Managing routine exceptions: A model of nurse problem solving behavior

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Abstract
This paper investigates how hospital work environments and manager behavior influence nurses' responses when faced with unexpected problems, or exceptions. Data from a qualitative study involving 239 hours of observation of 26 hospital nurses at nine hospitals suggest that exceptions occur frequently and that the work design of hospital nurses leads them to respond to exceptions through first-order problem solving, addressing only immediate symptoms without attempting to alter underlying causes. This pattern of behavior contrasts with recommended approaches found in the quality improvement literature (Ackoff, 1978; Deming, 1986; Juran, Godfrey, Hoogstoel & Schilling, 1999; Kepner & Tregoe, 1976). An implication of our findings is that health care managers may need to tailor front line quality improvement processes to meet the demands of the health care delivery environment — in which exceptions are so frequent as to be considered virtually routine — rather than expecting health care workers to engage in quality improvement practices developed for work environments with different characteristics. Building on empirical observations from our study, we draw from two literatures — healthcare management and organizational behavior — to develop a model of problem solving behavior by hospital nurses. The model proposes that nurse manager coaching, support, and proficiency, together with features of the organizational context — training, self management, work design, group norms, and reward interdependence — influence nurses' problem solving behavior through the mediating variable of nurse cognition (psychological safety and motivation). The use of a problem solving coordinator moderates the problem-solving behavior's impact on performance outcomes.