Estructura de la célula

easiest, that take the shortest amount of time to solve, or that may have the greatest urgency?

The most common cause for failure to resolve problems is the improper identification of the problem/issue; therefore problem recognition and identification are considered the most vital steps. The quality of the outcome depends on accurate identifi- cation of the problem, which is likely to recur if the true underlying causes are not targeted. Problem identification is influenced by the information avail- able; by the values, attitudes, and experiences of those involved; and by time. Sufficient time should be allowed for the collection and organization of data. Too often, an inadequate amount of time is allocated for this essential step, resulting in unsatisfactory out-

comes. Nurse leaders and managers should use the “5 Why” approach (Institute for Healthcare Improve- ment): after answering the first question as to why a problem occurred, ask why again, and so on, so on, and so on. This is particularly helpful for problems that keep resurfacing over time because it gets to the actual root causes of problems.

Girard (2005) asserted, “One of the most impor- tant one-word sentences that exists is ‘Why?’ ” (p. 961). She claims that because of increased reliance on unit protocols, algorithms, and policy and when “habits take over thinking” (p. 962), nurses forget to ask why they are doing something. She illustrated the value in asking “why” when a problem with operating room staff using broken stretchers was noted. The

Resource: Van Horn, R., & Freed, S. (2008). Journaling and dia-

logue pairs to promote reflection in clinical nursing education.

Nursing Education Perspectives, 29(4), 220-225.

Van Horn and Freed (2008) sought to explore whether working in

pairs would enhance students’ knowledge and problem-solving skills. The researchers separated students enrolled in an associate’s degree nursing program into two groups; half the group worked in pairs while the other half were unpaired. Students were instructed to maintain a weekly journal describing their clinical experiences over a 9-week period. The paired and unpaired students answered specific questions in the journals, but the paired students were encouraged to discuss the questions before recording their responses in the journal.

The questions posed related to the nursing and problem-solving processes. They were as follows:

1. Looking back, do you think that the problems that you identi- fied were the most important ones for the patients? What additional problems do you now identify as the result of caring for the patients?

2. Identify a problem or a need that arose during the shift. Explain the circumstances of this problem including who, what, when, where, and how urgent the problem was. 3. What knowledge was required for you to solve the problem? 4. What resources helped you solve the problem?

5. What steps did you take to help solve the problem? 6. What influenced your thinking about this problem? 7. What were your strengths for this clinical experience? 8. What were your weaknesses, and how will you strengthen

these weaknesses in the next clinical experience?

9. What were other thoughts and feelings about your clinical experience today? (p. 222)

Three themes emerged from analysis of the students’ journals: emotions, connections, and learning. Journal entries demonstrated that the paired students were able to support each other in the clinical setting, thus relieving anxiety and stress. Students who were unpaired experienced a higher degree of anxiety, fear, and doubt.

One of the purposes of journaling was to help students apply theoretical knowledge in the clinical setting. Both groups demon- strated the ability to make this connection. In addition, both groups demonstrated that learning took place as a result of the reflective practice of journaling. However, in the unpaired students, the learn- ing was primarily psychomotor skills (e.g., describing procedures that were accomplished). Students who were paired described learning that was of a social nature (e.g., learning from each other).

Van Horn and Freed (2008) assert that having students work in

pairs helps students in “finding their professional voice, learning to negotiate, checking one another for accuracy, and recognizing each other as a source of knowledge” (p. 224). They recommend that instructors model their thinking processes and how they solve problems.

Implications for Practice

Expert clinicians such as clinical nurse specialists, clinical nurse leaders, unit-based nurse managers, and clinical educators can adapt this approach in mentoring new staff on a unit. Reviewing the novice nurses’ responses to the questions can yield valuable information about their critical-thinking, problem-solving, and deci- sion-making skills and serve as a foundation for ongoing staff devel- opment, mentoring, and support.

postanesthesia care nurses wanted a policy written to address sending patients to the recovery area. Instead, by asking five “why” questions to different depart- ment personnel, Girard learned that the stretchers being used were not reparable because of obsolete parts. Instead, the solution was to make a case for ordering new stretchers. In this example, it is clear that writing a new policy would not have addressed the root cause of the problem.

Kritek (2002) asserted that there are two primary phases in solving a problem: (1) identifying the problem and (2) selecting the best solution to resolve it. However, she believes that a common error is to skip the first step and proceed directly to the second one. As a result, too few options may be determined or solutions may be implemented for an unrelated problem. Why does this happen? Kritek holds that the likely explanation is that people may avoid the step that requires the problem to be understood because it can reveal negative aspects about themselves that they may not want to address.

It is important to differentiate between the actual problem and the symptoms of a problem. Consider the problem of an inadequately stocked emergency cart from which emergency medications often are missing and equipment often fails to function prop- erly. Individuals charged with resolving this problem may discover that this is symptomatic of the underly- ing problem, perhaps inadequate staffing or staffing mix. Based on the proper identification of the problem in this scenario, a possible solution might be to assign the task of checking and stocking the emergency cart to the unlicensed personnel in the unit.

In work settings, problems often fall under certain categories that have been described as the four M’s:

manpower, methods, machines, and materials. Man-

power issues might include inadequate staffing or staffing mix and knowledge or skills deficits. Methods issues could include communication problems or lack of protocols. Machine issues could include lack of equipment or malfunctioning equipment. Last, prob- lems with materials could include inadequate supplies or defective materials. A fishbone diagram, also known as a cause-and-effect diagram, is a useful model for categorizing the possible causes of a problem. The diagram graphically displays, in increasing detail, all of the possible causes related to a problem to try to discover its root causes. This tool encourages problem

solvers to focus on the content of the problem and not be sidetracked by personal interests, issues, or agendas of team members. It also collects a snapshot of the collective knowledge of the team and helps build consensus around the problem. The “effect” is generally the problem statement, such as decreased morale, and is placed at the right end of the figure (the “head” of the fish). The major categories of causes are the main bones, and these are supported by smaller bones, which represent issues that contrib- ute to the main causes. An example of a fishbone diagram appears in Figure 6-4.

EXERCISE 6-5

Using a fishbone diagram, identify all the factors (causes) that are at the root of a problem you are currently facing in the work- place. After you have listed as many issues as possible, share the diagram with a work colleague. Are there other issues you did not consider? Where do most of the factors influencing the problem fit: manpower, methods, machines, or materials?

Gather Data

After the general nature of the problem is identified, individuals can focus on gathering and analyzing data to resolve the issue. Assessment, through the collec- tion of data and information, is done continuously throughout this dynamic process. The data gathered consist of objective (facts) and subjective (feelings) information. Information gathered should be valid, accurate, relevant to the issue, and timely. Moreover, individuals involved in the process must have access to information and adequate resources to make cogent decisions.

Analyze Data

Data are analyzed to further refine the problem statement and identify possible solutions or options. It is important to differentiate a problem from the symptoms of a problem. For example, a nurse manager is dismayed by the latest quality improve- ment (QI) report indicating nurses are not docu- menting patient teaching. Is this evidence that patient teaching is not being done? Is lack of documentation the actual problem? Perhaps it is a symptom of the actual problem. On further analysis, the manager

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