Some problems are so complex that you have to be highly intelligent and well informed just to be undecided about them.

—L. J. Peter

The CEO of a 600-bed regional hospital has invited the leadership of all clinical disciplines to a meeting. Nurses, physicians, physician assistants, and lab personnel begin to assemble. The mood in the room is upbeat, given that admissions for COVID-19 have been declining for 2 weeks and the situation is normalizing. The staff believes that the CEO has called this meeting to thank everyone for their herculean efforts and to give an update on the state of the hospital post COVID. Instead, the news was dire as he hesitantly explains.

The room is silent at first. As staff file out, you listen to the chatter in the hallway. Who will staff the units? What will staff patient ratios be, especially in critical care? Suppose staff resign, and there is a second wave of COVID-19? By the time the meeting disbands, negative emotions were running high—so many questions, conflicting perspectives, and outright fear. And then a voice from the center of the staff expresses the group’s anger and frustration, “Last week we were heroes!” This hospital is experiencing a wicked problem catalyzed by the COVID-19 pandemic dynamics and its unintended consequences.

The term wicked problem originated in the design and planning literature. It slowly crept into the health care literature since it captures what health professionals frequently experience in trying to solve problems such as access to health care, reducing errors, coordination of care, deconstructing and reconstructing medical and nursing education in a technological age, and, most recently, dealing with a pandemic. Rittel, an urban planner and designer, coined the terms wicked and tame problems to differentiate the solvability of problems encountered in his field.¹ Tame problems

Analyzing Aspects of the COVID-19 Pandemic Through the Wicked Problem Lens

The characteristics of wicked problems, listed in the following text, are applied to the COVID-19 pandemic to illustrate the tangled and evolving complexity that promotes both primary and secondary stress in clinicians on the front lines of care.

Making matters worse, experts and political figures continue to offer conflicting theories and viewpoints about the origins of and approaches to the pandemic. And so, questions like the following abound:

Medical and nursing personnel may also disagree on how to treat or provide care. For example, there have been conflicting views not only on testing but also on the effectiveness of drugs that might ameliorate symptoms. Early clinical trials validated the positive effects of Remdesivir, originally developed to treat Ebola, but will there be side effects and negative sequelae? Will there be enough of the drug available, and who will receive it?

Nesse³ illustrates the inherent conflict that resides in the differences with which health care providers and administrators view and intervene in specific health care problems. He cites as an example, health care costs; “Providers think of patient compliance, preventive services and cost shifting. Payers think of excess utilization, provider strongholds, and waste. The government apparently thinks we haven’t got enough regulations, and the patients think we (clinicians) are all at fault for the entire mess!”³

Clashing interprofessional viewpoints that conceptualize problems differently can be an enormous source of stress. The point here is that: unique problems with unclear definitions generate conflicting viewpoints and resultant social complexity. This social complexity can then deteriorate into dynamics of blame and finger-pointing exacerbating secondary stress for those involved. In summary,

There is no better illustration of a wicked problem’s no-stopping rule than a pandemic. History teaches that achieving “final control” of the virus or having “an end” to the cycles of infection will not happen, even if an effective vaccine is developed. A vaccine, hopefully, will confer some level of immunity in most individuals, but there is no guarantee. The virus may mutate multiple times and flourish in environments yet unknown. Consider the decades old common “flu,” for which there is a vaccine but also an annual flu season with which we all live. During the 2018–2019 influenza season, the Centers for Disease Control and Prevention estimated that 35.5 million people got sick, 16.5 million visited a health provider for their illness. There were also 490,600 hospitalizations and 34,200 deaths of those who contracted influenza.⁴

After coming to grips with the “no stopping rule” there are the “unintended consequences” of specific interventions or attempts to “solve the problem.” Consider the unintended consequences of “social distancing” such as loneliness, the anxiety of not seeing family or friends or not being able to visit the sick and dying. Those in clinical practice have reported living in hotels instead of at home to protect their families from possible infection. The rates of depression and suicide among medical and nursing professionals has increased through the pandemic as well.

Kupferschmidt points out that moving forward, “governments around the world must triangulate the health of their citizens, the freedoms of their population, and economic restraints. Can schools be reopened? Restaurants? Bars? Can people go back to their offices?”^5p218 These questions point to the inherent stress involved in possibly making the wrong call—in producing, unpredicted, unintended consequences.