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 Board of Directors has asked the hospital administration to begin a process of ‘rightsizing’ the clinical staff and to determine the best staffing and services mix to efficiently deliver the highest quality care in light of the devastating revenue loses for elective procedures during the last year. The board projects a 20% cut in staff in all major clinical areas. I have called you together to solicit ideas on how to get through this post-COVID period. Please put your recommendations in writing and send to my office by Friday afternoon. We will reconvene to discuss the most promising recommendations and develop our plan within the next 2 weeks.” The CEO leaves before anyone asks a question.
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
Medical and nursing professionals are taught to diagnose and solve problems using complex and systematic reasoning. When a patient presents with a specific problem/complaint, there are prescribed ways of assessing the patient and using diagnostic tests. This process results in a diagnosis of the problem and a standard treatment that may be tailored to the individual patient. Even though many clinical problems create pain and suffering for the patient and can be difficult to diagnosis, they can be characterized as tame since they most often resolve when the correct intervention is applied. Solving problems for patients and families is a source of great personal satisfaction for health professionals. The process applied in such cases becomes second nature: assess, plan, intervene and evaluate. On the other hand, intervening in wicked problems is messy, produces no definitive answers, and is fraught with conditions that spawn new problems, promoting secondary stress for medical and nursing clinicians. There are no protocols or clinical rubrics for addressing such wicked problems. Accordingly, the wicked problem-solver will need perseverance, resilience, equanimity, and creativity to be successful. Further, the strategies discussed in other chapters that promote calm, introspection, clear thinking, spirituality, humor, and the ability to relinquish perfectionism are all necessary in any effort to grapple with wicked 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.
Wicked problems are unique, often vague and defy definitive formulation especially since different individuals or groups see the problem situation from varying lenses, theories or even political perspectives which is referred to as “social complexity.”
The COVID-19 virus and the pandemic are unique in their expression. This SARS-related coronavirus (SARS-CoV-2) has defied previous notions of virus behavior and baffled the global scientific community. Drosten, a world-renowned virologist who has studied corona viruses for 17 years, expressed his surprise that coronavirus (COVID-19) emerged to be more deadly and much more transmissible than previous corona-type viruses. For example, it can spread from a host who is not experiencing symptoms.2 COVID-19 is also now linked to a new syndrome that effects children’s cardiac and respiratory systems, raising further questions concerning viral dynamics across the life span and with genetic and other individual variabilities.
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
Among the general population, those who are believers in science and public health principles may conflict with those who believe in individual rights and the freedom to defy legislated measures designed to protect the public’s health. There are also disagreements among medical and nursing professionals concerning the extent of their obligations to deliver care in environments that do not have sufficient protective equipment or staff. The question arises: Should they organize or just press on, caring for patients while risking health?
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,
wicked problems do not have final solutions. They are not problems that are definitively solved, like prescribing a proven drug for a common health problem. In fact, there are no solutions since wicked problems continue to morph into new, unique problems when attempts at solving are applied. Intervening in a wicked problem also produces unintended consequences that could be worse than what appeared to be the original problem.
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
Medical and nursing professionals are educated to “solve” clinical problems, yet wicked problems dictate that the word solution be removed from one’s vocabulary. The notion of a clinical problem without a solution is difficult for clinicians. As Nesse, a physician, comments, “in our clinical practice all our patient problems have a stopping rule. They recover and go home. They transfer to another system, or they die. Health care system challenges are not going anywhere. We have discussed the many problems of health care for all, of my 31 years in practice, and we will be doing it for the next 310 years.”3 Nesse’s approach is to select one aspect of a wicked problem and work to ameliorate it with the result of improving patient care and calmly facing the periodic storms.
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.
For example, the pandemic has brought mass vaccinations for other diseases such as measles, polio, yellow fever, and cholera to a halt in poor countries. Berkley, the head of the global vaccine alliance, calls the dilemma, “A devil’s choice”—to continue mass, door to door vaccination campaigns or move ahead and risk the spread of COVID-19.6 Further, 23 countries have already suspended measles vaccinations that would have provided immunity for 78 million children. The unintended consequences of this decision are likely to be catastrophic. While the pandemic provides dramatic examples of wicked problem principles, think of the challenges with which clinicians regularly grapple in clinical settings. How many of them are wicked? How many attempts at resolution have resulted in a worsening of the situation, as well as in being blamed or criticized for the “failure to solve”? Table 2.1 illustrates how the mitigation strategy of social distancing produced a cascade of both positive and negative unintended consequences.
Table 2.1 Unintended Consequences of Social Distancing/Lockdowns: A Pandemic Mitigation Strategy
|Positive Unintended Consequences||Negative Unintended Consequences|
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