problem solving in healthcare

What is Problem-Solving in Nursing? (With Examples, Importance, & Tips to Improve)

Whether you have been a nurse for many years or you are just beginning your nursing career, chances are, you know that problem-solving skills are essential to your success. With all the skills you are expected to develop and hone as a nurse, you may wonder, “Exactly what is problem solving in nursing?” or “Why is it so important?” In this article, I will share some insight into problem-solving in nursing from my experience as a nurse. I will also tell you why I believe problem-solving skills are important and share some tips on how to improve your problem-solving skills.

What Exactly is Problem-Solving in Nursing?

5 reasons why problem-solving is important in nursing, reason #1: good problem-solving skills reflect effective clinical judgement and critical thinking skills, reason #2: improved patient outcomes, reason #3: problem-solving skills are essential for interdisciplinary collaboration, reason #4: problem-solving skills help promote preventative care measures, reason #5: fosters opportunities for improvement, 5 steps to effective problem-solving in nursing, step #1: gather information (assessment), step #2: identify the problem (diagnosis), step #3: collaborate with your team (planning), step #4: putting your plan into action (implementation), step #5: decide if your plan was effective (evaluation), what are the most common examples of problem-solving in nursing, example #1: what to do when a medication error occurs, how to solve:, example #2: delegating tasks when shifts are short-staffed, example #3: resolving conflicts between team members, example #4: dealing with communication barriers/lack of communication, example #5: lack of essential supplies, example #6: prioritizing care to facilitate time management, example #7: preventing ethical dilemmas from hindering patient care, example #8: finding ways to reduce risks to patient safety, bonus 7 tips to improve your problem-solving skills in nursing, tip #1: enhance your clinical knowledge by becoming a lifelong learner, tip #2: practice effective communication, tip #3: encourage creative thinking and team participation, tip #4: be open-minded, tip #5: utilize your critical thinking skills, tip #6: use evidence-based practices to guide decision-making, tip #7: set a good example for other nurses to follow, my final thoughts, list of sources used for this article.

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Problem Solving in Nursing: Strategies for Your Staff

4 min read • September, 15 2023

Problem solving is in a nurse manager’s DNA. As leaders, nurse managers solve problems every day on an individual level and with their teams. Effective leaders find innovative solutions to problems and encourage their staff to nurture their own critical thinking skills and see problems as opportunities rather than obstacles.

Health care constantly evolves, so problem solving and ingenuity are skills often used out of necessity. Tackling a problem requires considering multiple options to develop a solution. Problem solving in nursing requires a solid strategy.

Nurse problem solving

Nurse managers face challenges ranging from patient care matters to maintaining staff satisfaction. Encourage your staff to develop problem-solving nursing skills to cultivate new methods of improving patient care and to promote  nurse-led innovation .

Critical thinking skills are fostered throughout a nurse’s education, training, and career. These skills help nurses make informed decisions based on facts, data, and evidence to determine the best solution to a problem.

Problem-Solving Examples in Nursing

To solve a problem, begin by identifying it. Then analyze the problem, formulate possible solutions, and determine the best course of action. Remind staff that nurses have been solving problems since Florence Nightingale invented the nurse call system.

Nurses can implement the  original nursing process  to guide patient care for problem solving in nursing. These steps include:

• Assessment . Use critical thinking skills to brainstorm and gather information.
• Diagnosis . Identify the problem and any triggers or obstacles.
• Planning . Collaborate to formulate the desired outcome based on proven methods and resources.
• Implementation . Carry out the actions identified to resolve the problem.
• Evaluation . Reflect on the results and determine if the issue was resolved.

How to Develop Problem-Solving Strategies

Staff look to nurse managers to solve a problem, even when there’s not always an obvious solution. Leaders focused on problem solving encourage their team to work collaboratively to find an answer. Core leadership skills are a good way to nurture a health care environment that supports sharing concerns and  innovation .

Here are some essentials for building a culture of innovation that encourages problem solving:

• Present problems as opportunities instead of obstacles.
• Strive to be a positive role model. Support creative thinking and staff collaboration.
• Encourage feedback and embrace new ideas.
• Respect staff knowledge and abilities.
• Match competencies with specific needs and inspire effective decision-making.
• Offer opportunities for  continual learning and career growth.
• Promote research and analysis opportunities.
• Provide support and necessary resources.
• Recognize contributions and reward efforts .

Embrace Innovation to Find Solutions

Try this exercise:

Consider an ongoing departmental issue and encourage everyone to participate in brainstorming a solution. The team will:

• Define the problem, including triggers or obstacles.
• Determine methods that worked in the past to resolve similar issues.
• Explore innovative solutions.
• Develop a plan to implement a solution and monitor and evaluate results.

Problems arise unexpectedly in the fast-paced health care environment. Nurses must be able to react using critical thinking and quick decision-making skills to implement practical solutions. By employing problem-solving strategies, nurse leaders and their staff can  improve patient outcomes  and refine their nursing skills.

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Nurse leaders as problem-solvers

Addressing lateral and horizontal violence.

Anthony, Michelle R. PhD, RN; Brett, Anne Liners PhD, RN

Michelle R. Anthony is a program coordinator at Columbia (S.C.) VA Health Care System. Anne Liners Brett is doctoral faculty at the University of Phoenix in Tempe, Ariz.

Acknowledgment: The authors acknowledge the support of the University of Phoenix Center for Educational and Instructional Technology Research.

The contents of this article do not represent the views of the US Department of Veterans Affairs or the United States Government.

The authors and planners have disclosed no potential conflicts of interest, financial or otherwise.

For more than 126 additional continuing-education articles related to management topics, go to NursingCenter.com/CE .

Earn CE credit online: Go to http://nursing.ceconnection.com and receive a certificate within minutes .

Read about a qualitative, grounded theory study that looked to gain a deeper understanding of nurse leaders' perceptions of their role in addressing lateral and horizontal violence, and the substantive theory developed from the results.

The issue of lateral and horizontal violence (LHV) has plagued the nursing profession for more than 3 decades, yet solutions remain elusive. The significance of LHV isn't lost on nurse leaders because it creates an unhealthy work environment. Research literature worldwide has continued to report the prevalence of disruptive behaviors experienced by nursing students, novice nurses, and seasoned nurses in the workforce. The World Health Organization, International Council of Nurses, and Public Services International have recognized this issue as a major global public health priority. 1

LHV, also called nurse-on-nurse aggression, disruptive behavior, or incivility, undermines a culture of safety and negatively impacts patient care. 2,3 This experience, known to nurses as “eating their young,” isn't only intimidating and disruptive, it's also costly and demoralizing to the nursing profession and healthcare organizations. 4,5 Although the impact of LHV can be dreadful for both the institution and its staff, little is known about the reasons for these behaviors among nursing professionals. 2

LHV encompasses all acts of meanness, hostility, disruption, discourtesy, backbiting, divisiveness, criticism, lack of unison, verbal or mental abuse, and scapegoating. 6 The sole intent of bullying behaviors is to purposefully humiliate and demean victims. Bullying behaviors also taint healthcare organizations; cause irreparable harm to workplace culture; breakdown team communication; and severely impact the quality of the care provided, thereby jeopardizing patient safety. 7,8 Researchers have reported that acts of LHV are used to demonstrate power, domination, or aggression; for retribution; to control others; and to enhance self-image. 9-12

Previous studies have shown that the frequency of LHV in healthcare organizations is quite severe, with about 90% of new nurses surveyed reporting acts of incivility by their coworkers. 13 Sixty-five percent of nurses in one survey reported witnessing incidents of despicable acts, whereas another 46% of coworkers in the same survey reported the issue as “very serious” and “somewhat serious.” 13

LHV poses a significant challenge for nurse leaders who are legally and morally responsible for providing a safe working environment. 2,6 The purpose of this qualitative, grounded theory study was to gain a deeper understanding of nurse leaders' perceptions of their role in addressing LHV and develop a substantive theory from the results.

Literature review

A paucity of evidence exists in the literature regarding how nurse leaders perceive their role in addressing LHV. 14 Studies have shown that this phenomenon is attributed to heavy workloads, a stressful work environment, and lack of workgroup cohesiveness, as well as organizational factors such as misuse of authority and the lack of organizational policies and procedures for addressing LHV behaviors. 15

In one study, one-third of the nurses reported that they had observed emotional abuse during several of their work shifts. 16 Another study indicated that 30% of survey respondents (n = 2,100) stated LHV occurs weekly. 17 A third study revealed that 25% of participants noted LHV happened monthly, and a fourth study of ED nurses reported that about 27.3% of the nurses had experienced LHV perpetrated by nursing leadership (managers, supervisors, charge nurses, and directors), physicians, or peers in the last 6 months. 18

In a survey completed by members of the Washington State Emergency Nurses Association, 27% of respondents experienced acts of bullying in the past 6 months. 19 Another study reported that 27% to 85% of nurse respondents had experienced some form of uncivil behavior. 20 Other data have shown that those more vulnerable to violent, disruptive, and intimidating behaviors are newly licensed nurses beginning their careers. 21

Although nurse leaders can be perpetrators of LHV, they play an essential role in addressing LHV behaviors and creating a safe work environment. 22 The literature suggests that, in many cases, a lack of awareness and response by nurse leaders adds to the prevalence of LHV. 23 This may be due, in part, to nurse leaders being aligned with the perpetrators who are creating the toxic work environment. 6 The literature suggests that an environment where staff members feel safe to practice results in a culture that decreases burnout and promotes nurse retention and quality outcomes. 24,25

This qualitative, grounded theory study focused on nurse leaders' perception of their role in breaking the cycle of LHV for staff members whom they supervise. Two research questions guided the study: 1. How do nurse leaders perceive their role in addressing LHV among nursing staff members under their supervision? 2. What substantive theory may emerge from the data collected during interviews with nurse leaders?

A grounded theory methodology was used to explore the nurse leader's role in addressing LHV with the intent of developing a substantive theory through the meaningful organization of data themes to provide a framework to address the phenomenon of LHV. Purposive sampling was used to recruit a total of 14 participants for this study from a large healthcare system in the Southeastern US. The participants were chosen because of their experience with LHV and their ability to discuss and reflect on those experiences. Informed consent was obtained before the start of the study, which included explaining the reason for the study and what to expect. In addition, permission was obtained from the Institutional Review Board.

Data collection and analysis

Demographic data collected to describe the sample included gender, age range, number of years holding a management position, supervisory responsibility, and highest degree obtained. (See Table 1 .)

Semistructured, in-depth interviews were the primary mode of data collection. The recorded interviews were conducted face-to-face and lasted about 60 minutes. Data collection continued until saturation was achieved. Data saturation occurred when no new descriptive codes, categories, or themes were emerging from the analyzed data. The interviews were transcribed verbatim and verified through a member check process.

During the data analysis process, themes and patterns were identified. Data from each participant's interview were examined to determine if the responses were aligned with the identified themes. Analysis of the data included coding at increasingly abstract levels and constant comparison. Qualitative software assisted in coding the information and uncovering subtle trends.

Four themes emerged from core categories developed during the qualitative data coding process.

Theme 1: Understanding/addressing LHV . In question one, participants were asked to describe their understanding of LHV. Five subthemes emerged from the data collected with this question. (See Table 2 .)

Theme 2: Experience addressing LHV . In the second question, participants were asked about their experience with addressing incidents of LHV. Six subthemes were identified. (See Table 3 .)

Theme 3: Role perception in addressing LHV . In the third question, participants were asked what they perceive their role to be in addressing LHV. Six subthemes resulted from this question. (See Table 4 .)

Theme 4: Organizational impediment to addressing LHV . In question four, participants were asked to describe the factors within the organization that influence or impede their role in addressing LHV. This question yielded nine subthemes. (See Table 5 .)

Substantive theory

As a result of the themes that emerged from the data, a substantive theory was developed. This is especially important for the nursing profession to develop as a scientifically based practice. Theories help guide research and provide the expansion, generation, and validation of the science of nursing knowledge. 26 The substantive theory will help nurse leaders become more cognizant of the role that effective leadership plays in preventing or intervening in incidents of LHV in the workplace. The analysis revealed that nurse leaders are aware that the quality of patient care and staff well-being can be adversely affected by the impact of LHV.

Data themes were used to formulate the following theory: Nurse leaders address LHV affecting their staff members by solving problems, creating a safe work environment, and reducing institutional barriers that impede addressing LHV in a timely fashion. Nurse leaders perceive their role as a problem-solver, which is a necessary step in advocacy. 27 Problem-solving is a process that contains the elements of decision-making and critical thinking. 28

The theory that emerged from the core categories explicitly focused on the central phenomenon of LHV in the nursing work environment. Figure 1 shows the interrelatedness of the themes to the resultant substantive theory.

Discussion and implications

The study results have several implications for both the nursing profession and nurse leaders. The nursing profession requires decisive and robust leadership, and the role of the nurse leader is to be a combination of nurturer, investigator, and judge to examine incidents of LHV. 26,29-32 Nurse leaders are responsible for setting the tone and expectations for a safe work environment. This includes modeling the expected ethical behaviors; for example, doing the right things for the right reasons, being collegial toward each other, and being respectful of other's differences. One participant remarked, “This is a different world based on how I was raised. I was raised to be respectful to people.”

In addition, nurse leaders are responsible for enforcing policies created to address disruptive behaviors and working with the administration as soon as an incident occurs. Past research indicates that a healthy and collaborative work environment fosters nurse engagement and patient safety. 25,30 Staff members and patients need a leader to protect them when necessary; thus, the nurse leader needs to “walk the walk” in providing a safe environment for all. Nurse leaders engaged in these kinds of behaviors are providing strong leadership and practicing strong decision-making, thus ensuring the continued robustness of their organizations.

Recommendations and limitations

Future research could replicate this study in a different geographic region to explore the causes of LHV by soliciting the views of nursing students, new graduate nurses, and nurse educators from unionized and nonunionized hospital systems and comparing the results to further understand this phenomenon. Additionally, developing a tool to test the substantive theory could substantiate the nurse leader's role as a problem-solver to address incidence of LHV in the workplace.

The decision to conduct this study in one type of healthcare organization limits the ability to compare the interviewed nurse leaders' experiences with nurse leaders in other healthcare organizations. The experiences of nurses in other healthcare organizations may be different; thus, overall generalizability of the study may be limited.

Say “no” to the status quo

The results of this study support the findings of previous researchers. 23,31,33,34 Accepting the status quo is unacceptable and can cause irreparable harm to organizational well-being if LHV isn't addressed. Collaboration between nurse leaders and administrators is essential to successfully reduce institutional obstacles that prevent the timely handling of LHV incidents. The role of the nurse leader as a problem-solver should be clear, defined, and well supported to seek resolutions to toxic behaviors that are hurting the work environment. But we must remember that creating a policy doesn't equal change. Every employee from the lowest level in the organization to the highest ranks of administration must model civil behaviors.

INSTRUCTIONS Nurse leaders as problem-solvers: Addressing lateral and horizontal violence

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Teaching Critical Thinking and Problem-Solving Skills to Healthcare Professionals

Affiliation.

• 1 Department of Medical Education, Paul L Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX USA.
• PMID: 34457878
• PMCID: PMC8368273
• DOI: 10.1007/s40670-020-01128-3

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Conflict of InterestThe authors declare that they have no conflict of interest.

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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
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• Research article
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• Published: 07 October 2020

Impact of social problem-solving training on critical thinking and decision making of nursing students

• Soleiman Ahmady 1 &
• Sara Shahbazi   ORCID: orcid.org/0000-0001-8397-6233 2 , 3  

BMC Nursing volume  19 , Article number:  94 ( 2020 ) Cite this article

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The complex health system and challenging patient care environment require experienced nurses, especially those with high cognitive skills such as problem-solving, decision- making and critical thinking. Therefore, this study investigated the impact of social problem-solving training on nursing students’ critical thinking and decision-making.

This study was quasi-experimental research and pre-test and post-test design and performed on 40 undergraduate/four-year students of nursing in Borujen Nursing School/Iran that was randomly divided into 2 groups; experimental ( n  = 20) and control (n = 20). Then, a social problem-solving course was held for the experimental group. A demographic questionnaire, social problem-solving inventory-revised, California critical thinking test, and decision-making questionnaire was used to collect the information. The reliability and validity of all of them were confirmed. Data analysis was performed using SPSS software and independent sampled T-test, paired T-test, square chi, and Pearson correlation coefficient.

The finding indicated that the social problem-solving course positively affected the student’ social problem-solving and decision-making and critical thinking skills after the instructional course in the experimental group ( P  < 0.05), but this result was not observed in the control group ( P  > 0.05).

Conclusions

The results showed that structured social problem-solving training could improve cognitive problem-solving, critical thinking, and decision-making skills. Considering this result, nursing education should be presented using new strategies and creative and different ways from traditional education methods. Cognitive skills training should be integrated in the nursing curriculum. Therefore, training cognitive skills such as problem- solving to nursing students is recommended.

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Continuous monitoring and providing high-quality care to patients is one of the main tasks of nurses. Nurses’ roles are diverse and include care, educational, supportive, and interventional roles when dealing with patients’ clinical problems [ 1 , 2 ].

Providing professional nursing services requires the cognitive skills such as problem-solving, decision-making and critical thinking, and information synthesis [ 3 ].

Problem-solving is an essential skill in nursing. Improving this skill is very important for nurses because it is an intellectual process which requires the reflection and creative thinking [ 4 ].

Problem-solving skill means acquiring knowledge to reach a solution, and a person’s ability to use this knowledge to find a solution requires critical thinking. The promotion of these skills is considered a necessary condition for nurses’ performance in the nursing profession [ 5 , 6 ].

Managing the complexities and challenges of health systems requires competent nurses with high levels of critical thinking skills. A nurse’s critical thinking skills can affect patient safety because it enables nurses to correctly diagnose the patient’s initial problem and take the right action for the right reason [ 4 , 7 , 8 ].

Problem-solving and decision-making are complex and difficult processes for nurses, because they have to care for multiple patients with different problems in complex and unpredictable treatment environments [ 9 , 10 ].

Clinical decision making is an important element of professional nursing care; nurses’ ability to form effective clinical decisions is the most significant issue affecting the care standard. Nurses build 2 kinds of choices associated with the practice: patient care decisions that affect direct patient care and occupational decisions that affect the work context or teams [ 11 , 12 , 13 , 14 , 15 , 16 ].

The utilization of nursing process guarantees the provision of professional and effective care. The nursing process provides nurses with the chance to learn problem-solving skills through teamwork, health management, and patient care. Problem-solving is at the heart of nursing process which is why this skill underlies all nursing practices. Therefore, proper training of this skill in an undergraduate nursing program is essential [ 17 ].

Nursing students face unique problems which are specific to the clinical and therapeutic environment, causing a lot of stresses during clinical education. This stress can affect their problem- solving skills [ 18 , 19 , 20 , 21 ]. They need to promote their problem-solving and critical thinking skills to meet the complex needs of current healthcare settings and should be able to respond to changing circumstances and apply knowledge and skills in different clinical situations [ 22 ]. Institutions should provide this important opportunity for them.

Despite, the results of studies in nursing students show the weakness of their problem-solving skills, while in complex health environments and exposure to emerging diseases, nurses need to diagnose problems and solve them rapidly accurately. The teaching of these skills should begin in college and continue in health care environments [ 5 , 23 , 24 ].

It should not be forgotten that in addition to the problems caused by the patients’ disease, a large proportion of the problems facing nurses are related to the procedures of the natural life of their patients and their families, the majority of nurses with the rest of health team and the various roles defined for nurses [ 25 ].

Therefore, in addition to above- mentioned issues, other ability is required to deal with common problems in the working environment for nurses, the skill is “social problem solving”, because the term social problem-solving includes a method of problem-solving in the “natural context” or the “real world” [ 26 , 27 ]. In reviewing the existing research literature on the competencies and skills required by nursing students, what attracts a lot of attention is the weakness of basic skills and the lack of formal and systematic training of these skills in the nursing curriculum, it indicates a gap in this area [ 5 , 24 , 25 ]. In this regard, the researchers tried to reduce this significant gap by holding a formal problem-solving skills training course, emphasizing the common social issues in the real world of work. Therefore, this study was conducted to investigate the impact of social problem-solving skills training on nursing students’ critical thinking and decision-making.

Setting and sample

This quasi-experimental study with pretest and post-test design was performed on 40 undergraduate/four-year nursing students in Borujen nursing school in Shahrekord University of Medical Sciences. The periods of data collection were 4 months.

According to the fact that senior students of nursing have passed clinical training and internship programs, they have more familiarity with wards and treatment areas, patients and issues in treatment areas and also they have faced the problems which the nurses have with other health team personnel and patients and their families, they have been chosen for this study. Therefore, this study’s sampling method was based on the purpose, and the sample size was equal to the total population. The whole of four-year nursing students participated in this study and the sample size was 40 members. Participants was randomly divided in 2 groups; experimental ( n  = 20) and control (n = 20).

The inclusion criteria to take part in the present research were students’ willingness to take part, studying in the four-year nursing, not having the record of psychological sickness or using the related drugs (all based on their self-utterance).

Intervention

At the beginning of study, all students completed the demographic information’ questionnaire. The study’s intervening variables were controlled between the two groups [such as age, marital status, work experience, training courses, psychological illness, psychiatric medication use and improving cognitive skills courses (critical thinking, problem- solving, and decision making in the last 6 months)]. Both groups were homogeneous in terms of demographic variables ( P  > 0.05). Decision making and critical thinking skills and social problem solving of participants in 2 groups was evaluated before and 1 month after the intervention.

All questionnaires were anonymous and had an identification code which carefully distributed by the researcher.

To control the transfer of information among the students of two groups, the classification list of students for internships, provided by the head of nursing department at the beginning of semester, was used.

Furthermore, the groups with the odd number of experimental group and the groups with the even number formed the control group and thus were less in contact with each other.

The importance of not transferring information among groups was fully described to the experimental group. They were asked not to provide any information about the course to the students of the control group.

Then, training a course of social problem-solving skills for the experimental group, given in a separate course and the period from the nursing curriculum and was held in 8 sessions during 2 months, using small group discussion, brainstorming, case-based discussion, and reaching the solution in small 4 member groups, taking results of the social problem-solving model as mentioned by D-zurilla and gold fried [ 26 ]. The instructor was an assistant professor of university and had a history of teaching problem-solving courses. This model’ stages are explained in Table  1 .

All training sessions were performed due to the model, and one step of the model was implemented in each session. In each session, the teacher stated the educational objectives and asked the students to share their experiences in dealing to various workplace problems, home and community due to the topic of session. Besides, in each session, a case-based scenario was presented and thoroughly analyzed, and students discussed it.

Instruments

In this study, the data were collected using demographic variables questionnaire and social problem- solving inventory – revised (SPSI-R) developed by D’zurilla and Nezu (2002) [ 26 ], California critical thinking skills test- form B (CCTST; 1994) [ 27 , 28 ] and decision-making questionnaire.

SPSI-R is a self - reporting tool with 52 questions ranging from a Likert scale (1: Absolutely not – 5: very much).

The minimum score maybe 25 and at a maximum of 125, therefore:

The score 25 and 50: weak social problem-solving skills.

The score 50–75: moderate social problem-solving skills.

The score higher of 75: strong social problem-solving skills.

The reliability assessed by repeated tests is between 0.68 and 0.91, and its alpha coefficient between 0.69 and 0.95 was reported [ 26 ]. The structural validity of questionnaire has also been confirmed. All validity analyses have confirmed SPSI as a social problem - solving scale.

In Iran, the alpha coefficient of 0.85 is measured for five factors, and the retest reliability coefficient was obtained 0.88. All of the narratives analyzes confirmed SPSI as a social problem- solving scale [ 29 ].

California critical thinking skills test- form B(CCTST; 1994): This test is a standard tool for assessing the basic skills of critical thinking at the high school and higher education levels (Facione & Facione, 1992, 1998) [ 27 ].

This tool has 34 multiple-choice questions which assessed analysis, inference, and argument evaluation. Facione and Facione (1993) reported that a KR-20 range of 0.65 to 0.75 for this tool is acceptable [ 27 ].

In Iran, the KR-20 for the total scale was 0.62. This coefficient is acceptable for questionnaires that measure the level of thinking ability of individuals.

After changing the English names of this questionnaire to Persian, its content validity was approved by the Board of Experts.

The subscale analysis of Persian version of CCTST showed a positive high level of correlation between total test score and the components (analysis, r = 0.61; evaluation, r = 0.71; inference, r = 0.88; inductive reasoning, r = 0.73; and deductive reasoning, r = 0.74) [ 28 ].

A decision-making questionnaire with 20 questions was used to measure decision-making skills. This questionnaire was made by a researcher and was prepared under the supervision of a professor with psychometric expertise. Five professors confirmed the face and content validity of this questionnaire. The reliability was obtained at 0.87 which confirmed for 30 students using the test-retest method at a time interval of 2 weeks. Each question had four levels and a score from 0.25 to 1. The minimum score of this questionnaire was 5, and the maximum score was 20 [ 30 ].

Statistical analysis

For analyzing the applied data, the SPSS Version 16, and descriptive statistics tests, independent sample T-test, paired T-test, Pearson correlation coefficient, and square chi were used. The significant level was taken P  < 0.05.

The average age of students was 21.7 ± 1.34, and the academic average total score was 16.32 ± 2.83. Other demographic characteristics are presented in Table  2 .

None of the students had a history of psychiatric illness or psychiatric drug use. Findings obtained from the chi-square test showed that there is not any significant difference between the two groups statistically in terms of demographic variables.

The mean scores in social decision making, critical thinking, and decision-making in whole samples before intervention showed no significant difference between the two groups statistically ( P  > 0.05), but showed a significant difference after the intervention ( P  < 0.05) (Table  3 ).

Scores in Table  4 showed a significant positive difference before and after intervention in the “experimental” group ( P  < 0.05), but this difference was not seen in the control group ( P  > 0.05).

Among the demographic variables, only a positive relationship was seen between marital status and decision-making skills (r = 0.72, P  < 0.05).

Also, the scores of critical thinking skill’ subgroups and social problem solving’ subgroups are presented in Tables  5 and 6 which showed a significant positive difference before and after intervention in the “experimental” group (P < 0.05), but this difference was not seen in the control group ( P  > 0.05).

In the present study conducted by some studies, problem-solving and critical thinking and decision-making scores of nursing students are moderate [ 5 , 24 , 31 ].

The results showed that problem-solving skills, critical thinking, and decision-making in nursing students were promoted through a social problem-solving training course. Unfortunately, no study has examined the effect of teaching social problem-solving skills on nursing students’ critical thinking and decision-making skills.

Altun (2018) believes that if the values of truth and human dignity are promoted in students, it will help them acquire problem-solving skills. Free discussion between students and faculty on value topics can lead to the development of students’ information processing in values. Developing self-awareness increases students’ impartiality and problem-solving ability [ 5 ]. The results of this study are consistent to the results of present study.

Erozkan (2017), in his study, reported there is a significant relationship between social problem solving and social self-efficacy and the sub-dimensions of social problem solving [ 32 ]. In the present study, social problem -solving skills training has improved problem -solving skills and its subdivisions.

The results of study by Moshirabadi (2015) showed that the mean score of total problem-solving skills was 89.52 ± 21.58 and this average was lower in fourth-year students than other students. He explained that education should improve students’ problem-solving skills. Because nursing students with advanced problem-solving skills are vital to today’s evolving society [ 22 ]. In the present study, the results showed students’ weakness in the skills in question, and holding a social problem-solving skills training course could increase the level of these skills.

Çinar (2010) reported midwives and nurses are expected to use problem-solving strategies and effective decision-making in their work, using rich basic knowledge.

These skills should be developed throughout one’s profession. The results of this study showed that academic education could increase problem-solving skills of nursing and midwifery students, and final year students have higher skill levels [ 23 ].

Bayani (2012) reported that the ability to solve social problems has a determining role in mental health. Problem-solving training can lead to a level upgrade of mental health and quality of life [ 33 ]; These results agree with the results obtained in our study.

Conducted by this study, Kocoglu (2016) reported nurses’ understanding of their problem-solving skills is moderate. Receiving advice and support from qualified nursing managers and educators can enhance this skill and positively impact their behavior [ 31 ].

Kashaninia (2015), in her study, reported teaching critical thinking skills can promote critical thinking and the application of rational decision-making styles by nurses.

One of the main components of sound performance in nursing is nurses’ ability to process information and make good decisions; these abilities themselves require critical thinking. Therefore, universities should envisage educational and supportive programs emphasizing critical thinking to cultivate their students’ professional competencies, decision-making, problem-solving, and self-efficacy [ 34 ].

The study results of Kirmizi (2015) also showed a moderate positive relationship between critical thinking and problem-solving skills [ 35 ].

Hong (2015) reported that using continuing PBL training promotes reflection and critical thinking in clinical nurses. Applying brainstorming in PBL increases the motivation to participate collaboratively and encourages teamwork. Learners become familiar with different perspectives on patients’ problems and gain a more comprehensive understanding. Achieving these competencies is the basis of clinical decision-making in nursing. The dynamic and ongoing involvement of clinical staff can bridge the gap between theory and practice [ 36 ].

Ancel (2016) emphasizes that structured and managed problem-solving training can increase students’ confidence in applying problem-solving skills and help them achieve self-confidence. He reported that nursing students want to be taught in more innovative ways than traditional teaching methods which cognitive skills training should be included in their curriculum. To this end, university faculties and lecturers should believe in the importance of strategies used in teaching and the richness of educational content offered to students [ 17 ].

The results of these recent studies are adjusted with the finding of recent research and emphasize the importance of structured teaching cognitive skills to nurses and nursing students.

Based on the results of this study on improving critical thinking and decision-making skills in the intervention group, researchers guess the reasons to achieve the results of study in the following cases:

In nursing internationally, problem-solving skills (PS) have been introduced as a key strategy for better patient care [ 17 ]. Problem-solving can be defined as a self-oriented cognitive-behavioral process used to identify or discover effective solutions to a special problem in everyday life. In particular, the application of this cognitive-behavioral methodology identifies a wide range of possible effective solutions to a particular problem and enhancement the likelihood of selecting the most effective solution from among the various options [ 27 ].

In social problem-solving theory, there is a difference among the concepts of problem-solving and solution implementation, because the concepts of these two processes are different, and in practice, they require different skills.

In the problem-solving process, we seek to find solutions to specific problems, while in the implementation of solution, the process of implementing those solutions in the real problematic situation is considered [ 25 , 26 ].

The use of D’zurilla and Goldfride’s social problem-solving model was effective in achieving the study results because of its theoretical foundations and the usage of the principles of cognitive reinforcement skills. Social problem solving is considered an intellectual, logical, effort-based, and deliberate activity [ 26 , 32 ]; therefore, using this model can also affect other skills that need recognition.

In this study, problem-solving training from case studies and group discussion methods, brainstorming, and activity in small groups, was used.

There are significant educational achievements in using small- group learning strategies. The limited number of learners in each group increases the interaction between learners, instructors, and content. In this way, the teacher will be able to predict activities and apply techniques that will lead students to achieve high cognitive taxonomy levels. That is, confront students with assignments and activities that force them to use cognitive processes such as analysis, reasoning, evaluation, and criticism.

In small groups, students are given the opportunity to the enquiry, discuss differences of opinion, and come up with solutions. This method creates a comprehensive understanding of the subject for the student [ 36 ].

According to the results, social problem solving increases the nurses’ decision-making ability and critical thinking regarding identifying the patient’s needs and choosing the best nursing procedures. According to what was discussed, the implementation of this intervention in larger groups and in different levels of education by teaching other cognitive skills and examining their impact on other cognitive skills of nursing students, in the future, is recommended.

Social problem- solving training by affecting critical thinking skills and decision-making of nursing students increases patient safety. It improves the quality of care because patients’ needs are better identified and analyzed, and the best solutions are adopted to solve the problem.

In the end, the implementation of this intervention in larger groups in different levels of education by teaching other cognitive skills and examining their impact on other cognitive skills of nursing students in the future is recommended.

Study limitations

This study was performed on fourth-year nursing students, but the students of other levels should be studied during a cohort from the beginning to the end of course to monitor the cognitive skills improvement.

The promotion of high-level cognitive skills is one of the main goals of higher education. It is very necessary to adopt appropriate approaches to improve the level of thinking. According to this study results, the teachers and planners are expected to use effective approaches and models such as D’zurilla and Goldfride social problem solving to improve problem-solving, critical thinking, and decision-making skills. What has been confirmed in this study is that the routine training in the control group should, as it should, has not been able to improve the students’ critical thinking skills, and the traditional educational system needs to be transformed and reviewed to achieve this goal.

Availability of data and materials

The datasets used and analyzed during the present study are available from the corresponding author on reasonable request.

Abbreviations

California critical thinking skills test

Social problem-solving inventory – revised

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Acknowledgments

This article results from research project No. 980 approved by the Research and Technology Department of Shahrekord University of Medical Sciences. We would like to appreciate to all personnel and students of the Borujen Nursing School. The efforts of all those who assisted us throughout this research.

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SA and SSH conceptualized the study, developed the proposal, coordinated the project, completed initial data entry and analysis, and wrote the report. SSH conducted the statistical analyses. SA and SSH assisted in writing and editing the final report. All authors read and approved the final manuscript.

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This study was reviewed and given exempt status by the Institutional Review Board of the research and technology department of Shahrekord University of Medical Sciences (IRB No. 08–2017-109). Before the survey, students completed a research consent form and were assured that their information would remain confidential. After the end of the study, a training course for the control group students was held.

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Ahmady, S., Shahbazi, S. Impact of social problem-solving training on critical thinking and decision making of nursing students. BMC Nurs 19 , 94 (2020). https://doi.org/10.1186/s12912-020-00487-x

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Applied Problem-Solving in Healthcare Management is a practical textbook devoted to developing and strengthening problem-solving and decision-making leadership competencies of healthcare administration students and healthcare management professionals. Built upon the University of Minnesota Master of Healthcare Administration Program’s Problem-Solving Method, the text describes the “never assume” mindset and the structured method that drive evidence-based, action-oriented problem-solving. The “never assume” mindset requires healthcare leaders to understand themselves and their stakeholders, and to engage in waves of divergent and convergent thinking. This structured method guides the problem solver through the phases of defining, studying, and acting on complex interrelated organizational problems that involve multiple root causes. The book also describes how the Problem-Solving Method is complementary to quality improvement methods and can be used in healthcare organizations along with Lean, Design Thinking, and Human Centered Design.

Providing step-by-step instruction including useful tips, tools, activities, and case studies, this effective resource demonstrates the utility of the method for all types of health organization settings including health systems, hospitals, clinics, population health, and long-term care. For students taking health management, capstone, and experiential learning courses, including internship and residency projects, this book allows them to test and apply their problem-solving and decision-making skills to real-world situations. Beyond the classroom, it is an indispensable resource for organizations seeking to enhance the problem-solving skills of their workforce.

The authors of the text have nearly 75 years of combined experience in healthcare management, leadership, and professional consulting, and teaching and advising healthcare administration students in classrooms, on student capstone, internship and residency projects, and case competitions. Synthesizing their expertise, this text serves as a guide for those who wish to strengthen their problem-solving abilities to systematically identify, analyze, study, and solve pressing organizational challenges in healthcare settings.

• Describes a mindset and a structured problem-solving method that builds leadership competencies
• Encourages a step-by-step problem-solving approach to define, study, and act on problems to drive action-oriented solutions
• Supports experiential learning and coaching for students and professionals early in their careers, applicable especially to healthcare management, capstone, and student consulting courses, internship and residency projects, case competitions, and professional development in organizations
• Compares the Problem-Solving Method to other complementary methods used in many healthcare organizations, including Lean, Design Thinking, and Human Centered Design
• Includes access to the fully downloadable eBook as well as ancillary materials such as Instructor’s Manual and Sample Syllabi

Part I: The Mindset and Method for Problem-Solving

Chapter 1: The Problem Isn’t Always What It Seems

Chapter 2: The Problem-Solving Method

Chapter 3: Comparison of Problem-Solving Methods

Chapter 4: Management and Leadership Competencies of the Problem-Solving Method

Part II: Practice the Define Phase

Overview of Parts II, III, IV

Chapter 5: Practice Define Step D1: Situation and Scope

Chapter 6: Practice Define Step D2: Stakeholders, Difficulties and Problem Areas

Chapter 7: Practice Define Step D3: Issue Statements and Problem Statement

Chapter 8: Define Phase Activity Key

Part III: Practice the Study Phase

Chapter 9: Practice Study Step S1: Root Causes and Alternative Solutions

Chapter 10: Practice Study Step S2: Decision Criteria, Research, and Findings

Chapter 11: Practice Study Step S3: Conclusions

Chapter 12: Study Phase Activity Key

Part IV: Practice the Act Phase

Chapter 13: Practice Act Step A1: Recommendations and Milestones

Chapter 14: Practice Act Step A2: Communication Strategy and Consensus Building

Chapter 15: Practice Act Step A3: Implementation and Monitoring

Chapter 16: Act Phase Activity Key

Part V: Problem-Solving Cases

Overview of Part V

Chapter 17: Operations and Quality Cases

Chapter 18: Strategic Healthcare Cases

Chapter 19: Population Health Cases

Chapter 20: Long Term Care Cases

Sandra Potthoff, PhD is a retired Professor from the University of South Florida, Tampa, where she served as the Chair of the Department of Health Policy and Management.

Justine Mishek, MHA is an experienced graduate education lecturer and healthcare management consultant. Ms. Mishek currently serves as Senior Lecturer for the University of Minnesota Masters of Healthcare Administration Program and is a part of the Program Leadership Team.

Gregory Hart, MHA is a principal with CliftonLarsenAllen (CLA) where he serves in the healthcare consulting practice and an alumni of the University of Minnesota MHA Program. Mr. Hart has more than 40 years of experience in healthcare leadership and management. Before joining CLA in 1995 he served as CEO for the University of Minnesota Health System, an academic medical center. Mr. Hart is a Senior Fellow at the University of Minnesota School of Public Health.

• Release Date: October 22, 2020
• Paperback / softback
• Trim Size: 7in x 10in
• Number of Illustrations: 25
• ISBN: 9780826165640
• eBook ISBN: 9780826165657

More From Forbes

15 innovative ideas for fixing healthcare from 15 brilliant minds.

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Top row: Malcolm Gladwell, Elisabeth Rosenthal, David Feinberg, Devi Shetty, Eric Topol. Second row: ... [+] Richard Pollack, Donald Berwick, Zubin Damania, Amanda Calhoun, Christopher and Gordon Chen. Third row: Rod Rohrich, Jen Gunter, Vinod Khosla. Fourth row: Marty Makary, Jonathan Fisher, Robert Pearl.

After 18 years as CEO in Kaiser Permanente , I set my sights on improving the heatlh of the nation, hoping to find a way to achieve the same quality, technology and affordability our medical group delivered to 5 million patients on both coasts.

That quest launched the Fixing Healthcare podcast in 2018, and it inspired interviews with dozens of leaders, thinkers and doers, both in and around medicine. These experts shared innovative ideas and proven solutions for achieving (a) superior quality, (b) improved patient access, (c) lower overall costs, and (d) greater patient and clinician satisfaction.

This month, after 150 combined episodes , three questions emerged:

• Which of the hundreds of ideas presented remain most promising?
• Why, after five years and so many excellent solutions, has our nation experienced such limited improvements in healthcare?
• And finally, how will these great ideas become reality?

To answer the first question, I offer 15 of the best Fixing Healthcare recommendations so far. Some quotes have been modified for clarity with links to all original episodes (and transcripts) included.

Best Short-Term Health Insurance Companies Of 2022

Best health insurance companies of 2022, fixing the business of medicine.

1. Malcolm Gladwell , journalist and five-time bestselling author: “In other professions, when people break rules and bring greater economic efficiency or value, we reward them. In medicine, we need to demonstrate a consistent pattern of rewarding the person who does things better.”

2. Richard Pollack , CEO of the American Hospital Association (AHA): “I hope in 10 years we have more integrated delivery systems providing care, not bouncing people around from one unconnected facility to the next. I would hope that we’re in a position where there’s a real focus on ensuring that people get care in a very convenient way.”

Eliminating burnout

3. Zubin Damania , aka ZDoggMD, hospitalist and healthcare satirist: “In the culture of medicine, specialists view primary care as the weak medical students, the people who couldn’t get the board scores or rotation honors to become a specialist. Because why would you do primary care? It’s miserable. You don’t get paid enough. It’s drudgery. We must change these perceptions.”

4. Devi Shetty , India’s leading heart surgeon and founder of Narayana Health: “When you strive to work for a purpose, which is not about profiting yourself, the purpose of our action is to help society, mankind on a large scale. When that happens, cosmic forces ensure that all the required components come in place and your dream becomes a reality.”

5. Jonathan Fisher , cardiologist and clinician advocate: “The problem we’re facing in healthcare is that clinicians are all siloed. We may be siloed in our own institution thinking that we’re doing it best. We may be siloed in our own specialty thinking that we’re better than others. All of these divides need to be bridged. We need to begin the bridging.”

Making medicine equitable

6. Jen Gunter , women’s health advocate and “the internet’s OB-GYN”: “Women are not listened to by doctors in the way that men are. They have a harder time navigating the system because of that. Many times, they’re told their pain isn’t that serious or their bleeding isn’t that heavy. We must do better at teaching women’s health in medicine.”

7. Amanda Calhoun , activist, researcher and anti-racism educator: “A 2015 survey showed that white residents and medical students still thought Black people feel less pain, which is wild to me because Black is a race. It’s not biological. This is actually an historical belief that persists. One of the biggest things we can do as the medical system is work on rebuilding trust with the Black community.”

Addressing social determinants of health

8. Don Berwick , former CMS administrator and head of 100,000 Lives campaign: “We know where the money should go if we really want to be a healthy nation: early childhood development, workplaces that thrive, support to the lonely, to elders, to community infrastructures like food security and transportation security and housing security, to anti-racism and criminal-justice reform. But we starve the infrastructures that could produce health to support the massive architecture of intervention.”

9. David T. Feinberg , chairman of Oracle Health: “Twenty percent of whether we live or die, whether we have life in our years and years in our life, is based on going to good doctors and good hospitals. We should put the majority of effort on the stuff that really impacts your health: your genetic code, your zip code, your social environment, your access to clean food, your access to transportation, how much loneliness you have or don’t have.”

Empowering patients

10. Elisabeth Rosenthal , physician, author and editor-in-chief of KHN : “To patients, I say write about your surprise medical bills. Write to a journalist, write to your local newspaper. Hospitals today are very sensitive about their reputations and they do not want to be shamed by some of these charges.”

11. Gordon Chen , ChenMed CMO: “If you think about what leadership really is, it’s influence. Nothing more, nothing less. And the only way to achieve better health in patients is to get them to change their behaviors in a positive way. That behavior change takes influence. It requires primary care physicians to build relationship and earn trust with patients. That is how both doctors and patients can drive better health outcomes.”

Utilizing technology

12. Vinod Khosla , entrepreneur, investor, technologist: “The most expensive part of the U.S. healthcare system is expertise, and expertise can relatively be tamed with technology and AI. We can capture some of that expertise, so each oncologist can do 10 times more patient care than they would on their own without that help.”

13. Rod Rohrich , influential plastic surgeon and social media proponent: “Doctors, use social media to empower your audience, to educate them, and not to overwhelm them. If you approach social media by educating patients about their own health, how they can be better, how can they do things better, how they can find doctors better, that’s a good thing.”

Rethinking medical education

14. Marty Makary , surgeon and public policy researcher: “I would get rid of all the useless sh*t we teach our medical students and residents and fellows. In the 16 years of education that I went through, I learned stuff that has nothing to do with patient care, stuff that nobody needs to memorize.”

15. Eric Topol , cardiologist, scientist and AI expert: “It’s pretty embarrassing. If you go across 150 medical schools, not one has AI as a core curriculum. Patients will get well versed in AI. It’s important that physicians stay ahead, as well.”

Great ideas, but little progress

Since 2018, our nation has spent $20 trillion on medical care, navigated the largest global pandemic in a century and developed an effective mRNA vaccine, nearly from scratch. And yet, despite all this spending and scientific innovation, American medicine has lost ground.

American life expectancy has dropped while maternal mortality rates have worsened. Clinician burnout has accelerated amid a growing shortage of primary care and emergency medicine physicians. And compared to 12 of its wealthiest global peers, the United States spends nearly twice as much per person on medical care, but ranks last in clinical outcomes .

Guests on Fixing Healthcare generally agree on the causes of stagnating national progress. Healthcare system giants, including those in the drug, insurance and hospital industries, find it easier to drive up prices than to prevent disease or make care-delivery more efficient. Over the past decade, they’ve formed a conglomerate of monopolies that prosper from the existing rules, leaving them little incentive to innovate on behalf of patients. And in this era of deep partisan divide, meaningful healthcare reforms have not (and won’t) come from Congress.

Then who will lead the way?

Industry change never happens because it should. It happens when demand and opportunity collide, creating space for new entrants and outsiders to push past the established incumbents. In healthcare, I see two possibilities:

1. Providers will rally and reform healthcare

Doctors and hospitals are struggling. They’re struggling with declining morale and decreasing revenue. Clinicians are exiting the profession and hospitals are shuttering their doors. As the pain intensifies, medical group leaders may be the ones who decide to begin the process of change.

The first step would be to demand payment reform. Today’s reimbursement model, fee-for-service, pays doctors and hospitals based on the quantity of care they provide—not the quality of care. This methodology pushes physicians to see more patients, spend less time with them, and perform ever-more administrative (billing) tasks. Physicians liken it to being in a hamster wheel: running faster and faster just to stay in place.

Instead, providers of care could be paid by insurers, the government and self-funded businesses directly, through a model called “ capitation .” With capitation, groups of providers receive a fixed amount of money per year. That sum depends on the number of enrollees they care for and the amount of care those individuals are expected to need based on their age and underlying diseases.

This model puts most of the financial risk on providers, encouraging them to deliver high-quality, effective medical care. With capitation, doctors and hospitals have strong financial incentives to prevent illnesses through timely and recommended preventive screenings and a focus on lifestyle-medicine (which includes diet, exercise and stress reduction). They’re rewarded for managing patients’ health and helping them avoid costly complications from chronic diseases, such as heart attacks, strokes and cancer.

Capitation encourages doctors from all specialties to collaborate and work together on behalf of patients, thus reducing the isolation physicians experience while ensuring fewer patients fall through the cracks of our dysfunctional healthcare system. The payment methodology aligns the needs of patients with the interests of providers, which has the power to restore the sense of mission and purpose medicine has lost.

Capitation at the delivery-system level eliminates the need for prior authorization from insurers (a key cause of clinician burnout) and elevates the esteem accorded to primary care doctors (who focus on disease prevention and care coordination). And because the financial benefits are tied to better health outcomes, the capitated model rewards clinicians who eliminate racial and gender disparities in medical care and organizations that take steps to address the social determinants of health.

2. Major retailers will take over

If clinicians don’t lead the way, corporate behemoths like Amazon, CVS and Walmart will disrupt the healthcare system as we know it. These retailers are acquiring the insurance, pharmacy and direct-patient-care pieces needed to squeeze out the incumbents and take over American healthcare.

Each is investing in new ways to empower patients, provide in-home care and radically improve access to both in-person and virtual medicine. Once generative AI solutions like ChatGPT gain enough computing power and users, tech-savvy retailers will apply this tool to monitor patients, enable healthier lifestyles and improve the quality of medical care compared to today.

When Fixing Healthcare debuted five years ago, none of the show’s guests could have foreseen a pandemic that left more than a million dead. But, had our nation embraced their ideas from the outset, many of those lives would have been saved. The pandemic rocked an already unstable and underperforming healthcare system. Our nation’s failure to prevent and control chronic disease resulted in hundreds of thousands of unnecessary deaths from Covid-19. Outdated information technology systems, medical errors and disparities in care caused hundreds of thousands more. As a nation, we could have done much better.

With the cracks in the system widening and the foundation eroding, disruption in healthcare is inevitable. What remains to be seen is whether it will come from inside or outside the U.S. healthcare system.

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‘It is clear that support workers need more support themselves’

STEVE FORD, EDITOR

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Thinking your way to successful problem-solving

13 September, 2001 By NT Contributor

VOL: 97, ISSUE: 37, PAGE NO: 36

Jacqueline Wheeler, DMS, MSc, RGN, is a lecturer at Buckinghamshire Chilterns University College

Problems - some people like them, some do not think they have any, while others shy away from them as if they were the plague. Opportunities, in the form of problems, are part of your life.

The most difficult decision is deciding to tackle a problem and implement a solution, especially as it is sometimes easier to ignore its existence. Problem-solving takes time and effort, but once a problem has been addressed the nurse can feel satisfied that the issue has been resolved and is therefore less likely to re-emerge.

Nurses make clinical decisions using two different approaches. The first is the rationalist approach, which involves an analysis of a situation so that subsequent actions are rational, logical and based on knowledge and judgement. The second approach is based on a phenomenological perspective, where a fluid, flexible and dynamic approach to decision-making is required, such as when dealing with an acutely ill patient.

Types of problems

Problems come in different guises and the solver can perceive them either as a challenge or a threat. One of the most common types of problem is when the unexpected happens. As a nurse you plan and implement care for a patient based on your knowledge and experience, only to find that the patient’s reaction is totally different from that expected but without any apparent reason.

Another type of problem is an assignment where others set a goal or task. Throughout your working life you will be required to undertake duties on behalf of other people. For some this is difficult as they feel unable to control their workload. Others see it as an opportunity to develop new skills or take on additional responsibilities. Opportunities can be perceived as problems by those who fear failure.

A third type of problem is when a dilemma arises. This is when it is difficult to choose the best solution to a problem because the nurse is confronted with something that challenges his or her personal and/or professional values.

Diagnosing problems

The sooner a problem is identified and solutions devised, the better for all involved. So try to anticipate or identify problems when they occur through continuously monitoring staff performance and patient outcomes.

Listening to and observing junior staff will help you to detect work or organisational concerns, because when there are problems staff are likely to behave in an unusual or inconsistent manner.

Initial analysis

Remember that people view things differently, so what you perceive as a problem may not be one to anyone else. So before you begin thinking about what to do - whether to keep it under surveillance, contain it or find a solution - you should undertake an initial analysis. This will help you to understand the problem more clearly.

An analysis will also enable you to prioritise its importance in relation to other problems as problems do not occur one at a time.

Routine problems often need little clarification, so an initial analysis is recommended for non-routine problems only. Even then, not all problems justify the same degree of analysis. But where it is appropriate, an initial analysis will provide a basis from which to generate solutions.

Perception is also important when dealing with patients’ problems. For example, if a patient gives up reading because he or she cannot hold the book (objective), the nurse may assume it is because the patient has lost interest (subjective, one’s own view).

Generating solutions

It is essential for the problem-solver to remember that, where possible, solutions must come from those connected with the problem. If it is to be resolved, agreement must be owned by those involved as they are probably the best and only people who can resolve their differences. The manager should never feel that he or she must be on hand to deal with all disputes.

To solve a problem you need to generate solutions. However, the obvious solution may not necessarily be the best. To generate solutions, a mixture of creative and analytical thinking is needed (Bransford, 1993).

Creativity is about escaping from preconceived ideas that block the way to finding an innovative solution to a problem. An effective tool for assisting in this process is the technique of lateral thinking, which is based largely on the work of Edward de Bono, who regards thinking as a skill.

There are several ways to encourage creative decision-making. One method that works best for specific or simple problems is brainstorming. If the ground rules of confidentiality and being non-judgemental are applied, it will produce a free flow of ideas generated without fear of criticism (Rawlinson, 1986).

Time constraints and staff availability may make it difficult for all those involved in a problem to meet. In such cases an adaptation of brainstorming - where a blank piece of paper is given to those involved and each writes down four solutions to the problem - may be the answer. A similar technique is the collective notebook, where people are asked to record their thoughts and ideas about a problem for a specified period.

An alternative is where one person writes down a list of solutions in order of priority, which is then added to by others. This helps to prioritise the ideas generated. All these methods produce data that can then be analysed by the problem-solver.

When the problem affects people in different geographical areas, solutions can be generated by obtaining the opinion of experts through the use of a questionnaire, which is known as the Delphi technique (McKenna, 1994).

When an apparently insurmountable problem presents itself, it is often useful to divide it into smaller pieces. This is known as convergent thinking. Using divergent thinking - where you consider a problem in different ways to expand your view - may also help. 

A final alternative is the stepladder technique, which is time-consuming but effective if the issue is stirring up strong feelings. This requires the people involved in the problem to be organised into groups. First, two people try to solve the problem, then a third member is drawn in, to whom the solution reached by the first two is presented. All three then try to agree a solution. More people are added to the group, if necessary, in a similar way, until there is agreement of all involved. Provided the individuals are motivated to solve the problem, this technique creates ownership and commitment to implementing the agreed solution.

Analytical thinking, which follows a logical process of eliminating ideas, will enable you to narrow the range down to one feasible solution.

Although someone has to make the ultimate decision on which solution to implement, there are advantages to group decision-making: a greater number of possible solutions are generated and conflicts are resolved, resulting in decisions being reached through rational discussion.

This does, however, require the group to be functioning well or the individuals involved may feel inhibited in contributing to the decision-making. One individual may dominate the group or competition between individuals may result in the need to win taking precedence over deciding on an agreed practical solution.

As nursing becomes less bureaucratic individuals are being encouraged to put forward their own ideas, but social pressures to conform may inhibit the group. We do not solve problems and make decisions in isolation, but are influenced by the environment in which we work and the role we fulfil in that environment. If group members lack commitment and/or motivation, they may accept the first solution and pay little attention to other solutions offered.

Making a decision

There are three types of decision-making environments: certain, risk and uncertain. The certain environment, where we have sufficient information to allow us to select the best solution, is the most comfortable within which to make a decision, but it is the least often encountered.

We usually encounter the risk environment, where we lack complete certainty about the outcomes of various courses of action.

Finally, the uncertain environment is the least comfortable within which to make decisions as we are almost forced to do this blind. We are unable to forecast the possible outcomes of alternative courses of action and, therefore, have to rely heavily on creative intuition and the educated guess.

Taking this into consideration, you should not contemplate making a decision until you have all the information needed. Before you make your decision, remind yourself of the objective, reassess the priorities, consider the options and weigh up the strengths, weaknesses, opportunities and threats of each solution.

An alternative is to use the method that Thomas Edison used to solve the problem of the electric light bulb. Simply focus on your problem as you drift off to sleep, and when you wake up your subconscious mind will have presented you with the answer. But bear in mind that this is not a scientific way of solving problems - your subconscious can be unreliable.

If you are not sure about your decision, test the solution out on others who do not own the problem but may have encountered a similar dilemma. Once you have made your choice stick to it, or you may find it difficult to implement because those involved will never be sure which solution is current. They will also be reluctant to become involved in any future decision-making because of your uncertainty.

The next step is to ensure that all the people involved know what decision has been made. Where possible, brief the group and follow this up with written communication to ensure everyone knows what is expected of them. You may need to sell the decision to some, especially if they were not involved in the decision-making process or the solution chosen is not theirs.

Implementing the solution

Finally, to ensure the solution is implemented, check that the people involved know who is to do what, by when and that it has happened. Review the results of implementing your solution (see Box) and praise and thank all those involved.

- Part 1 of this series was published in last week’s issue: Wheeler, J. (2001) How to delegate your way to a better working life. Nursing Times; 97: 36, 34-35.

Next week. Part three: a step-by-step guide to effective report writing.

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To Improve Health Care, Focus on Fixing Systems — Not People

• Kedar S. Mate,
• Josh Clark,
• Jeff Salvon-Harman

Leadership and culture are often blamed when underlying systems are the real problem.

When efforts to improve health care fall short, the failures are often blamed on leadership and culture. But the main problem often is the underlying systems. To generate better outcomes, increase safety, and improve efficiency, health care organizations should shift their focus to designing systems that facilitate delivery of the highest-quality care.

Over the past three decades, many health systems have pursued improvements in care delivery to make it safer, more effective, and more efficient. Many banners have flown over this work: quality improvement, systems change, lean daily management, performance improvement, to name a few. When these activities fail to deliver on expected goals, two common and inter-related failure modes are usually cited: leadership and culture. Leadership because it has failed to create conditions that would lead to the improvement succeeding; and culture because it has failed to be the fertile soil in which the improvement could take root.

• Kedar S. Mate , MD, is president and chief executive officer of the Institute for Healthcare Improvement and a member of the faculty of Weill Cornell Medical College.
• Josh Clark is a vice president at the Institute of Healthcare Improvement. Prior to joining IHI, Josh served as the senior vice president of quality and safety operations at Jefferson Health, an 18-hospital system covering the greater Philadelphia region and southern New Jersey, and senior director of quality and safety at Carilion Clinic, a health system based in Roanoke, Virginia.
• Jeff Salvon-Harman , MD, is vice president of safety at the Institute for Healthcare Improvement.

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FACT FOCUS: A look at false claims around Kamala Harris and her campaign for the White House

Democrats are quickly rallying around Vice President Kamala Harris as their likely presidential nominee after President Joe Biden’s ground-shaking decision to bow out of the 2024 race.

Vice President Kamala Harris arrives to speak from the South Lawn of the White House in Washington, Monday, July 22, 2024, during an event with NCAA college athletes. This is her first public appearance since President Joe Biden endorsed her to be the next presidential nominee of the Democratic Party. (AP Photo/Alex Brandon)

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The announcement that Vice President Kamala Harris will seek the Democratic nomination for president is inspiring a wave of false claims about her eligibility and her background. Some first emerged years ago, while others only surfaced after President Joe Biden’s decision to end his bid for a second term.

Here’s a look at the facts.

CLAIM: Harris is not an American citizen and therefore cannot serve as commander in chief.

THE FACTS: Completely false . Harris is a natural born U.S. citizen. She was born on Oct. 20, 1964, in Oakland, California, according to a copy of her birth certificate, obtained by The Associated Press.

Her mother, a cancer researcher from India, and her father, an economist from Jamaica, met as graduate students at the University of California, Berkeley.

Under the 14th Amendment to the Constitution, anyone born on U.S. soil is considered a natural born U.S. citizen and eligible to serve as either the vice president or president.

“All persons born or naturalized in the United States, and subject to the jurisdiction thereof, are citizens of the United States and of the State wherein they reside,” reads the amendment.

There is no question or legitimate debate about whether a citizen like Harris is eligible to serve as president or vice president, said Jessica Levinson, a professor at Loyola Law School.

“So many legal questions are really nuanced — this isn’t one of those situations,” Levinson told the AP on Monday.

Still, social media posts making the debunked assertion that Harris cannot serve as president went viral soon after Biden announced Sunday that he was dropping out of the race and would back Harris for president.

“Kamala Harris is not eligible to run for President,” read one post on X that was liked more than 34,000 times. “Neither of her parents were natural born American citizens when she was born.”

False assertions about Harris’ eligibility began circulating in 2019 when she launched her bid for the presidency. They got a boost, thanks in part to then-President Donald Trump, when Biden selected her as his running mate.

“I heard today that she doesn’t meet the requirements,” the Republican said of Harris in 2019.

CLAIM: Harris is not Black.

THE FACTS: This is false. Harris is Black and Indian . Her father, Donald Harris, is a Black man who was born in Jamaica. Shyamala Gopalan, her mother, was born in southern India. Harris has spoken publicly for many years, including in her 2019 autobiography , about how she identifies with the heritage of both her parents.

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Despite ample evidence to the contrary, social media users are making erroneous claims about Harris’ race.

“Just a reminder that Kamala Harris @KamalaHarris isn’t black,” reads one X post that had received approximately 42,000 likes and 20,400 shares as of Monday. “She Indian American. She pretends to be black as part of the delusional, Democrat DEI quota.”

But Harris is both Black and Indian. Indeed, she is the first woman, Black person and person of South Asian descent to serve as vice president. This fact is highlighted in her biography on WhiteHouse.gov and she has spoken about her ethnicity on many occasions.

Harris wrote in her autobiography, “The Truths We Hold: An American Journey,” that she identifies with the heritage of both her mother and father.

“My mother, grandparents, aunts, and uncle instilled us with pride in our South Asian roots,” she wrote. “Our classical Indian names harked back to our heritage, and we were raised with a strong awareness and appreciation for Indian culture.”

In the next paragraph, she adds, “My mother understood very well that she was raising two black daughters.” Harris again refers to herself as a “black woman” in the book’s next chapter.

CLAIM: Harris got her start by having an affair with a married man, California politician Willie Brown.

THE FACTS: This is missing some important context. Brown was separated from his wife during the relationship, which was not a secret.

Brown, 90, is a former mayor of San Francisco who was serving as speaker of the California State Assembly in the 1990s when he and Harris were in a relationship. Brown had separated from his wife in 1982.

“Yes, we dated. It was more than 20 years ago,” Brown wrote in 2020 in the San Francisco Chronicle under the article title, “Sure, I dated Kamala Harris. So what?”

He wrote that he supported Harris’ first race to be San Francisco district attorney — just as he has supported a long list of other California politicians, including former House Speaker Nancy Pelosi, former Sen. Dianne Feinstein and Gov. Gavin Newsom.

Harris, 59, was state attorney general from 2011-2017 and served in the Senate from 2017 until 2021, when she became vice president. She has been married to Doug Emhoff since 2014.

Harris’ critics have used the past relationship to question her qualifications, as Fox News personality Tomi Lahren did when she wrote on social media in 2019: “Kamala did you fight for ideals or did you sleep your way to the top with Willie Brown.” Lahren later apologized for the comment.

Trump and some of his supporters have also highlighted the nearly three-decade old relationship in recent attacks on Harris .

CLAIM: An Inside Edition clip of television host Montel Williams holding hands with Harris and another woman is proof that Harris was his “side piece.”

THE FACTS: The clip shows Montel with Harris and his daughter, Ashley Williams. Harris and Williams, a former marine who hosted “The Montel Williams Show” for more than a decade, dated briefly in the early 2000s.

In the clip, taken from a 2019 Inside Edition segment , Williams can be seen posing for photographs and holding hands with both women as they arrive at the 2001 Eighth Annual Race to Erase MS in Los Angeles.

But social media users are misrepresenting the clip, using it as alleged evidence that Harris was Montel’s “side piece” — a term used to describe a person, typically a woman, who has a sexual relationship with a man in a monogamous relationship.

Williams addressed the false claims in an X post on Monday, writing in reference to the Inside Edition clip, “as most of you know, that is my daughter to my right.” Getty Images photos from the Los Angeles gala identify the women as Harris and Ashley Williams.

In 2019, Williams described his relationship with Harris in a post on X, then known as Twitter.

“@KamalaHarris and I briefly dated about 20 years ago when we were both single,” he wrote in an X post at the time. “So what? I have great respect for Sen. Harris. I have to wonder if the same stories about her dating history would have been written if she were a male candidate?”

CLAIM: Harris promised to inflict the “vengeance of a nation” on Trump supporters.

THE FACTS: A fabricated quote attributed to Harris is spreading online five years after it first surfaced.

In the quote, Harris supposedly promises that if Trump is defeated in 2020, Trump supporters will be targeted by the federal government: “Once Trump’s gone and we have regained our rightful place in the White House, look out if you supported him and endorsed his actions, because we’ll be coming for you next. You will feel the vengeance of a nation.”

The quote was shared again on social media this week. One post on X containing an image of the quote was shared more than 22,000 times as of Monday afternoon.

The remarks didn’t come from Harris , but from a satirical article published online in August 2019. Shortly after, Trump supporters like musician Ted Nugent reposted the comments without noting they were fake.

CLAIM: A video shows Harris saying in a speech: “Today is today. And yesterday was today yesterday. Tomorrow will be today tomorrow. So live today, so the future today will be as the past today as it is tomorrow.”

THE FACTS: Harris never said this. Footage from a 2023 rally on reproductive rights at Howard University, her alma mater, was altered to make it seem as though she did.

In the days after Harris headlined the Washington rally, Republicans mocked a real clip of her speech, with one critic dubbing her remarks a “word salad,” the AP reported at the time .

Harris says in the clip: “So I think it’s very important — as you have heard from so many incredible leaders — for us, at every moment in time, and certainly this one, to see the moment in time in which we exist and are present, and to be able to contextualize it, to understand where we exist in the history and in the moment as it relates not only to the past, but the future.”

NARAL Pro-Choice America, an abortion rights nonprofit whose president also spoke at the rally, livestreamed the original footage. It shows Harris making the “moment in time” remark, but not the “today is today” comment.

The White House’s transcript of Harris’ remarks also does not include the statement from the altered video. Harris’ appearance at the event came the same day that Biden announced their reelection bid .

Find AP Fact Checks here: https://apnews.com/APFactCheck .

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Google DeepMind’s new AI systems can now solve complex math problems

AlphaProof and AlphaGeometry 2 are steps toward building systems that can reason, which could unlock exciting new capabilities.

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AI models can easily generate essays and other types of text. However, they’re nowhere near as good at solving math problems, which tend to involve logical reasoning—something that’s beyond the capabilities of most current AI systems.

But that may finally be changing. Google DeepMind says it has trained two specialized AI systems to solve complex math problems involving advanced reasoning. The systems—called AlphaProof and AlphaGeometry 2—worked together to successfully solve four out of six problems from this year’s International Mathematical Olympiad (IMO), a prestigious competition for high school students. They won the equivalent of a silver medal.

It’s the first time any AI system has ever achieved such a high success rate on these kinds of problems. “This is great progress in the field of machine learning and AI,” says Pushmeet Kohli, vice president of research at Google DeepMind, who worked on the project. “No such system has been developed until now which could solve problems at this success rate with this level of generality.” 

There are a few reasons math problems that involve advanced reasoning are difficult for AI systems to solve. These types of problems often require forming and drawing on abstractions. They also involve complex hierarchical planning, as well as setting subgoals, backtracking, and trying new paths. All these are challenging for AI. 

“It is often easier to train a model for mathematics if you have a way to check its answers (e.g., in a formal language), but there is comparatively less formal mathematics data online compared to free-form natural language (informal language),” says Katie Collins, an researcher at the University of Cambridge who specializes in math and AI but was not involved in the project. 

Bridging this gap was Google DeepMind’s goal in creating AlphaProof, a reinforcement-learning-based system that trains itself to prove mathematical statements in the formal programming language Lean. The key is a version of DeepMind’s Gemini AI that’s fine-tuned to automatically translate math problems phrased in natural, informal language into formal statements, which are easier for the AI to process. This created a large library of formal math problems with varying degrees of difficulty.

Automating the process of translating data into formal language is a big step forward for the math community, says Wenda Li, a lecturer in hybrid AI at the University of Edinburgh, who peer-reviewed the research but was not involved in the project. 

“We can have much greater confidence in the correctness of published results if they are able to formulate this proving system, and it can also become more collaborative,” he adds.

The Gemini model works alongside AlphaZero —the reinforcement-learning model that Google DeepMind trained to master games such as Go and chess—to prove or disprove millions of mathematical problems. The more problems it has successfully solved, the better AlphaProof has become at tackling problems of increasing complexity.

Although AlphaProof was trained to tackle problems across a wide range of mathematical topics, AlphaGeometry 2—an improved version of a system that Google DeepMind announced in January—was optimized to tackle problems relating to movements of objects and equations involving angles, ratios, and distances. Because it was trained on significantly more synthetic data than its predecessor, it was able to take on much more challenging geometry questions.

To test the systems’ capabilities, Google DeepMind researchers tasked them with solving the six problems given to humans competing in this year’s IMO and proving that the answers were correct. AlphaProof solved two algebra problems and one number theory problem, one of which was the competition’s hardest. AlphaGeometry 2 successfully solved a geometry question, but two questions on combinatorics (an area of math focused on counting and arranging objects) were left unsolved.   

“Generally, AlphaProof performs much better on algebra and number theory than combinatorics,” says Alex Davies, a research engineer on the AlphaProof team. “We are still working to understand why this is, which will hopefully lead us to improve the system.”

Two renowned mathematicians, Tim Gowers and Joseph Myers, checked the systems’ submissions. They awarded each of their four correct answers full marks (seven out of seven), giving the systems a total of 28 points out of a maximum of 42. A human participant earning this score would be awarded a silver medal and just miss out on gold, the threshold for which starts at 29 points. 

This is the first time any AI system has been able to achieve a medal-level performance on IMO questions. “As a mathematician, I find it very impressive, and a significant jump from what was previously possible,” Gowers said during a press conference. 

Myers agreed that the systems’ math answers represent a substantial advance over what AI could previously achieve. “It will be interesting to see how things scale and whether they can be made faster, and whether it can extend to other sorts of mathematics,” he said.

Creating AI systems that can solve more challenging mathematics problems could pave the way for exciting human-AI collaborations, helping mathematicians to both solve and invent new kinds of problems, says Collins. This in turn could help us learn more about how we humans tackle math.

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Chaos and Confusion: Tech Outage Causes Disruptions Worldwide

Airlines, hospitals and people’s computers were affected after CrowdStrike, a cybersecurity company, sent out a flawed software update.

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By Adam Satariano Paul Mozur Kate Conger and Sheera Frenkel

• July 19, 2024

Airlines grounded flights. Operators of 911 lines could not respond to emergencies. Hospitals canceled surgeries. Retailers closed for the day. And the actions all traced back to a batch of bad computer code.

A flawed software update sent out by a little-known cybersecurity company caused chaos and disruption around the world on Friday. The company, CrowdStrike , based in Austin, Texas, makes software used by multinational corporations, government agencies and scores of other organizations to protect against hackers and online intruders.

But when CrowdStrike sent its update on Thursday to its customers that run Microsoft Windows software, computers began to crash.

The fallout, which was immediate and inescapable, highlighted the brittleness of global technology infrastructure. The world has become reliant on Microsoft and a handful of cybersecurity firms like CrowdStrike. So when a single flawed piece of software is released over the internet, it can almost instantly damage countless companies and organizations that depend on the technology as part of everyday business.

“This is a very, very uncomfortable illustration of the fragility of the world’s core internet infrastructure,” said Ciaran Martin, the former chief executive of Britain’s National Cyber Security Center and a professor at the Blavatnik School of Government at Oxford University.

A cyberattack did not cause the widespread outage, but the effects on Friday showed how devastating the damage can be when a main artery of the global technology system is disrupted. It raised broader questions about CrowdStrike’s testing processes and what repercussions such software firms should face when flaws in their code cause major disruptions.

How a Software Update Crashed Computers Around the World

Here’s a visual explanation for how a faulty software update crippled machines.

How the airline cancellations rippled around the world (and across time zones)

Share of canceled flights at 25 airports on Friday

50% of flights

Ai r po r t

Bengalu r u K empeg o wda

Dhaka Shahjalal

Minneapolis-Saint P aul

Stuttga r t

Melbou r ne

Be r lin B r anden b urg

London City

Amsterdam Schiphol

Chicago O'Hare

Raleigh−Durham

B r adl e y

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Reagan National

Philadelphia

1:20 a.m. ET

CrowdStrike’s stock price so far this year

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Biden asked Harris to tackle the 'root causes' of migration. Here's what happened after that.

President Joe Biden tapped Kamala Harris to tackle the daunting issue of immigration in March 2021, but the vice president’s public-facing work on addressing the root causes of migration largely evaporated within months, according to an NBC News analysis of public documents, U.S. aid disbursements and Harris’ travel schedule.

Harris traveled to Mexico in June 2021 to sign an agreement that has led to a commitment of $4 billion in direct assistance and over $5.2 billion in private-public investment from the U.S. But she has not visited the southern border, or the countries to its south, since January 2022. And despite requests from Mexico for more investment, her “Root Causes Strategy” made no new financial commitments.

When Harris became Biden’s “ border czar ,” as critics called her, the administration was under pressure from both sides to address the rising number of migrants — particularly unaccompanied children — crossing the border and landing in poor conditions in U.S. custody. On March 24, 2021, Biden took the stage at the White House and seemed to hand the keys on the issue over to his vice president.

“The vice president has agreed — among the multiple other things that I have her leading, and I appreciate it — agreed to lead our diplomatic effort to work with those nations to accept returnees and enhance migration enforcement at their borders,” Biden said.

In accepting the task, Harris made her role more specific, describing largely diplomatic responsibilities. “I look forward to engaging in diplomacy with government, with the private sector, with civil society and the leaders of each in El Salvador, Guatemala and Honduras to strengthen democracy and the rule of law and ensure shared prosperity in the region. We will collaborate with Mexico and other countries throughout the Western Hemisphere.”

Biden administration officials have pointed to those remarks in rejecting criticism that Harris did not solve the crisis at the border, where there have been record crossings under Biden. They say her job was to focus on working with countries in the region to address root causes, and they reject the mocking title “border czar.” 

The Border Patrol union says Harris did not deliver on any of her immigration-related assignments. 

When Harris’ name is mentioned at the border, “it’s a lot of eye rolls,” said Jon Anfinsen, national executive vice president of the National Border Patrol Council, the Border Patrol union. 

“I would ask what has she done in terms of solving the root causes. This has been a goal of hers for this many years. What’s changed? I would argue it’s not improved; it has only gotten worse,” Anfinsen said. “Shortly around that period of time, it kind of just went away, and you didn’t hear it.”

But Daniel Suvor, who was chief of policy for Harris from 2014 to 2017 while she was California's attorney general, said he was unsurprised she was tapped to address root causes of migration in Central America.

“She’s been interested in Central America for some time, and she has built up a wide range of relationships down there,” Suvor said.

Suvor said Harris' connections in Latin America stemmed from her work as attorney general to combat drug trafficking by transnational criminal organizations and her trips to Mexico City to meet with foreign officials.

“She understood all the way back then that we needed to work with the Mexican government, El Salvador, Honduran, Guatemalan government, to take on the cartels.”

'Don't come'

An NBC News review found that her travel to address root issues in the region was largely limited to June 2021, with one trip to the border in El Paso, Texas, and another to Mexico and Guatemala. She made one additional trip to Honduras in January 2022. 

Her work in Guatemala may have been most memorable. It was where she faced criticism from immigration groups for telling migrants “don’t come” to the U.S. 

But her work in Mexico was arguably the most significant. It was there that Mexico and the U.S. signed a memorandum of understanding to “strengthen development cooperation in northern Central America ... to exchange knowledge, experiences, assets, and resources to address the root causes of irregular migration in northern Central America,” according to a description of the agreement by the State Department.

The agreement sent funds from the U.S. Agency for International Development, coupled with those from the Mexican Agency for International Development Cooperation, to help people in Central America. Since then, the U.S. has stayed on track to meet its commitment of $4 billion to address root causes, but Harris has also been able to solicit significant help from private companies, which have invested $5.2 billion in the region since 2021.

Those investments have funded entrepreneurs, ensured labor rights, strengthened food security and launched “19 projects in Guatemala, El Salvador, and Honduras across sectors, including financial inclusion, healthcare, climate finance, and affordable housing,” according to the White House.

Since 2021, however, the Root Causes Strategy has made no new commitments, despite Mexican pleas for more direct investment from the U.S., not just from U.S. companies.

Mexican President Andrés Manuel López Obrador said in May 2022 that the private investment strategy is too slow.

“ We are convincing the government of the United States to invest with readiness,” he said at a news conference. “They have a very special system — they think that it’s enough to promote private investments. That if plants, factories are installed in Central America, then employment will be generated. … That is good, but that takes time.”

Harris made one more trip to Central America after 2021, to attend the inauguration of Honduran President Xiomara Castro in January 2022. According to the White House, Harris talked to her about “combating corruption and gender-based violence as a way to address the root causes of migration.”

Since then, she has held two meetings in Washington, one with López Obrador in July 2022 and the other most recently with Guatemalan President Bernardo Arévalo in March.

A White House official defended Harris’ record and said her work is ongoing. “Vice President Harris continues to lead the effort to address the root causes of migration from Honduras, Guatemala, and El Salvador, including by generating more than $5.2 billion in investments into the region to give people economic opportunity at home. These investments are creating jobs and have connected more than 4.5 million people to the internet and brought more than 2.5 million people into the formal financial system.”

“Under the Vice President’s leadership, the Biden-Harris Administration continues to implement the Root Causes Strategy. As a part of this strategy, the Administration is on track to meet its commitment to provide $4 billion to the region over four years and continues to work to combat corruption, reduce violence, and empower women,” the White House official wrote.

Think tanks that study immigration and international non-governmental organizations have also questioned the impact of Harris’ work in addressing immigration.

“She had a very narrow mandate, which was to be the diplomatic representative in Central America at the time when most unauthorized immigration was coming from Central America,” said Andrew Selee, president of the Migration Policy Institute, a nonpartisan think tank based in Washington.

Since 2021, immigration from the Central American countries of Guatemala, El Salvador and Honduras, once the leaders in illegal immigration across the southwest border, has fallen from 86,089 in March 2021 to 25,015 in June 2024, according to Customs and Border Protection data. 

But immigration experts point out that the decline is most likely driven by other factors, including U.S. policies restricting asylum at the border and an increase in Mexican interdictions of U.S.-bound migrants. And during that time, migration from countries like Venezuela and China — where Harris has no involvement in immigration discussions — has mounted.

Selee said USAID took over the money the U.S. sent to Central America for development while Harris stayed focused on the private-sector investment.

“Vice President Harris was very involved diplomatically early on with Central American governments, clearing the way to get these two initiatives underway and talking about how to stem unauthorized migration,” Selee said. “But, as near as I can tell, she just hasn’t stayed as engaged diplomatically on this. And, you know, over time, the State Department and the National Security Council really took over the diplomatic side.”

Krish O’Mara Vignarajah, president and CEO of Global Refuge, noted Harris’ role launching an anti-corruption task force with the Justice Department focused on Northern Triangle countries.

“I do think she [Harris] has played a leadership role in addressing the root causes,” Vignarajah said.

“Do we believe this solves the problem? No. Of course not. And this is where Congress needs to be a real player,” she said.

Didi Martinez is an associate producer with the NBC News Investigative Unit. 

Julia Ainsley is the homeland security correspondent for NBC News and covers the Department of Homeland Security for the NBC News Investigative Unit.

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• v.5(3); 2018 Oct

A systems approach to healthcare: from thinking to ­practice

John clarkson.

A Cambridge Engineering Design Centre, University of Cambridge, Cambridge, UK

B Royal College of Physicians, London, UK

C Cambridge Engineering Design Centre, University of Cambridge, Cambridge, UK

Alexander Komashie

D Cambridge Engineering Design Centre, University of Cambridge, Cambridge, UK

Tom Bashford

E Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, Cambridge, UK.

Medicine is increasingly complex, involving a highly connected system of people, resources, processes, and institutions. Attempts to improve care involve disruptions to this system, with the potential for wide-ranging consequences, both positive and negative. Despite this, many improvement methodologies are poorly equipped to manage either complexity or risk – instead focusing on discrete interventions whose effects are narrowly monitored. Engineers have long understood that complex problems require a systems view, and that attempts to make things better can themselves introduce new risk into a system. Given this, an engineering systems approach may be of significant value to those trying to improve healthcare. Two fundamental questions emerge from such an approach: what can we do better, and what could possibly go wrong? This paper describes the evolution of a systems approach to healthcare, and explores a recently co-developed framework outlining a systems approach based upon a synergy between healthcare and engineering.

Introduction

Healthcare is the product of a complex adaptive system of people, equipment, processes, and institutions working together. Problems can arise with either deficiencies in individual system elements, or in their relationship with each other, and improving the overall function of such a system can be challenging. 1 This insight – a systems view of healthcare – reframes our understanding as to how care is delivered and can be improved.

A striking example of this is the case of Dr Hadiza Bawa-Garba, 2,3 a paediatrician convicted of gross negligence and manslaughter in 2015 , temporarily suspended from practising medicine by a medical practitioners tribunal, and later struck off by the General Medical Council (GMC). The case has raised many questions both about how we allocate blame when systems fail and how we improve them in the future to avoid catastrophe. The British Medical Journal (BMJ) responded: ‘It is tragic that a child has died. But no one is served when one doctor is blamed for the failings of an overstretched and understaffed system.’ 4

The Bawa-Garba case highlights the complexity of direct healthcare, where the actions of an individual doctor can be contextualised within a team, a ward, and a hospital all facing deficiencies. However, it also throws into relief the wider system in play – of regulatory bodies, the legal framework within which medicine is practised, the media, and prevailing cultural attitudes toward the NHS.

‘Systems that work do not just happen, they need to be planned, designed and built.’ This is the view of the Royal Academy of Engineering, 5 experts in the design of complex systems. Engineers have long understood that well designed systems can prompt individuals toward desired behaviours, and act to restrain them from undesirable ones. This understanding is reflected in much of the medical literature around improvement from fields such as quality improvement, implementation science, and operational research. However, a consolidated systems approach to healthcare improvement has been elusive.

Critics of a systems approach to healthcare might argue that it is simply a mechanism to absolve individuals where they have made mistakes or acted inappropriately, or that it is an excuse to paint improvement as too difficult to attempt. We argue instead that a systems approach should seek to answer fundamental questions about the people involved in a given situation, the wider system in which they operate, the opportunities for risk, and what can be designed to mitigate these. There will be occasions where individuals are culpable, where machines fail, or where processes are weak; the system should be designed to reduce the possible harm which results. More optimistically perhaps, robust systems offer the opportunity for increased quality and efficiency without a commensurate increase in material resources – an increasing priority for an NHS under pressure.

Background to the need for a systems approach

The idea of a systems approach is not new. The first half of the 20th century saw a growing interest in systems and their inherent complexities in several disciplines including engineering and biology. 6 Within healthcare, however, the turn of the new millennium may be seen as a watershed in the recognition of a systems approach to improvement.

The World Health Report 2000 had a primary focus on health systems. 7 This report on global health systems began to address questions around the elements of a good health system and the monitoring of system performance. In the following few years, high profile reports were published both in the USA and the UK that were to significantly challenge the status quo and justify the need for a better approach to improving the quality of the healthcare delivery systems in these countries.

In the USA, the publication of two key reports by the Institute of Medicine (IOM) – To err is human 8 and Crossing the Quality Chasm 9 – demonstrated a disparity in the state of patient safety and the concerning discrepancy between the care that was possible and that which many patients were receiving. The revelation of these challenges within the American healthcare system were enough to raise quality of healthcare to centre stage.

Similar challenges were being described in the UK over the same period. 10–12 A report into the systematic failures that led to the deaths of nearly 30 children at the Bristol Royal Infirmary (BRI) in 2001 concluded that the poor performance and errors identified at the BRI were the results of systems which were poorly performing. 13 More importantly, the report suggested that these problems were reflective of the state of the wider NHS at the time. In response to these findings the Department of Health (DoH) made far-reaching changes to the health system with a focus on standards, performance monitoring, patient-centeredness, patient and public involvement. The response also provided opportunity for design and systems engineers to contribute to the challenges through a commitment to ‘working with the Design Council to identify opportunities for design solutions to patient safety’. 14 The Design Council also establishes the RED team to bring design thinking to healthcare improvement and transformation. 15,16

This led to the first review of design and systems practice within the NHS. The review concluded that ‘the NHS is seriously out of step with modern thinking and practice with regard to design’. 17 Since then, several reports, initiatives and models have been produced but of particular relevance is Building a Better Delivery System , the report which launched the ‘New Engineering/Health Care Partnership’. 18 More than a dozen major reports had echoed the essence of this new partnership by 2010 with many describing the heightened interest in solving problems in healthcare delivery using industrial and systems engineering tools. 19 More recently, the President’s Council of Advisors on Science and Technology (PCAST) recommended that a systems engineering approach be propagated at all levels of the health care system in the USA. 20

Several other high profile reports have consistently alluded to the need for a systems approach, although often lacking guidance on how to realise this at any level of the NHS or in the USA. 17 , 21–32 Even within the academic literature, it is difficult to find a definition or presentation of a systems approach that lends itself to pragmatic improvement efforts.

Realising a systems approach in practice

In 2016, in response to the calls to adopt a systems approach to designing and delivering high-quality services in the UK, the Royal Academy of Engineering (RAEng), in collaboration with the Royal College of Physicians (RCP) and the Academy of Medical Sciences (AMS), established a cross-disciplinary Working Group to work with the health and care professions to explore how engineers can add to current understanding and practice of systems engineering in quality improvement and healthcare design.’

To an engineer, the world is full of systems. From the simple water heater to the fully integrated international airport, all systems share one key feature: their elements together produce results not obtainable by the same elements alone. A systems approach involves integrating the necessary disciplines into a team who then use a structured process to deliver a system, working from needs to requirements and from design to delivery. 33–35 A systems approach has also been described as

…a framework for seeing interrelationships rather than things, for seeing patterns rather than static snapshots – it is a set of general principles spanning fields as diverse as physical and social sciences, engineering, and management. 36

This can be depicted as a ‘V-model’ (Fig ​ (Fig1), 1 ), which illustrates the logical relationships between different activities. However, to those unfamiliar with the language of systems engineering, the nuances and value of the V-model may be difficult to appreciate.

The INCOSE (2009) V-model.

Early discussions within the RAEng Working Group reflected on the importance of people, systems, design and risk perspectives on a system, and on the realisation that particular focus on these complementary views could deliver many of the benefits of a systems approach (Table ​ (Table1 1 ).

The elements of a systems approach

These perspectives provided the framework for a series of workshops with engineers and health and care professionals to explore the relevance of each perspective to health and care improvement and to express them as a series of open questions. These were subsequently merged with a number of project management questions to form a simple spiral (Fig ​ (Fig2), 2 ), an ordered list of questions pertinent to systems improvement. The spiral illustrates that the questions are revisted at each stage of design and delivery in an iterative manner.

A spiral model of the questions that define an iterative approach to health and care improvement.

This representation, of an idealised view of a systems approach, does little to guide how it might be used in practice. The health and care professionals consulted were more used to a linear improvement process, typified as one that transforms current performance into something measurably better (Fig ​ (Fig3). 3 ). This approach is common to all improvement processes with a focus on the critical stages required for success (Table ​ (Table2 2 ).

A linear improvement process transforming current performance into a measurably better state.

The critical stages of an improvement approach

The linear (improvement) and spiral (systems) models may be combined to generate a helical model of health and care improvement (Fig ​ (Fig4). 4 ). This resonated with health and care improvement specialists, going some way toward translating the description of a systems approach into a practical implementation guide. To help further, case studies from published work were used to illustrate the potential of a systems approach in practice, reviews of improvement approaches eg the Model for Improvement, Lean etc, and key literature were undertaken. Further background to the core concepts were provided. The final report, Engineering Better Care: a systems approach to health and care design and continuous improvement, 37 provides an accessible description of a systems approach, and how it can build on current approaches to improvement in healthcare, nearly 20 years after the first call to adopt such an approach. 17

A systems-spiral improvement process. An ordered and iterative set of activities drawn from people , systems , design and risk perspectives and linked to the spiral questions, applied at each stage of the improvement process.

A healthcare–engineering synergy

The practice of healthcare can be conceived as two objectives: to provide care, and to avoid causing harm. Similarly, engineering can be considered as the practice of solving problems, while managing the risk inherent in those solutions. A shared understanding between engineering and healthcare might then be – what can we do better, and what could possibly go wrong?

In England the New Care Models programme 38 and similar work, are showing promise in a redesigning and delivering health and care systems to meet population and system needs. These have had varying approaches to design and improvement, with varying outcomes.

The value of the systems approach put forward in Engineering Better Care is that it provides a simple framework for those trying to improve care to reflect on their efforts with a new perspective. Seeking to answer the questions posed prompts reflection on both the methodologies used, and the desired outcomes. This does not need to supplant existing methods, but instead might suggest where alternative techniques could add value. The ongoing challenge is to bring this framework to bear on real problems, in partnership with those already striving to make things better.

Further work is now underway to develop a practical toolkit that transforms the systems approach into practice (Fig ​ (Fig5). 5 ). The focus here is on the definition of a range of simple but effective interventions to identify a real need, define a problem and a business case for change, develop viable solutions and deliver the preferred solution into practice.

An Engineering Better Care toolkit, facilitating a systems approach to health and care improvement.