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Nurses are constantly solving problems, often in highly emotional environments. The results of their decisions can have life or death consequences. So they seemed the ideal subject for a study on how front-line workers can contribute—or fail to contribute—to organizational learning. This recent working paper out of Harvard Business School, "When Solving Problems Prevents Organizational Learning", takes a fresh look at the constraints that hinder front-line workers from sharing their knowledge with each other and their organizations.—Sean Silverthorne, HBS Working Knowledge
Abstract
We propose that research on problem-solving behavior can provide critical insight into mechanisms through which organizations resist learning and change. In this paper, we describe typical front-line worker response to obstacles that hinder their effectiveness and argue that this pattern of behavior creates an important and overlooked barrier to organizational change. Past research on quality improvement and problem solving has found that the type of approach used affects the results of problem solving efforts but has not considered constraints that may limit the ability of front-line workers to use preferred approaches. To investigate actual problem-solving behavior of front-line workers, we conducted 197 hours of observation of hospital nurses, whose jobs present both clinical and system problem-solving opportunities. We identify implicit heuristics that govern the problem-solving behaviors of these front-line workers, and suggest cognitive, social, and organizational factors that may reinforce these heuristics and thereby prevent organizational change and improvement.
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Introduction: The Case of the Missing Tags
The new mother, seated in a wheelchair and cradling her two-day-old infant in her arms, was ready to leave the hospital when Abby, the nurse on duty, noticed that the security tag that should encircle the baby's ankle was missing. These reusable tags were expensive, costing over $100 each. Abby quickly searched for the tag and was able to locate it in the baby's bassinet. Three hours later, a similar event occurred. However, despite enlisting assistance from other nurses and spending eight minutes looking in the bassinet and the nursery, Abby was unable to find the tag and notified the nurse manager of its disappearance. It seemed likely that the distracting and potentially serious problem would happen again because investigation into underlying causes of the two incidences had not occurred.
Problems occur frequently in organizations (Hackman and Wageman, 1995); these problems can be visible symptoms of faulty procedures or processes which, if changed, could result in organizational improvement (Sitkin, 1992), particularly when they emerge repeatedly in the day to day operational activities through which an organization produces and delivers products and services to customers. The above example is one of many problems we observed in eight hospitals that did not receive further attention or lead to procedural or structural changes in these organizations. Seeing a similar pattern across hospitals led us to ask what might lead an organization to ignore these important signals for change.
In this article, we propose that how employees respond to problems encountered on the job is a critical factor in enabling or preventing positive organizational change. In an inductive field study of hospital nurses, we observed a dominant pattern of problem solving behavior, and we propose that this pattern—characterized by overcoming immediate obstacles and ignoring opportunities for change and learning—provides an unexplored source of resistance to organizational change. Our analysis of qualitative data suggests that the problem-solving behavior of front-line workers may reduce an organization's ability to detect underlying causes of recurring problems and thus take corrective action. We explore organizational factors that may reinforce the tendency to engage in short-term fixes and thereby limit organizational learning from front-line failures (Argyris, 1990).
While many researchers (Boje and Murnighan, 1982; Mitroff et al., 1979; Taylor, 1975; Ulrich, 1977; White et al., 1980) and practitioners (Deming, 1986; Goldratt, 1997; Ishikawa, 1985; Juran et al., 1999; Kepner and Tregoe, 1976) have proposed problem-solving methods to improve quality in operations settings, few have examined how front-line workers actually approach problems. Analogous to the concepts of single and double loop learning identified by organizational learning researchers (Argyris and Schon, 1978), research on problem solving makes a distinction between fixing problems (first-order solutions) and diagnosing and altering root causes to prevent recurrence (second-order solutions). First-order problem solving allows work to continue but does nothing to prevent a similar problem from occurring. Workers exhibit first-order problem solving when they do not expend any more energy on a problem after obtaining the missing input needed to complete a task. Second-order problem solving, in contrast, investigates and seeks to change underlying causes of a problem.
Methodology
We gathered data on the actual problem situation and response of front-line workers through observation, enabling a better understanding of the nature and contextual triggers of different kinds of problem solving behaviors than would be possible with interviews or a survey. The first author shadowed twenty-two nurses in eight different hospitals for a total of 197 hours. Observations were made on all three shifts and on all days of the week to ensure an accurate representation of cycles of nursing work and support systems available to nurses.
Results
Through qualitative analysis of the 120 system problems we observed, we discerned a pattern of first-order problem solving that characterized the majority (92%) of nurses' responses when confronted with these obstacles. The pattern was comprised of two heuristics, or rules of thumb, that were embedded in the work system, and can be seen as guiding—either alone or in combination—nurses' problem responses for all but ten observed problem events. When nurses responded to problems using Heuristic #1, "Do what it takes to continue the care of the patient," their behavior was characterized by concern for securing the information or material they need to do their jobs and not on understanding what caused the problem to occur. After the nurses were able to resume caring for the patient, they did not expend any further effort on the problem, including communicating that it occurred. Heuristic #2, "Get help from your friends," was characterized by choosing to ask for help from people who were socially close rather than from those who were best equipped to correct the problem. The nurses followed this heuristic 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).
When we observed nurses engaging in second-order problem solving behavior, it was limited to relaying information about a problem, rather than suggesting or implementing a solution. Specifically, they 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.
Discussion
We identified three factors, embedded in psychological, organizational, and institutional features of the work environment that reinforced an emphasis on first-order over second-order problem solving. First, the nurses we observed had a heroic attitude about their ability to take care of and protect their patients. Second, the nurses' jobs, as observed in this study, were structured to foster first-order problem solving. These workers rarely had time in their work cycle to resolve problems, they did not have easy and convenient methods for communicating about problems, and they lacked access to other human resources who could assist them with difficulties. A third factor that may contribute to first-order problem solving behavior is the lower status of nurses relative to doctors and administrators. In the hospital setting, nurses are often reluctant to intrude upon a physician's time, even when the physician may have caused or have valuable information about a problem's cause (Edmondson, 1996).
Conclusions
This study investigated how the front-line context affects workers' responses to system problems. Our research suggested that a lack of available time and norms that valued quick, self-sufficient solutions to problems contributed to a pattern of front-line workers rarely engaging 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 were revealed to others within the organization, dramatically reducing the potential for organizational learning and improvement.
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| Our analysis of qualitative data suggests that the problem-solving behavior of front-line workers may reduce an organization's ability to detect underlying causes of recurring problems and thus take corrective action. | |
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In addition, when communication occurred, the significance of the problem was often ignored or downplayed by the receiver, resulting in further missed opportunities for investigation into the root cause of the disturbance. The data suggested that these small front-line problems collectively frustrate both the customer and the worker, and hinder the worker's ability to perform effectively, but when taken out of context and viewed individually, appear trivial. Thus, system aberrations that are often dismissed in the literature as being "simple to solve" often persist because of a cycle of inactivity.
We propose several necessary conditions for enabling 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, there needs to be frequent opportunities for communicating about problems with individuals who are responsible for supplying front-line workers with materials or information. We only observed front-line workers surfacing problems with others when they were able to communicate easily. Encouraging people to communicate and creating a psychologically safe environment (e.g., Edmondson, 1996) is not sufficient. There must be convenient opportunities in the course of the day for workers to give feedback. Third, when the signal is given that there is a problem, proper attention must be paid to it. Organizations 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, but too often this worker ran the risk of being considered a "complainer." 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, once the other conditions are in place, we can begin to encourage solution generation, experimentation, and consideration of the longer-term consequences of actions. Sixth, publicizing successful system problem solving will further encourage people to recognize the potential benefits of engaging in this kind of "extra" work.
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Five Questions For Anita Tucker
Anita L. Tucker, an HBS doctoral candidate in the Technology and Operations Management unit, is co-author of "When Solving Problems Prevents Organizational Learning". The paper has received conditional acceptance from the Journal of Organizational Change Management. Tucker recently shared her insights with HBS Working Knowledge editor Sean Silverthorne.
Silverthorne: Why did your study focus on nurses and hospitals?
Tucker: We decided to focus on nurses because nurses, who are highly skilled, motivated, and who use a problem-solving framework when caring for their patients, nonetheless seemed to face recurring obstacles throughout their work day. We wondered why this was so—that is, why with their skills and motivation, nurses did not seem to create substantial process improvements in the process of encountering problems on the job. Furthermore, it seemed like a fruitful place to study front-line problem solving because problems are plentiful, nurses are motivated, intelligent workers, and the problems pose a potential threat to patient safety—making the setting one in which our learning might ultimately have genuine usefulness. For our research method, we decided to use inductive, field-based observation because Steve Spear was able to gain such insights into the Toyota Production System using similar methods.
Although your work concentrates on hospital workers, do you think your results will apply broadly to other organizations across industries?
Yes, especially service industries, such as restaurant staff or airline workers. Most front-line workers, and service workers in particular, often rely on many other groups to provide tools and materials they need to do their jobs and it is almost inevitable that mistakes and difficulties will occur. However, the relatively low status of front-line workers in organizations means they often have trouble getting these other groups to improve their work systems so that the tools and materials are more reliable and useable on the front lines. Additionally, these workers are often under time pressure because they face a continuous stream of customers or goods. Their jobs are not normally structured so that they can work on something other than their immediate responsibilities.
You outline several potential remedies, and mention that several hospitals employ a person dedicated to improving system resources for nurses. In general, would it benefit companies to pinpoint a single individual to drive this awareness through the organization? Or is this better the work of a team?
There are roles for both individuals and teams to play. However, I think the most important thing is having an organizational culture where people ask the question, "What can we do so this problem does not happen again?" Once people have this mind set, there needs to be some mechanism for doing the hard work of investigating and removing root causes of problems. In our study, two nursing units had a dedicated person responsible for resolving problems that crossed boundaries. In these units, nurses brought their issues to this person, who then took responsibility for finding out what had gone wrong and ensuring that something was done to correct the situation. In units that did not have such a person, the nurses usually did not bring issues forward, or if they did, they lacked the organizational clout and available time to achieve any kind of success.
How can company leaders know if their organization is ignoring opportunities for change and learning from their front-line workers? What are the telltale signs?
The telltale sign is silence. I think most workers face daily challenges and obstacles. If managers don't hear about issues and problems, chances are they are missing opportunities to improve because workers have no way to—or are reluctant to—communicate about these problems. We are building on Amy Edmondson's research on psychological safety that shows learning and improvement is hampered when workers don't communicate about concerns.
It's interesting that after all the work that has been done on empowering front-line workers and on the importance of knowledge management, that problems like this seemingly remain commonplace in organizations. Why don't we learn these lessons?
I think that the notion of "empowerment" can be misleading because workers are sometimes expected to make improvements when they do not have any systems or processes to solve cross boundary problems. Front-line workers have a lot of good ideas on what should be improved and how to do it, but they need help getting these ideas implemented because their job demands do not leave them much slack time for improvement activities. Managers also need to be physically present and accessible so that workers have an opportunity to mention the problems they encountered. Empowerment is not abandonment.