudes toward resolving system
breakdowns. First, scholars suggest that the organizational climate should be conducive to
discussing problems and errors, with the emphasis on finding and removing the source of the
problem rather than assigning blame (Deming, 1986; Dutton & Ashford, 1993; Edmondson,
1999; Ishikawa, 1985; MacDuffie, 1997; Roethlisberger & Dickson, 1939). Second, studies
highlight the importance of group norms concerning information flows between and within
groups. Groups can provide common language for talking about problems (Bechky, 1999),
resource banks of solutions (Edmondson, 1999; Orr, 1990), and support networks that enable
workers to cope with problems (Roethlisberger & Dickson, 1939; Trist & Bamforth, 1951).
Third, research has found that better results are obtained with structured approaches (Tyre,
Eppinger, & Csizinszky, 1993) that take place as soon and as physically near as possible
following a problem, because vital information is not easily transferred (Tyre & von Hippel,
1995) and decays rapidly (Spear, 1999). In addition, interest in problem solving deteriorates
quickly (Tyre & Orlikowski, 1994).

However, past research does not shed insight into the actual problem solving behaviors of front
line workers. Prior research on problem solving tends to be normative and context free, and may
have limited applicability to the harried front lines of work. The difference between the
management ideal and the front-line reality of how workers actually react to exceptions is likely
to be considerable (Hackman & Wageman, 1995). For example, an off-line style of second order
problem solving is challenging to implement in fast paced environments where customers expect
immediate responses. This is illustrated in the comment of a hotel worker who found it difficult
to integrate total quality management into her daily work, We dont get to sit down as a group
and talk about things. Thats not the way we work together (Zbaracki, 1998: 621). Second,
there is a tension that front-line workers face on a daily basis between delivering services and

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improving the delivery process (Sitkin, Sutcliffe, & Schroeder, 1994). Research has shown that
there is a double edge to interactive, helping behavior; key persons are interrupted frequently by
requests for assistance, which hurts their productivity (Perlow, 1999; Tyre & Staudenmayer,
1995). Third, many problem-solving studies have dealt with strategic problems (Mitroff,
Emshoff, & Kilmann, 1979; Smith, 1989; Zand, 1972), highly visible new product innovations
(Dailey, 1978; Tushman & Romanelli, 1983), or new process implementations (Tyre &
Orlikowski, 1993; Tyre & Orlikowski, 1994; Tyre & von Hippel, 1995). These lessons are
unlikely to generalize to front lines where workers face a wide array of annoyances and lack the
organizational power of managers or development engineers. In summary, qualitative research is
needed to understand the important interaction between the environment in which first-line
employees toil and the activities they engage in to handle ISC malfunctions that inevitably arise.

METHODS

The present study thus investigates problem-solving behaviors in a setting where exceptions are
common and both opportunity and need for first and second order corrections are present.
Hospital nurses, whose jobs involve clinical and internal supply chain (ISC) problem solving,
meet these criteria. Although a primary focus of nurses problem solving activities are immediate
clinical problems, nurses ability to address ISC problemssuch as missing or malfunctioning
materials, medications, or resourcesthat hinder the ability to care for patients also matters
greatly for patient safety and nurse productivity.

Nurse behavior has important implications for both patient safety and hospital productivity.
Recent estimates maintain that between 44,000 and 98,000 people die in hospitals each year
because of medical errors (Kohn, Corrigan, & Donaldson, 2000). ISC exceptions are likely to
contribute to error rates (Edmondson, 1996). Surveys of nurses show that fatigue, interruptions,
and a chaotic work environment are leading causes of medication errors (e.g., Osbourne, Blais, &
Hayes, 1999). Resolving system problems contributes to nursing productivity, which matters
because the rising cost of hospital care is an issue of national concern. Moreover, nurses are both
an expensive resourcecomprising more than 50% of many hospitals budgets (Buerhaus &
Staiger, 1996)and are in short supply (Buerhaus, Staiger, & Auerbach, 2000).

We collected qualitative data on actual situations and responses of these front-line workers to
develop new descriptive theoretical propositions about the phenomenon of problem-solving
behavior. Because little is known about actualrather than prescribedbehavior in response to
problems, it was essential to observe this behavior directly. We observed twenty-two nurses in
eight different hospitals, viewing all three shifts and days of the week to ensure an accurate
representation of nursing work. We went with the nurse into patients rooms after they gave
consent, but did not observe care in which patients privacy would be violated. During the
observation, we recorded notes in a small reporters notebook. Ten of the 22 nurses, from five
different hospitals, were shadowed for the entire shift, and we recorded on a minute-by-minute
basis what the nurse was doing, to whom the nurse was talking, and for which patient the nurse
was working.
FINDINGS

The nurses we observed appeared virtually unable to engage in the kinds of second order
problem solving behaviors prescribed in the literature. Instead, for 110 (92%) of the 120
observed problems (approximately 1 problem every 1.6 hours), nurses responded with first order
PSB that allowed continued care for the patient but ignored the possibility of investigating or

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changing causes of the problem. In addition, we found that nurses refrained from sharing
information that could have been used to aid their own and the organizations learning and
improvement. Finally, nurses engaged in second-order problem solving for a scant ten (8%) of
the problems observed, and even then it was in a minimal fashion, such as using an opportune
moment to relay information about a problem to another person.

Through qualitative analysis, we discerned three distinct, but not mutually incompatible, first-
order problem solving heuristics that characterized the majority of nurses responses when
confronted with obstacles. These heuristics, or rules of thumb, were embedded in the work
system, and can be seen as guidingeither alone or in combinationnurses responses for all
but a very few (the 8% noted above) observed problem events. The three dominant heuristics
are: (H1) do what it takes to continue the care of the patient, (H2) use a sequential trial and error
search to find a solution, and (H3) involve people with whom you are most comfortable, rather
than the ones who are best able to solve the problem. Each of these is explained below.

Heuristic 1 (H1), focusing problem-solving effort on continuing the current patient task,
governed 93% of the responses to ISC exceptions. Only 3% of the problem solving efforts
observed contradicted H1, while the other 4% that did not follow this rule did not affect
immediate patient care. When nurses responded to problems using H1, their behavior was
characterized by concern for securing the information or material they needed to do their job, not
on understanding what caused the exception to occur. After the nurse was able to resume her
care of the patient, she did not expend any further effort on the problem, including
communicating that it happened.

Second, we identified the frequent use (in response to 24% of the problems) of a sequential trial
and error process of searching for a solution. The search started with the easiest solution that
satisfied standards of care. If the first attempt failed, the nurses would then try a second solution,
which involved escalation in effort, time, or cost. Heuristic 2 (H2) thus was characterized by
sequential rather than parallel attempts to solve a problem, each of which moved the nurse
further away from the initial solution.

Heuristic 3 (H3) was characterized by asking for help from people who were socially close rather
than from those who were best equipped to correct the exception. The nurses followed H3 for 41
(34%) of the problems and deviated from it for only six (5%) of the problems (e.g. contacting a
physician or other hospital personnel rather than attempting a first order solution on their own).
Responding to problems using H3 involved first trying to solve problems alone and, if that
failed, asking a nurse colleague, particularly one who was a friend, for help. If it was necessary
for patient care, nurses requested help from hospital staff outside of the nursing department.
Used only as a last resort and when all the other options had been exhausted, the final call for
help was to a physician.

The second order problem solving heuristics: (H4) use windows of opportunity to address issues
likely to reoccur, and (H5) limit responsibility to conveying or receiving information, were not
found to occur frequently and did not guarantee success even when used. They both consisted of
relaying information about an exception, rather than suggesting or implementing a solution. H4
states that in the absence of a window of opportunityavailable time or the ability to talk with a
key personnurses did not engage in the kind of root cause investigation problem solving
experts recommend. For seven (6%) of the problems observed, nurses engaged in opportunistic
problem communication and for only two problems in which a window of opportunity was

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present, did nurses fail to use it. The window of opportunity appeared to be particularly
important because second order problem solving had to take place during regular working hours
and on the nursing unit. Therefore, the nurses needed available time, motivation, and easy
access to key people to engage in problem solving activities outside their regular scope of
responsibilities. H5 provides information about what form second order problem solving was
likely to take. Nurses communicated to the person responsible with the purpose of informing
them about a problem for only eight (7%) of the problems. (Conversely, we also observed
nurses withhold information that pertained to solving six (5%) of the problems.) We observed
only one problem instance where the nurses altered the system to reduce problem reoccurrence.

Factors that reinforce first order problem solving

The overwhelming response to ISC problems was to use first order heuristics that allowed the
nurse to continue caring for the patient but ignored possible sources of the problem. Here, we
speculate about factors that make second order problem solving almost non-existent. The first
workplace norm that is likely to limit this, thereby limiting organization learning, is a shared
belief that competent nurses can manage the challenges that they encounter without asking for
help. This hinders learning because the person responsible for the exception is not made aware
of the difficulty and remains ignorant of the negative impact he or she had on patient care and
nurse productivity. The second factor that we propose bolsters the use of first order heuristics is
the time shortage faced by most nurses. We observed nursing balancing the time required
against the time available by working overtime (often unpaid) or by not performing less critical
nursing tasks. In a time-starved situation, the immediate patient needs supercede the less urgent
needs for improving internal supply chains. Third, the self-sufficiency ethic interacts with
chronic time shortage to encourage nurses to favor quick solutions over other more lasting
solutions. However, fast responses, such as fixing the missing material issue on your own, often
hinder individual and organizational learning and result in further problem generation.

DISCUSSION

By relying on first order heuristics, nurses contributed to an environment where problems

continued to reappear. First, organizational learning was limited by the lack of communication
about problems. We observed problems that, if the nurse had given feedback to the responsible
person, could have been used as platforms for improvement, such as an insufficient
communication report from a fellow nurse at the change of shift. Second, first order solutions
can create problems for other people. For example, we frequently observed employees, and even
ourselves, responding to missing equipment or linen by obtaining supplies from another storage
location. While this action provided immediate gratification by solving the short-term crisis, it
depleted the supplies at the second location without signaling to suppliers that the first location
needed to be refilled, increasing the chance that another nurse would encounter the same
problem. Third, when workers solve their problems individually, the aggregate impact that a
particular problem had on the effectiveness of the unit was lost. This information would help
justify that the problem was severe enough to be fixed. Thus, nurses used first order problem
solving in an attempt to navigate through the stream of problems that they encounter during their
day, but in so doing contributed to the force working against them.

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 CONCLUSIONS

Increased communication about problems and the use of preferred problem-solving methods
have been viewed in the literature as explanations for problem solving effectiveness. This study
investigated, instead, how the context of the front lines affected worker response to system
problems. Our research suggested that a lack of available time together with group norms that
valued quick, self-sufficient solutions to problems created an environment where front-line
workers rarely engaged in root cause removal. When they did, it was usually only to
communicate that they had experienced a problem. Therefore, only a small percentage of the
problems encountered got surfaced to others within the organization, dramatically reducing the
potential for organizational learning and improvement.

If organizations are going to improve at their front lines, more care needs to be paid to workers
problems. We propose that there are several conditions that need to exist in order to increase
organizational learning on the front lines. First, if workers are to engage in root cause removal,
this activity must be an explicit part of their job and enough time allocated for improvement
efforts. Second, frequent opportunities for communicating about problems with individuals
responsible for supplying the front line workers with materials or information are needed. We
only observed front-line workers surfacing problems when they were able to easily communicate
with the relevant person. Encouraging people to communicate and creating a safe environment
is not sufficient. There must be convenient opportunities in the course of the day for workers to
give feedback. Ideally, this feedback would be immediate, while the information required for
root cause analysis was still available. Third, when the signal is given that there is a problem,
proper attention must be paid to it. We must recognize communication about problems as a valid
step in the direction of improvement. Often the best that the worker could do was to merely raise
the issue. We did not observe any instances where the nurse contacted someone about a trivial or
insignificant problem. In fact, we observed several occasions where we were surprised that the
nurse did not raise awareness around a problem that we felt could have serious consequences.
Fourth, we observed two hospitals units that had a dedicated person who served as a system
improvement resource for the nurses. This person helped to address the nurses concerns,
particularly for those situations that required more time away from their front-line duties than the
nurses could spare. Fifth, putting these other conditions in place is likely to encourage solution
generation, experimentation, and consideration of the longer-term consequences of actions.
Sixth, publicizing successful system problem solving may further encourage people to recognize
the potential benefits of engaging in this kind of extra work.

This research has implications for other front-line workers that face a similarly unpredictable and
demanding environment. An environment is unpredictable when customers are individuals who
have different reactions to situations and unique requests. Other service workers such as airline
crews, air traffic controllers, hotel clerks, teachers, and waitresses thus face similar work
environments. Further, a similar emphasis on reducing costs through minimizing the number of
workers and the pressure to satisfy the immediate needs of the customers is present in all of these
situations. These are precisely the situations in which the productivity of the workers is crucial,
and yet is difficult to improve if second-order problem solving is discouraged.

REFERENCES AND DATA TABLES AVAILABLE FROM THE FIRST AUTHOR

1. All names are pseudonyms to protect confidentiality.

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