Problem solving that takes into account critical thinking,
creative, non-traditional and reflective approaches enables
additional solutions to be formulated (Chabelli, 2006). The
different methods of problem solving are explained below.
However, the first step to problem solving is recognising
that there is a problem.
Recognising a problem
As previously discussed, in any clinical situation, the clini-
cian is presented with a wide range of information acquired
through observation, patient records, knowledge of the
person and the context of the environment. When all of this
information is indexed against the knowledge base and
experience of the clinician, patterns are built. The clinician
is able to recognise when there is a discrepancy between the
needs of the person and what is actually happening. The cli-
nician is therefore able to recognise this as a problem. This
recognition may in turn lead to the collection of more cues.
In Chapter 1, the context of modern practice and rapid
change in knowledge and technology is discussed. One point
that is made is that the acuity of patients in hospitals has
increased, and their care has correspondingly become more
complicated (Duffield et al., 2007). This may create circum-
stances in which there is a potential for error through not
recognising that a problem is occurring. This might lead to
incorrect decisions or actions by the clinician. Such errors are
called
adverse events
, and they may affect the health or well-
being of the patient. They may also be unrelated to the reasons
for the patient’s admission. These events that occur by com-
mission or omission are now measured and studied using such
techniques as critical incident analysis to determine if there is
an error in the system that can be rectified (Wilson et al.,
1995). In Chapter 13, an adverse event by commission—a
medication error—is used in an example of a critical incident
analysis. The other type of error is one of omission, where
poor clinical reasoning leads to a failure to act, often called a
‘
failure to rescue
’, where a deteriorating situation (a problem)
is not recognised or is not responded to appropriately by a cli-
nician (Duffield et al., 2007; Thompson et al., 2008).
Therefore, problem-solving skills are imperative for any clini-
cian preparing for practice (Higuchi & Donald, 2002).
Once a problem has been identified, problem solving
may then take different forms, as explained below.
Forms of problem solving
Trial-and-error problem solving
Trial-and-error problem solving involves testing a number of
solutions until one is found that works for that particular
problem. For example, you might use this approach in trying
to solve a clue in a cryptic crossword puzzle, coming up with
several possible answers and then working out which one
best fits the clue. However, if used in clinical practice, this
method can be dangerous for the patient. For example, you
would not use a trial-and-error approach when deciding
which of the multiple chest drains to remove for a patient fol-
lowing surgery, as the wrong option may harm the patient.
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Chapter 14 Thoughtful practice: Clinical reasoning, clinical judgement, actions and the process of care
Scientific problem solving
Scientific problem solving is closely related to the more
general problem-solving processes commonly used by health-
care professionals as they work with patients. It involves
identifying a problem, collecting data and interpreting the
results to form a hypothesis based on scientific knowledge,
which in turn drives the action taken. An example is where a
clinician responds to a person who says ‘I feel unwell’ (a
problem) by taking the person’s temperature (collecting data),
reviewing these data against what the clinician knows to be
the normal parameters for body temperature (interpreting the
results), deciding that the person needs medical review
because of a possible infection (forming a hypothesis) and so
ringing a doctor (taking an action).
Intuitive problem solving
Many experienced clinicians can describe situations in
which a ‘gut feeling’ or ‘inner prompting’ led to a quick
intervention that saved the life of a patient. This type of
feeling is often referred to as ‘tacit knowledge’, and is built
up over years of experience (Benner, Hughes & Sutphen,
2008). When nurses and midwives directly relate a situation
to other situations based on similarities or differences, they
are using intuitive problem solving. An emergency nurse
who realises that a trauma patient is deteriorating before
there are measurable signs to suggest trouble is using intu-
itive problem solving, as is a midwife who somehow
‘senses’ the right moment to intervene in a seemingly
uncomplicated birth.
As intuitive problem-solving ability comes only through
years of practice and observation, beginning clinicians
must use their knowledge and scientific problem solving
skills as the basis of the care they give (Benner, Tanner &
Chelsa, 2009).
However, intuition is a skill that can be nurtured through
such techniques as brainstorming (Alfaro-LeFevre, 2012).
You may have used brainstorming in your group work.
Thinking logically about each new idea can sometimes stifle
the flow of ideas; therefore, in brainstorming we draw on
our intuitive thinking to generate ideas, which can then be
discussed in a more logical fashion once the brainstorming
is complete and all the new ideas have been collected.
Recall a time when you used brainstorming. Think
about how this process worked. Did you use your
intuition or did you rely on logical thinking?
However, intuitive problem solving also has disadvan-
tages. While the use of intuition can often move problem
solving forward quickly, it can also result in a trial-and-error
approach and it does not necessarily foster ‘outside-the-box’
ideas or creative ways of solving problems. As well as this,
certain aspects of practice require a more logical or evidence-
based approach to thinking, such as developing policies and
procedures or planning care. If we were to undertake these
tasks based purely on intuition without the benefit of evi-
dence, we may increase the risk to the patient with little or
