Ask An Expert Nursing-sensitive safety and quality outcomes: the taming of a wicked problem? Marcelline Harris, PhD, RN a , Catherine Vanderboom, PhD, RN a , Ronda Hughes, PhD, MHS b, ⁎ a Mayo Clinic b Agency for Healthcare Research and Quality Received 19 January 2009; accepted 4 February 2009 Abstract There are tremendous opportunities associated with the increasing interest in outcomes that are sensitive to the effects of nursing. However, the challenges in realizing these opportunities are significant, and can be characterized as “wicked". Taming these challenges requires that we manage highly interdependent processes and techniques, including health information technologies. © 2009 Published by Elsevier Inc. Nursing's participation in health care safety and quality initiatives has intensified over the past decade, fueled in large part by an expanding research literature on preventable hospital complications in acute care settings, the association of nurse staffing with those events, and indications that evidence-based practices may reduce certain poor outcomes. The national interest in reporting initiatives, arising from within the discipline and within health care generally, places nursing at a unique point in the history of the discipline with respect to defining, measuring, classifying, analyzing, report- ing, and acting on safety and quality outcomes that are sensitive to the effects of nursing. However, pulling all of this together is proving to be extremely complex and challenging. A recent editorial by Smith (Smith, 2007) focused on the challenges to clinical agencies, applying the analogy of a zoo to nursing-sensitive care measures and invoking images of “a room full of gorillas” (including but not limited to the National Quality Forum [NQF], Joint Commission, Centers for Medicare and Medicaid Services [CMS], and the American Nurses Association [ANA]) who are “teaching elephants to dance.” Although all of these organizations are well intended in their efforts to drive organizations toward the goal of applying and acting on standard measures that demonstrate relationships between dimensions of nursing practice and patient outcomes, Smith notes that it is not yet clear whether the “frenzy” generated by these efforts is an opportunity or a threat. Specifically focusing on the value of nursing's contribution to inpatient care quality and safety outcomes, Kurtzman and Jennings (2008) highlighted the current situation where “Despite the proliferation of pay-for- reporting, pay-for-performance, and other value-based purchasing schemes, nurses, for the most part, have been excluded from deriving any financial benefit from the contributions to quality … a conceptual and practical connection between rewards and incentives for nurses has not been addressed ” (p. 352). Why is it so hard to connect (a) the research that defines, measures, classifies, and demonstrates the effects of nursing on quality and safety outcomes; (b) the reporting and rewarding of those outcomes; and (c) actions within clinical agencies that result in further improvements in patient care? Why has understanding the quality of care become an “experiment in democracy” (Lang & Kizer, 2003). The following presents an overview of key literature in this area and sets forth a framework for analyzing this situation and navigating toward solutions. 1. Wicked problems and tame problems Originally proposed by Rittel and Webber (1973), the term wicked problem refers to complex problems that are incompletely described and seem to have competing and changing requirements. Solutions to wicked problems are difficult to recognize because of the complex interdepen- dencies that surround the problem. Conklin (2006) summar- ized Rittel and Weber's work and characterized wicked problems as those problems with (a) no definitive statement of the problem, (b) an open-ended search for a solution, (c) a Available online at www.sciencedirect.com Applied Nursing Research 22 (2009) 146 – 151 www.elsevier.com/locate/apnr ⁎ Corresponding author. E-mail address: ronda.hughes@ahrq.hhs.gov (R. Hughes). 0897-1897/$ – see front matter © 2009 Published by Elsevier Inc. doi:10.1016/j.apnr.2009.02.002