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• Research article
• Open access
• 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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Community-Oriented Nursing Midwifery Research Center, Shahrekord University of Medical Sciences, Shahrekord, Iran

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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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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
• Tsui-Mei, H, Lee-Chun, H & Chen-Ju MSN, K 2015, 'How Mental Health Nurses Improve Their Critical Thinking Through Problem-Based Learning', Journal for Nurses in Professional Development , vol. 31, no. 3, pp. 170-175, viewed 7 December 2018, https://journals.lww.com/jnsdonline/Abstract/2015/05000/How_Mental_Health_Nurses_Improve_Their_Critical.8.aspx

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Critical thinking in healthcare and education

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• Jonathan M Sharples , professor 1 ,
• Andrew D Oxman , research director 2 ,
• Kamal R Mahtani , clinical lecturer 3 ,
• Iain Chalmers , coordinator 4 ,
• Sandy Oliver , professor 1 ,
• Kevan Collins , chief executive 5 ,
• Astrid Austvoll-Dahlgren , senior researcher 2 ,
• Tammy Hoffmann , professor 6
• 1 EPPI-Centre, UCL Department of Social Science, London, UK
• 2 Global Health Unit, Norwegian Institute of Public Health, Oslo, Norway
• 3 Centre for Evidence-Based Medicine, Oxford University, Oxford, UK
• 4 James Lind Initiative, Oxford, UK
• 5 Education Endowment Foundation, London, UK
• 6 Centre for Research in Evidence-Based Practice, Bond University, Gold Coast, Australia
• Correspondence to: J M Sharples Jonathan.Sharples{at}eefoundation.org.uk

Critical thinking is just one skill crucial to evidence based practice in healthcare and education, write Jonathan Sharples and colleagues , who see exciting opportunities for cross sector collaboration

Imagine you are a primary care doctor. A patient comes into your office with acute, atypical chest pain. Immediately you consider the patient’s sex and age, and you begin to think about what questions to ask and what diagnoses and diagnostic tests to consider. You will also need to think about what treatments to consider and how to communicate with the patient and potentially with the patient’s family and other healthcare providers. Some of what you do will be done reflexively, with little explicit thought, but caring for most patients also requires you to think critically about what you are going to do.

Critical thinking, the ability to think clearly and rationally about what to do or what to believe, is essential for the practice of medicine. Few doctors are likely to argue with this. Yet, until recently, the UK regulator the General Medical Council and similar bodies in North America did not mention “critical thinking” anywhere in their standards for licensing and accreditation, 1 and critical thinking is not explicitly taught or assessed in most education programmes for health professionals. 2

Moreover, although more than 2800 articles indexed by PubMed have “critical thinking” in the title or abstract, most are about nursing. We argue that it is important for clinicians and patients to learn to think critically and that the teaching and learning of these skills should be considered explicitly. Given the shared interest in critical thinking with broader education, we also highlight why healthcare and education professionals and researchers need to work together to enable people to think critically about the health choices they make throughout life.

Essential skills for doctors and patients

Critical thinking is not a new concept in education: at the beginning of the last century the US educational reformer John Dewey identified the need to help students “to think well.” 3 Critical thinking encompasses a broad set of skills and dispositions, including cognitive skills (such as analysis, inference, and self regulation); approaches to specific questions or problems (orderliness, diligence, and reasonableness); and approaches to life in general (inquisitiveness, concern with being well informed, and open mindedness). 4

An increasing body of evidence highlights that developing critical thinking skills can benefit academic outcomes as well as wider reasoning and problem solving capabilities. 5 For example, the Thinking, Doing, Talking Science programme trains teachers in a repertoire of strategies that encourage pupils to use critical thinking skills in primary school science lessons. An independently conducted randomised trial of this approach found that it had a positive impact on pupils’ science attainment, with signs that it was particularly beneficial for pupils from poorer families. 6

In medicine, increasing attention has been paid to “critical appraisal” in the past 40 years. Critical appraisal is a subset of critical thinking that focuses on how to use research evidence to inform health decisions. 7 8 9 The need for critical appraisal in medicine was recognised at least 75 years ago, 10 and critical appraisal has been recognised for some decades as an essential competency for healthcare professionals. 11 The General Medical Council’s Good Medical Practice guidance includes the need for doctors to be able to “provide effective treatments based on the best available evidence.” 12

If patients and the public are to make well informed health choices, they must also be able to assess the reliability of health claims and information. This is something that most people struggle to do, and it is becoming increasingly important because patients are taking on a bigger role in managing their health and making healthcare decisions, 13 while needing to cope with more and more health information, much of which is not reliable. 14 15 16 17

Teaching critical thinking

Although critical thinking skills are given limited explicit attention in standards for medical education, they are included as a key competency in most frameworks for national curriculums for primary and secondary schools in many countries. 18 Nonetheless, much health and science education, and education generally, still tends towards rote learning rather than the promotion of critical thinking. 19 20 This matters because the ability to think critically is an essential life skill relevant to decision making in many circumstances. The capacity to think critically is, like a lot of learning, developed in school and the home: parental influence creates advantage for pupils who live in homes where they are encouraged to think and talk about what they are doing. This, importantly, goes beyond simply completing tasks to creating deeper understanding of learning processes. As such, the “critical thinking gap” between children from disadvantaged communities and their more advantaged peers requires attention as early as possible.

Although it is possible to teach critical thinking to adults, it is likely to be more productive if the grounds for this have been laid down in an educational environment early in life, starting in primary school. Erroneous beliefs, attitudes, and behaviours developed during childhood may be difficult to change later. 21 22 This also applies to medical education and to health professionals. It becomes increasingly difficult to teach these skills without a foundation to build on and adequate time to learn them.

Strategies for teaching students to think critically have been evaluated in health and medical education; in science, technology, engineering, and maths; and in other subjects. 23 These studies suggest that critical thinking skills can be taught and that in the absence of explicit teaching of critical thinking, important deficiencies emerge in the abilities of students to make sound judgments. In healthcare studies, many medical students score poorly on tests that measure the ability to think critically , and the ability to think critically is correlated with academic success. 24 25

Evaluations of strategies for teaching critical thinking in medicine have focused primarily on critical appraisal skills as part of evidence based healthcare. An overview of systematic reviews of these studies suggests that improving evidence based healthcare competencies is likely to require multifaceted, clinically integrated approaches that include assessment. 26

Cross sector collaboration

Informed Health Choices, an international project aiming to improve decision making, shows the opportunities and benefits of cross sector collaboration between education and health. 27 This project has brought together people working in education and healthcare to develop a curriculum and learning resources for critical thinking about any action that is claimed to improve health. It aims to develop, identify, and promote the use of effective learning resources, beginning at primary school, to help people to make well informed choices as patients and health professionals, and well informed decisions as citizens and policy makers.

The project has drawn on several approaches used in education, including the development of a “spiral curriculum,” measurement tools, and the design of learning resources. A spiral curriculum begins with determining what people should know and be able to do, and outlines where they should begin and how they should progress to reach these goals. The basic ideas are revisited repeatedly, building on them until the student has grasped a deep understanding of the concepts. 28 29 The project has also drawn on educational research and methods to develop reliable and valid tools for measuring the extent to which those goals have been achieved. 30 31 32 The development of learning resources to teach these skills has been informed by educational research, including educational psychology, motivational psychology, and research and methods for developing learning games. 33 34 35 It has also built on the traditions of clinical epidemiology and evidence based medicine to identify the key concepts required to assess health claims. 29

It is difficult to teach critical thinking abstractly, so focusing on health may have advantages beyond the public health benefits of increasing health literacy. 36 Nearly everyone is interested in health, including children, making it easy to engage learners. It is also immediately relevant to students. As reported by one 10 year old in a school that piloted primary school resources, this is about “things we might actually use instead of things we might use when we are all grown up and by then we’ll forget.” Although the current evaluation of the project is focusing on outcomes relating to appraisal of treatment claims, if the intervention shows promise the next step could be to explore how these skills translate to wider educational contexts and outcomes.

Beyond critical thinking

Exciting opportunities for cross sector collaboration are emerging between healthcare and education. Although critical thinking is a useful example of this, other themes cross the education and healthcare domains, including nutrition, exercise, educational neuroscience, learning disabilities and special education needs, and mental health.

In addition to shared topics, several common methodological and conceptual issues also provide opportunities for sharing ideas and innovations and learning from mistakes and successes. For example, the Education Endowment Foundation is the UK government’s What Works Centre for education, aiming to improve evidence based decision making. Discussions hosted by the foundation are exploring how methods to develop guidelines in healthcare can be adapted and applied in education and other sectors.

Similarly, the foundation’s universal use of independent evaluation for teaching and learning interventions is an approach that should be explored, adapted, and applied in healthcare. Since the development and evaluation of educational interventions are separated, evaluators have no vested interested in the results of the assessment, all results are published, and bias and spin in how results are analysed and presented are reduced. By contrast, industry sponsorship of drug and device studies consistently produces results that favour the manufacturer. 37

Another example of joint working between educators and health is the Best Evidence Medical Education Collaboration, an international collaboration focused on improving education of health professionals. 38 And in the UK, the Centre for Evidence Based Medicine coordinates Evidence in School Teaching (Einstein), a project that supports introducing evidence based medicine as part of wider science activities in schools. 39 It aims to engage students, teachers, and the public in evidence based medicine and develop critical thinking to assess health claims and make better choices.

Collaboration has also been important in the development of the Critical Thinking and Appraisal Resource Library (CARL), 40 a set of resources designed to help people understand fair comparisons of treatments. An important aim of CARL is to promote evaluation of these critical thinking resources and interventions, some of which are currently under way at the Education Endowment Foundation. On 22 May 2017, the foundation is also cohosting an event with the Royal College of Paediatrics and Child Health that will focus on their shared interest in critical thinking and appraisal skills.

Education and healthcare have overlapping interests. Doctors, teachers, researchers, patients, learners, and the public can all benefit from working together to help people to think critically about the choices they make. Events such as the global evidence summit in September 2017 ( https://globalevidencesummit.org ) can help bring people together and build on current international experience.

Contributors and sources: This article reflects conclusions from discussions during 2016 among education and health service researchers exploring opportunities for cross sector collaboration and learning. This group includes people with a longstanding interest in evidence informed policy and practice, with expertise in evaluation design, reviewing methodology, knowledge mobilisation, and critical thinking and appraisal.

Competing interests: We have read and understood BMJ policy on declaration of interests and declare that we have no competing interests.

Provenance and peer review: Not commissioned; externally peer reviewed.

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The Development of Problem-Solving Knowledge for Social Care Practice

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Peter Marsh, Mike Fisher, The Development of Problem-Solving Knowledge for Social Care Practice, The British Journal of Social Work , Volume 38, Issue 5, July 2008, Pages 971–987, https://doi.org/10.1093/bjsw/bcm116

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The continuing modernization of social care in the UK has placed a high premium on evidence. However, there is a lack of investment in social care research in general, and in practice-based research in particular. The paper argues that there is a need to make better connections between research and practice if there are to be substantial improvements in services. The implications of these improved links include more efficient translation of research into action, and more embedding of research within the range of literature that supports service development. The necessary increase in research can be achieved by building on the substantial, albeit piecemeal, achievements of social work research, and by enhancing the practice literacy of the academic workforce as well as the research literacy of the practice workforce. In the context of a new strategy for social work research in UK universities, this paper examines the obstacles to achieving a voice for social work research and how these obstacles are being addressed.

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What Is Problem-Solving Therapy?

Arlin Cuncic, MA, is the author of The Anxiety Workbook and founder of the website About Social Anxiety. She has a Master's degree in clinical psychology.

Daniel B. Block, MD, is an award-winning, board-certified psychiatrist who operates a private practice in Pennsylvania.

Verywell / Madelyn Goodnight

Problem-Solving Therapy Techniques

How effective is problem-solving therapy, things to consider, how to get started.

Problem-solving therapy is a brief intervention that provides people with the tools they need to identify and solve problems that arise from big and small life stressors. It aims to improve your overall quality of life and reduce the negative impact of psychological and physical illness.

Problem-solving therapy can be used to treat depression , among other conditions. It can be administered by a doctor or mental health professional and may be combined with other treatment approaches.

At a Glance

Problem-solving therapy is a short-term treatment used to help people who are experiencing depression, stress, PTSD, self-harm, suicidal ideation, and other mental health problems develop the tools they need to deal with challenges. This approach teaches people to identify problems, generate solutions, and implement those solutions. Let's take a closer look at how problem-solving therapy can help people be more resilient and adaptive in the face of stress.

Problem-solving therapy is based on a model that takes into account the importance of real-life problem-solving. In other words, the key to managing the impact of stressful life events is to know how to address issues as they arise. Problem-solving therapy is very practical in its approach and is only concerned with the present, rather than delving into your past.

This form of therapy can take place one-on-one or in a group format and may be offered in person or online via telehealth . Sessions can be anywhere from 30 minutes to two hours long. 

Key Components

There are two major components that make up the problem-solving therapy framework:

• Applying a positive problem-solving orientation to your life
• Using problem-solving skills

A positive problem-solving orientation means viewing things in an optimistic light, embracing self-efficacy , and accepting the idea that problems are a normal part of life. Problem-solving skills are behaviors that you can rely on to help you navigate conflict, even during times of stress. This includes skills like:

• Knowing how to identify a problem
• Defining the problem in a helpful way
• Trying to understand the problem more deeply
• Setting goals related to the problem
• Generating alternative, creative solutions to the problem
• Choosing the best course of action
• Implementing the choice you have made
• Evaluating the outcome to determine next steps

Problem-solving therapy is all about training you to become adaptive in your life so that you will start to see problems as challenges to be solved instead of insurmountable obstacles. It also means that you will recognize the action that is required to engage in effective problem-solving techniques.

Planful Problem-Solving

One problem-solving technique, called planful problem-solving, involves following a series of steps to fix issues in a healthy, constructive way:

• Problem definition and formulation : This step involves identifying the real-life problem that needs to be solved and formulating it in a way that allows you to generate potential solutions.
• Generation of alternative solutions : This stage involves coming up with various potential solutions to the problem at hand. The goal in this step is to brainstorm options to creatively address the life stressor in ways that you may not have previously considered.
• Decision-making strategies : This stage involves discussing different strategies for making decisions as well as identifying obstacles that may get in the way of solving the problem at hand.
• Solution implementation and verification : This stage involves implementing a chosen solution and then verifying whether it was effective in addressing the problem.

Other Techniques

Other techniques your therapist may go over include:

• Problem-solving multitasking , which helps you learn to think clearly and solve problems effectively even during times of stress
• Stop, slow down, think, and act (SSTA) , which is meant to encourage you to become more emotionally mindful when faced with conflict
• Healthy thinking and imagery , which teaches you how to embrace more positive self-talk while problem-solving

What Problem-Solving Therapy Can Help With

Problem-solving therapy addresses life stress issues and focuses on helping you find solutions to concrete issues. This approach can be applied to problems associated with various psychological and physiological symptoms.

Mental Health Issues

Problem-solving therapy may help address mental health issues, like:

• Chronic stress due to accumulating minor issues
• Complications associated with traumatic brain injury (TBI)
• Emotional distress
• Post-traumatic stress disorder (PTSD)
• Problems associated with a chronic disease like cancer, heart disease, or diabetes
• Self-harm and feelings of hopelessness
• Substance use
• Suicidal ideation

Specific Life Challenges

This form of therapy is also helpful for dealing with specific life problems, such as:

• Death of a loved one
• Dissatisfaction at work
• Everyday life stressors
• Family problems
• Financial difficulties
• Relationship conflicts

Your doctor or mental healthcare professional will be able to advise whether problem-solving therapy could be helpful for your particular issue. In general, if you are struggling with specific, concrete problems that you are having trouble finding solutions for, problem-solving therapy could be helpful for you.

Benefits of Problem-Solving Therapy

The skills learned in problem-solving therapy can be helpful for managing all areas of your life. These can include:

• Being able to identify which stressors trigger your negative emotions (e.g., sadness, anger)
• Confidence that you can handle problems that you face
• Having a systematic approach on how to deal with life's problems
• Having a toolbox of strategies to solve the issues you face
• Increased confidence to find creative solutions
• Knowing how to identify which barriers will impede your progress
• Knowing how to manage emotions when they arise
• Reduced avoidance and increased action-taking
• The ability to accept life problems that can't be solved
• The ability to make effective decisions
• The development of patience (realizing that not all problems have a "quick fix")

Problem-solving therapy can help people feel more empowered to deal with the problems they face in their lives. Rather than feeling overwhelmed when stressors begin to take a toll, this therapy introduces new coping skills that can boost self-efficacy and resilience .

Other Types of Therapy

Other similar types of therapy include cognitive-behavioral therapy (CBT) and solution-focused brief therapy (SFBT) . While these therapies work to change thinking and behaviors, they work a bit differently. Both CBT and SFBT are less structured than problem-solving therapy and may focus on broader issues. CBT focuses on identifying and changing maladaptive thoughts, and SFBT works to help people look for solutions and build self-efficacy based on strengths.

This form of therapy was initially developed to help people combat stress through effective problem-solving, and it was later adapted to address clinical depression specifically. Today, much of the research on problem-solving therapy deals with its effectiveness in treating depression.

Problem-solving therapy has been shown to help depression in: 

• Older adults
• People coping with serious illnesses like cancer

Problem-solving therapy also appears to be effective as a brief treatment for depression, offering benefits in as little as six to eight sessions with a therapist or another healthcare professional. This may make it a good option for someone unable to commit to a lengthier treatment for depression.

Problem-solving therapy is not a good fit for everyone. It may not be effective at addressing issues that don't have clear solutions, like seeking meaning or purpose in life. Problem-solving therapy is also intended to treat specific problems, not general habits or thought patterns .

In general, it's also important to remember that problem-solving therapy is not a primary treatment for mental disorders. If you are living with the symptoms of a serious mental illness such as bipolar disorder or schizophrenia , you may need additional treatment with evidence-based approaches for your particular concern.

Problem-solving therapy is best aimed at someone who has a mental or physical issue that is being treated separately, but who also has life issues that go along with that problem that has yet to be addressed.

For example, it could help if you can't clean your house or pay your bills because of your depression, or if a cancer diagnosis is interfering with your quality of life.

Your doctor may be able to recommend therapists in your area who utilize this approach, or they may offer it themselves as part of their practice. You can also search for a problem-solving therapist with help from the American Psychological Association’s (APA) Society of Clinical Psychology .

If receiving problem-solving therapy from a doctor or mental healthcare professional is not an option for you, you could also consider implementing it as a self-help strategy using a workbook designed to help you learn problem-solving skills on your own.

During your first session, your therapist may spend some time explaining their process and approach. They may ask you to identify the problem you’re currently facing, and they’ll likely discuss your goals for therapy .

Keep In Mind

Problem-solving therapy may be a short-term intervention that's focused on solving a specific issue in your life. If you need further help with something more pervasive, it can also become a longer-term treatment option.

Get Help Now

We've tried, tested, and written unbiased reviews of the best online therapy programs including Talkspace, BetterHelp, and ReGain. Find out which option is the best for you.

Shang P, Cao X, You S, Feng X, Li N, Jia Y. Problem-solving therapy for major depressive disorders in older adults: an updated systematic review and meta-analysis of randomized controlled trials .  Aging Clin Exp Res . 2021;33(6):1465-1475. doi:10.1007/s40520-020-01672-3

Cuijpers P, Wit L de, Kleiboer A, Karyotaki E, Ebert DD. Problem-solving therapy for adult depression: An updated meta-analysis . Eur Psychiatry . 2018;48(1):27-37. doi:10.1016/j.eurpsy.2017.11.006

Nezu AM, Nezu CM, D'Zurilla TJ. Problem-Solving Therapy: A Treatment Manual . New York; 2013. doi:10.1891/9780826109415.0001

Owens D, Wright-Hughes A, Graham L, et al. Problem-solving therapy rather than treatment as usual for adults after self-harm: a pragmatic, feasibility, randomised controlled trial (the MIDSHIPS trial) .  Pilot Feasibility Stud . 2020;6:119. doi:10.1186/s40814-020-00668-0

Sorsdahl K, Stein DJ, Corrigall J, et al. The efficacy of a blended motivational interviewing and problem solving therapy intervention to reduce substance use among patients presenting for emergency services in South Africa: A randomized controlled trial . Subst Abuse Treat Prev Policy . 2015;10(1):46. doi:doi.org/10.1186/s13011-015-0042-1

Margolis SA, Osborne P, Gonzalez JS. Problem solving . In: Gellman MD, ed. Encyclopedia of Behavioral Medicine . Springer International Publishing; 2020:1745-1747. doi:10.1007/978-3-030-39903-0_208

Kirkham JG, Choi N, Seitz DP. Meta-analysis of problem solving therapy for the treatment of major depressive disorder in older adults . Int J Geriatr Psychiatry . 2016;31(5):526-535. doi:10.1002/gps.4358

Garand L, Rinaldo DE, Alberth MM, et al. Effects of problem solving therapy on mental health outcomes in family caregivers of persons with a new diagnosis of mild cognitive impairment or early dementia: A randomized controlled trial . Am J Geriatr Psychiatry . 2014;22(8):771-781. doi:10.1016/j.jagp.2013.07.007

Noyes K, Zapf AL, Depner RM, et al. Problem-solving skills training in adult cancer survivors: Bright IDEAS-AC pilot study .  Cancer Treat Res Commun . 2022;31:100552. doi:10.1016/j.ctarc.2022.100552

Albert SM, King J, Anderson S, et al. Depression agency-based collaborative: effect of problem-solving therapy on risk of common mental disorders in older adults with home care needs . The American Journal of Geriatric Psychiatry . 2019;27(6):619-624. doi:10.1016/j.jagp.2019.01.002

By Arlin Cuncic, MA Arlin Cuncic, MA, is the author of The Anxiety Workbook and founder of the website About Social Anxiety. She has a Master's degree in clinical psychology.

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Open Access

Peer-reviewed

Research Article

In the here and now: Future thinking and social problem-solving in depression

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing

* E-mail: [email protected] (SN); [email protected] (BD)

Affiliation Department of Psychology, De Montfort University, Leicester, England

Roles Conceptualization, Methodology, Writing – review & editing

Affiliation School of Psychology and Neuroscience, University of St Andrews, St Andrews, Scotland

• Saima Noreen, 
• Barbara Dritschel

• Published: June 30, 2022
• https://doi.org/10.1371/journal.pone.0270661
• Reader Comments

This research investigates whether thinking about the consequences of a problem being resolved can improve social problem-solving in clinical depression. We also explore whether impaired social problem solving is related to inhibitory control. Thirty-six depressed and 43 non-depressed participants were presented with six social problems and were asked to generate consequences for the problems being resolved or remaining unresolved. Participants were then asked to solve the problems and recall all the consequences initially generated. Participants also completed the Emotional Stroop and Flanker tasks. We found that whilst depressed participants were impaired at social problem-solving after generating unresolved consequences, they were successful at generating solutions for problems for which they previously generated resolved consequences. Depressed participants were also impaired on the Stroop task, providing support for an impaired inhibitory control account of social problem-solving. These findings advance our understanding of the mechanisms underpinning social problem-solving in depression and may contribute to the development of new therapeutic interventions to improve social-problem solving in depression.

Citation: Noreen S, Dritschel B (2022) In the here and now: Future thinking and social problem-solving in depression. PLoS ONE 17(6): e0270661. https://doi.org/10.1371/journal.pone.0270661

Editor: Anna Manelis, University of Pittsburgh, UNITED STATES

Received: December 20, 2021; Accepted: June 14, 2022; Published: June 30, 2022

Copyright: © 2022 Noreen, Dritschel. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The data underlying the results presented in the study are available from the following URL DOI 10.17605/OSF.IO/SDNH7 .

Funding: The authors received no specific funding for this work.

Competing interests: No authors have competing interests.

Introduction

Social problem-solving reflects the process through which people generate effective solutions to problems experienced in everyday life [ 1 , 2 ]. Given that we frequently encounter social or interpersonal problems in everyday life, such as disagreements with friends, workplace disputes and marital conflicts, the ability to solve these problems effectively is not only important for our relationships with others, but also our psychological health and mental well-being [ 3 , 4 ]. Furthermore, the ability to maintain good social relationships is also important for our psychological well-being.

Deficits in social problem-solving are a central feature of depression [ 1 , 3 , 5 , 6 ]. Priester and Chun [ 7 ] for example, found that depressed individuals exhibit a negative orientation towards a social problem compared to non-depressed healthy individuals. Furthermore, Watkins and Baracaia [ 8 ] and Goddard, Dritschel & Burton [ 3 ] found that depressed individuals generated fewer relevant steps during problem-solving and their proposed solutions were less effective than their non-depressed counterparts.

Research also suggests that rumination, which involves individuals focusing their thoughts and behaviour on their depressive symptoms and the consequences of these symptoms [ 9 ] may be a key mechanism underlying poor social problem-solving in depression. The importance of rumination in depressive disorders has been well established [ 10 ] with rumination linked to depression maintenance, negative cognitions and enhanced accessibility of negative memories [ 11 – 13 ].

Research has also found that rumination impairs social problem-solving, with ruminative thinking having a detrimental impact on both problem orientation and problem-solving skill. Lyubomirsky et al. [ 14 ] had dysphoric and non-dysphoric participants complete the Means-End Problem-solving Task (MEPS, [ 15 ]). In the MEPS, participants are presented with a hypothetical social problem and a positive resolution to the problem. Participants are asked to generate a number of steps to reach the proposed solution. Lyubomirsky et al. [ 14 ] found that dysphoric individuals induced to ruminate generated fewer steps and produced fewer effective solutions on the MEPS compared to dysphoric individuals who distracted themselves from their mood and their non-dysphoric counterparts. Furthermore, they also found that dysphoric individuals who ruminated appraised their problems as overwhelming and unresolvable, thus reflecting a negative problem orientation.

It is also possible, however, that poor problem-solving contributes to the maintenance of rumination in depression. As rumination involves recurrent thinking, it can be conceptualised as an attempt to problem solve and resolve unfulfilled goals [ 16 , 17 ]. Indeed, research has found that the content of rumination in depression often focuses on trying to solve personal problems [ 14 ]. Furthermore, ruminative thinking continues to persist until a goal is attained or discarded. These findings suggest that a vicious cycle can ensue. There is considerable evidence that rumination impairs effective problem-solving [ 12 , 14 ], increasing the likelihood of the problem being unresolved. In turn, the lack of resolution continues to trigger and maintain further rumination [ 18 ].

Another important feature of depressive thinking is hopelessness, which is defined as the extent to which an individual is pessimistic about the future [ 4 , 19 – 21 ]. Research has found that depressed individuals generate fewer positive future events [ 22 ] which may impair social problem-solving. Noreen, Whyte & Dritschel [ 23 ], for example, had participants engage in future thinking by presenting them with a hypothetical social problem and asking them to generate the consequences of the social problem being resolved or remaining unresolved. Participants were presented with some of the solutions and were asked to solve the problem in order to achieve the resolution described. Participants were also asked to recall all of the consequences generated. The study found that participants reporting higher levels of depression and rumination were less effective at generating solutions. Furthermore, they also found that those reporting higher levels of rumination produced fewer effective solutions for social problems that they had previously generated unresolved consequences for. Individuals scoring high in rumination also recalled more of the unresolved consequences in a subsequent memory test. Taken together, these findings suggest that negative future thinking impairs the generation of effective solutions for individuals with high rumination tendencies.

One explanation for these findings may relate to the type of thinking evoked when participants were asked to think of the consequences of the problem being resolved or unresolved. According to the concreteness theory [ 24 ], there are two types of thinking; abstract and concrete. Abstract thinking is operationalised as ‘indistinct, equivocal, unclear and aggregated’ and reflects broad overarching general memories, whilst concrete thinking is ‘distinct, situational, specific and clear’ and reflects more specific individualised memories. As rumination is characterised by increased abstract thinking and reduced concrete thinking, it is possible that encouraging high ruminating individuals to think about the consequences of a problem remaining unresolved leads to greater abstract thinking, which subsequently impairs problem-solving. This is consistent with research by Watkins & Moulds [ 25 ] who found that abstract thinking, typical of rumination, impaired social problem-solving in depression. Similarly, Goddard, Dritschel & Burton [ 3 ] found that reduced social problem-solving performance in a clinically depressed sample was associated with the retrieval of spontaneous abstract categoric memories during problem-solving.

It is also possible, however, that encouraging participants to think about the consequences of a problem being resolved would encourage more concrete thinking and improve social problem-solving. Indeed, Watkins & Moulds [ 25 ] found that by encouraging participants to self-focus more concretely (i.e., focusing on the self in more concrete terms, such as, focusing on your experience of the way you feel inside) improved social problem-solving in depression. Given that Noreen, Whyte & Dritschel [ 23 ], did not have a baseline measure of problem-solving (one where no consequences were generated) it is unclear whether generating the consequences of a problem being resolved in individuals high in rumination may actually improve social problem-solving.

This is an important issue given that ineffective problem-solving has been linked to both the aetiology and maintenance of depression, which has led to the development of depression treatments that target social problem-solving [ 26 , 27 ]. These treatments have demonstrated some clinical improvements in social problem-solving [ 28 , 29 ], and have been found to alleviate some of the symptoms of depression [ 30 – 32 ]. However, these strategies do not address ruminative thinking directly associated with information related to social problem-solving. Therefore, it is possible that the task developed by Noreen, Whyte & Dritschel [ 23 ] may be an effective tool to improve social problem-solving in high ruminating individuals.

It is also possible that Noreen, Whyte & Dritschel’s [ 23 ] findings may be due to impaired inhibitory control. For example, people scoring high in rumination may be unable to inhibit the negative consequences they generated earlier. Difficulties inhibiting previously generated negative consequences may subsequently affect their ability to think clearly about the steps needed to solve a problem, thus resulting in impaired social problem-solving. It has been well established that inhibition is necessary to prevent irrelevant information from entering memory and instead focusing on relevant material [ 33 ]. Indeed, research has found that individuals scoring high on measures of rumination and depression demonstrate greater difficulty in inhibiting irrelevant information [ 34 , 35 ]. Joormann [ 36 ], for example, found that dysphoric participants were impaired in their ability to inhibit negative material in comparison to non-depressed controls. There were no group differences, however, for positive material. Taken together, these findings suggest that both depression and rumination are associated with poor inhibitory control.

Whilst there have been a number of studies implicating the role of rumination in impairing social problem-solving, the role of inhibiting irrelevant information has not yet been examined. Thus, a key underlying process that could potentially contribute to the relationship between depression, rumination and impaired social problem-solving is currently unknown.

The aim of the present research is to provide further insight into the mechanisms that contribute to poor social problem-solving in depression. Specifically, we investigate whether thinking about the consequences of a problem being resolved can improve social problem-solving in a clinically depressed sample relative to non-depressed controls. We also examine whether thinking about the consequences of a problem being unresolved impairs social problem-solving in a clinically depressed sample significantly more than non-depressed controls. Furthermore, we also explore whether impaired social problem-solving is related to impaired inhibitory control.

To this end, participants took part in three sessions. In the first session, participants were screened for depression using the MINI-Plus. In the second session, depressed and non-depressed participants were presented with 8 vignettes that consisted of a series of interpersonal problems using a modified version [ 23 ] of the Means-End Problem-solving Task (MEPS; [ 15 ]). Participants were asked to generate four consequences of the problem being resolved for three of the vignettes and four consequences for the problem being unresolved for another three of the vignettes. Subsequently, participants were given six of the vignettes (including two that had not previously been presented, which acted as a baseline measure of problem-solving) with their resolutions and were asked to describe the steps they would take to solve the problem in order to achieve the resolution described. Following a ten-minute distraction task, participants were presented with all of the original six vignettes and were asked to recall all of the consequences that they had previously generated.

In the third session, participants were given the Flanker task [ 37 ] and the Emotional Stroop task (adapted from Strand, Oram & Hammar, [ 38 ]) to assess inhibitory control for both emotional and non-emotional stimuli. Comparing the performance on these two tasks would allow us to assess whether poor inhibitory control is greater for emotional stimuli. For social problem-solving we predicted that depressed individuals would perform poorer than non-depressed individuals in the baseline condition and also when they generate unresolved consequences. We also predicted that depressed individuals would recall more unresolved than resolved consequences, compared to non-depressed participants. For the Emotional Stroop and Flanker Tasks, we predicted that depressed participants would show inhibitory impairments on these tasks, compared to non-depressed participants. Finally, we also predicted that there would be a relationship between social-problem solving and inhibitory control, with poorer social problem-solving abilities related to impaired inhibitory control.

Participants

One hundred and thirteen participants (51M & 62F; age M = 23.41; SD = 3.46) took part in the initial screening session. Participants were university students that were recruited using posters advertising the study at Goldsmiths, University of London and were reimbursed for their participation (£5 per session). Participants completed the Mini-International Neuropsychiatric Interview-Plus (MINI-Plus; [ 39 ]) and the Beck Depression Inventory-II (BDI-II; [ 40 ]) in order to identify the depressed and non-depressed control groups. To be included in the depressed group, participants had to meet the criteria for current depression according to the MINI-Plus and have a minimum BDI-II score of 15. Eligibility for the controls required having no current or past Axis One disorders (e.g., anxiety disorders, dissociative disorders, mood disorders, psychotic disorders and substance use disorders) based on the MINI-Plus criteria and having a BDI-II score of 5 or below. These inclusion criteria resulted in a sample of 86 participants (41 White British; 23 British Asian (Pakistani, Indian or Bengali) and 22 Black British (African or Caribbean). A further 7 participants had to be excluded as they failed to complete all three study sessions. This resulted in 43 non-depressed control participants (17M, 26F; Mean age = 21.95; SD = 3.80) and 36 depressed participants (12M, 24F; Mean age = 21.06; SD = 4.41) in the final sample. For the currently depressed participants nine also met the criteria for dysthymic disorder, 11 met the criteria for panic disorder, 9 for social phobia, 2 for anorexia, 1 bulimia and 9 had mixed depression and anxiety. Seventeen reported taking antidepressant medications in the past and 12 had a history of past depression. The MINI-Plus was administered by a trained researcher. A second trained rater scored 25% of the interviews and there was 100% agreement regarding diagnostic status. The study was approved by the Psychology Ethics Committee, Goldsmiths, University of London. All participants provided written consent before taking part in the study.

The Beck Depression Inventory-II [ 40 ]. The BDI-II consists of 21 items that assess both psychological and physiological symptoms of depression. Participants rate the degree to which they experience each symptom over the past two weeks on a 4- point scale. The BDI-II scale has excellent psychometric properties with good internal consistency, re-test reliability and concurrent validity with other measures of depression [ 41 ]. In the present study BDI-II was found to be highly reliable (21 items; α = .97).

The Rumination Response Scale (RRS; [ 42 ]). The RRS scale consists of 22 items that assess how participants typically respond to sad or dysphoric mood. Each item is rated on a 4- point scale (with 1 = Almost never to 4 = Almost always ). Scores range from 22–88, with higher scores indicating greater rumination. RRS has good construct validity and internal consistency [ 43 ]. In the present study RRS was found to be highly reliable (22 items; α = .95).

The Spielberger State-Trait Anxiety Inventory (STAI; [ 44 ]). STAI is comprised of two questionnaires each containing 20-items that assess dispositional and situational anxiety, respectively. Each item is rated on a 4- point scale (with, 1 = not at all to 4 = very much ). Scores range from 20–80 on each questionnaire, with higher scores indicating increased anxiety. Research has found that STAI has good construct and concurrent validity [ 44 , 45 ]. The STAI also has good internal consistency with dispositional anxiety ranging from α = .92- α = .94 and situational anxiety ranging from α = .88 - α = .93 [ 44 , 46 ]. In the present study both state and trait measures were found to be highly reliable (20 items each scale; α = .96, α = .97, respectively).

Emotional Stroop task

The Emotional Stroop task (adapted from Strand, Oram & Hammar [ 38 ]) was used to investigate emotional inhibition and attention. The task consists of lexical and visual facial stimuli in the form of an emotional word (i.e., positive or negative) being superimposed on an emotional face (i.e., happy or sad). The task is to identify the emotional valence of the word and ignore the emotion displayed on the face. Half of the trials were congruent and the other half were incongruent. Congruent trials were defined as emotional words whose semantic meaning corresponded to the emotion of the face that it was superimposed on (i.e., the word ‘depressed’ superimposed on a sad face). Incongruent trials were defined as emotional words whose semantic meaning differed from the emotion expressed on the face that it was superimposed on (i.e., the word ‘elated’ superimposed on a sad face, or the word ‘miserable’ superimposed on a happy face).

The stimulus material consisted of 10 photographic colour images of faces (5 male & 5 female; Strand, Oram & Hammer, [ 38 ]) unknown to the participants. The images were developed at the University of St Andrews [ 47 ] with the emotional expressions and valence based on the Facial Acting Coding system developed by Ekman and colleagues [ 48 ]. Forty emotional (20 positive and 20 negative) words were superimposed in black font across the nose. All of the faces were used in the experimental session, with each face appearing with 2 positive and 2 negative words. Each word was presented twice, once with a happy face and once with a sad face. Thus, in a block of 80 trials, participants saw each of the 10 faces 8 times, and each of the 40 words twice, with half of the words superimposed on happy faces and the other half superimposed on the sad faces. The block of 80 stimuli was repeated in random order two times. The second block contained the same emotional words and faces as the first block but differed in terms of the word-face combinations. In total participants were given 160 trials.

In the task participants had to report the emotional valence of the word irrespective of the valence of the facial expression. Participants were asked to press the left arrow “<” when the word was positive and right arrow “>” when the word was negative. Prior to the experimental blocks, participants completed a practice block. This was similar to the main block but differed in terms of the faces and words that were presented. The practice block consisted of emotional words (20 positive and 20 negative) being superimposed on emotionally neutral faces. The practice block consisted of 40 trials with each emotional word-face combination presented once. To determine if there were any group differences, stroop responses were scored. In the task both correct and incorrect responses were recorded and error rates for incongruent trials were analysed. Furthermore, participant’s reaction times for correct responses were also analysed. Mean reaction times for congruent and incongruent trials were calculated. In the present study, the split half reliability for the Emotional Stroop task was found to be good (α = .42).

Flanker task [ 37 ]

In the flanker task, participants were presented with a string of 5 letters (e.g., CCHCC) and were asked to focus their attention solely on the middle letter. Participants were instructed to press the left arrow if the target letter was H or K (straight-lined stimulus) and the right arrow if the target letter was C or S (curvy-lined stimulus). The remaining letters were one of the remaining three possible letters (H, K, C or S) and were either the same type of stimuli (e.g., HHKHH; compatible) or were a different type (CCKCC; incompatible). For the task, participants must exercise inhibitory control by ignoring the irrelevant stimuli (i.e., the outlaying four letters) and instead focus on the central stimulus.

Each trial consisted of a 1000ms fixation cross followed by the presentation of the 5-letter string. Participants were given unlimited time to respond, but were told to respond as quickly and accurately as possible. Accuracy and response times were recorded. Participants were given 2 blocks of 48 experimental trials to complete. After one block, participants were given a short 2-min break. The order of the blocks was fully counterbalanced across participants. In order to learn the response keys, participants were initially given 12 practice trials to complete. The practice trials were similar to the experimental trials but participants were given accuracy feedback (i.e., correct or incorrect response) after each trial. In the present study, the split half reliability for the Flanker task was found to be adequate (α = .42).

Means End Problem-Solving (MEPS; [ 15 ]).

We constructed a modified version of the MEPS using eight hypothetical scenarios (adapted from Noreen, Whyte & Dritschel, [ 23 ]). The scenarios consisted of hypothetical interpersonal problems that could be encountered by a student population, such as, your supervisor finding fault with your work or your housemates not doing their chores etc. The scenarios were matched on word count, openness, difficulty in solving the hypothetical problem and the number of consequences generated (see Noreen, Whyte & Dritschel [ 23 ] for more information).

Each scenario consisted of a problem and a positive resolution. During the consequence generation phase, participants were only presented with the problem and asked to generate possible consequences for the problem either being resolved or remaining unresolved. During the problem-solving phase, participants were presented with both the problem and the positive resolution and were asked to describe the steps they would take to solve the problem and reach the proposed resolution.

The number of relevant means taken to reach the proposed solution and the effectiveness of the solutions was scored by an independent coder blind to the participant’s group status. The number of relevant means was defined as the number of relevant (and detailed) steps taken to reach the proposed solution. Effectiveness was rated using a 7- point scale with 1 being not at all effective and 7 being extremely effective. Solutions to problems were considered to be effective if they maximized positive and minimized negative consequences [ 49 ]. A second coder, also blind to participant’s group status was employed to validate findings. This coder rated 30% of the proposed solutions. Inter-rater reliability was calculated through a Pearson correlation coefficient (relevant means, r = . 92 , p < .001; effectiveness, r = . 95 , p < .001). In the present study, the split half reliability for MEPs was found to be good (α = .70).

The study consisted of three sessions. In the first session, participants completed the MINI-Plus, BDI II, RRS and STAI. In the second session, participants were presented with six of the eight hypothetical problems. For each problem they were given 4 minutes to generate 4 possible consequences of the problem either being resolved or remaining unresolved. Consequences were defined as “the possible long or short-term outcomes IF the scenario was [or was not] resolved” . Participants were asked to make sure they did not attempt to solve the scenario but only list the consequences of it being resolved or remaining unresolved. For half the hypothetical scenarios, participants generated consequences for the problem being resolved and for the remaining scenarios participants generated consequences for the problem remaining unresolved. The order of scenarios was counterbalanced so that no two ‘resolved’ or ‘not resolved’ scenarios appeared together.

Participants then completed the problem-solving task which consisted of solving six of the eight problem scenarios. These consisted of 4 scenarios that participants had generated consequences for (2 resolved and 2 unresolved) and the remaining two scenarios that participants did not generate any consequences for (a baseline measure of problem-solving).

The allocation of the scenarios to the consequence generation (resolved and unresolved) and the problem-solving phase were fully counterbalanced across participants.

For each problem-scenario, participants were presented with the problem and the positive resolution and were asked to complete the missing part of the story. Participants were given four minutes to generate a solution. Participants were subsequently given a 10-minute distraction task which involved completing some math problems. Finally, participants were given a recall test for the consequences generated earlier. Participants were presented with the 6 hypothetical scenarios presented in the recall generation phase. For each scenario, participants were given four minutes to recall all of the consequences that they had generated previously (prior to the problem-solving phase). Participants were asked to recall all of the consequences as accurately as possible. Participants were asked to recall the consequences for the baseline condition followed by the unresolved consequences and then the resolved consequences.

In a third session, participants completed the executive tasks (the Emotional Stroop task and the Flanker task). The order of the executive tasks was counterbalanced. Furthermore, the order of the administration of sessions 2 & 3 were fully counterbalanced across all participants.

Group characteristics

The depressed group scored significantly higher than the non-depressed group on the BDI, t(36.39) = 17.33, p < .001, RRS, t(70.02) = 9.13, p < .001, and state, t(73.20) = 9.86, p < .001 and trait anxiety scales t(60.34) = 12.90, p < .001. There were no differences, however, between the depressed and non-depressed groups in terms of age, t(69.62) = .96, p = .34. See Table 1 .

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https://doi.org/10.1371/journal.pone.0270661.t001

Social problem-solving ability: Relevant means

The mean number of relevant means (i.e., steps) taken to reach the proposed solution was assessed using a 2 (group: depressed vs. non-depressed) x 3 (condition: resolved vs. not resolved consequences vs. baseline) ANOVA. We found significant main effects of group, F (1, 77) = 33.66, p < .001, η 2 p = .30, and condition, F (2, 77) = 50.27, p < .001, η 2 p = .40. These were qualified by a group by condition interaction, F (2, 77) = 22.68, p < .001, η 2 p = .23, with the depressed group taking fewer steps than the non-depressed group in the baseline condition, t (61.36) = 3.32, p = .002, d = .76 and in the unresolved condition, t (67.54) = 7.04, p < .001, d = 1.60. There were no differences, however, in the relevant means between the depressed and non-depressed groups in the resolved condition, t (58.19) = 2.03, p = .047, d = .47.

Interestingly, we also found that the non-depressed group did not differ in the relevant means between the baseline condition and the resolved, t (42) = 1.25, p = .22, d = .24, and unresolved conditions, t (42) = 1.63, p = .11, d = .24. The non-depressed group, did, however, take significantly more steps in the resolved than unresolved conditions, t (42) = 2.36, p = .02, d = .46. The depressed group took significantly more steps in the resolved than baseline, t (35) = 3.47, p = .001, d = .57, and unresolved conditions, t (35) = 10.50, p < .001, d = 1.76. Depressed participants, however, took fewer steps in the unresolved than the baseline condition, t (35) = 6.29, p < .001, d = 1.12. We also investigated the effects of gender on social problem-solving, memory accuracy and on the Emotional Stroop and Flanker tasks. We did not find any significant main or interaction effects of gender on any of these variables, all p>.05.

Effectiveness

The effectiveness of the proposed solutions was assessed using a 2 (group: depressed vs. non-depressed) x 3 (condition: resolved vs. not resolved consequences vs. baseline) ANOVA. Our analysis found main effects of group, F (1, 77) = 11.35, p < .001, η 2 p = .13, and condition, F (2, 77) = 13.72, p < .001, η 2 p = .15. A significant group by condition interaction was also found, F (2, 77) = 3.96, p = .02, η 2 p = .05, with the depressed group less effective at generating solutions than the non-depressed group in the baseline, t (72.05) = 2.53, p = .01, d = .58 and the unresolved conditions, t (76.73) = 4.01, p < .001, d = .90. There were no differences, however in the effectiveness of solutions generated by the depressed and non-depressed groups in the resolved condition, t (72.73) = 1.0, p = .31, d = .23.

Subsequent analysis also found that the non-depressed group showed no significant differences in the effectiveness of solutions generated between the baseline and resolved, t (42) = .11, p = .91, d = .02, and unresolved conditions, t (42) = 1.58, p = .12, d = .30. There were also no differences in the effectiveness of solutions generated between resolved and unresolved conditions, t (42) = 1.32, p = .20, d = .26. The depressed group, however, were more effective at generating solutions in the resolved than baseline, t (35) = 2.49, p = .02, d = .39 and unresolved conditions, t (35) = 6.47, p < .001, d = 1.18. The depressed group was also more effective at generating solutions in the baseline than the unresolved condition, t (35) = 4.35, p < .01, d = .65. See Table 2 .

https://doi.org/10.1371/journal.pone.0270661.t002

Memory accuracy for consequences

In order to assess recall accuracy for the consequences generated, a 2 (group: depressed vs. control) x 3 (condition: resolved vs. unresolved consequences vs. baseline) mixed design ANOVA was conducted. There were no main effects of either group, F (1, 77) = .94, p = .36, η 2 p = .01 or condition, F (1.84, 141.65) = 1.64, p = .20, η 2 p = .02. However, a significant group by condition interaction was found, F (1.84, 141.65) = 22.89, p < .001, η 2 p = .23, which revealed that whilst the depressed group recalled significantly fewer resolved consequences than the non-depressed group, t (65.55) = 5.12, p < .001, d = 1.17. they recalled significantly more unresolved consequences, t (76.28) = 3.66, p < .001, d = .82. There was no difference, however, between depressed and non-depressed groups in their recall of baseline consequences, t (76.19) = .17, p = .87, d = .04.

Subsequent analyses also revealed that the depressed group recalled significantly more unresolved than resolved consequences, t (35) = 6.79, p < .001, d = 1.25, and baseline consequences, t (35) = 2.41, p = .02, d = .54. The depressed group, however, recalled significantly fewer resolved than baseline consequences, t (35) = 4.22, p < .01, d = .76. Conversely, the non-depressed group recalled significantly fewer unresolved than baseline consequences, t (42) = 2.21, p = .03, d = .36, but recalled significantly more resolved than unresolved consequences, t (42) = 2.84, p = .007, d = .74. There was no difference, however, between the non-depressed groups recall of resolved and baseline consequences, t (42) = 1.70, p = .10, d = .40. See Table 2 .

A 2 (group: depressed vs. control) x 2 (valence: positive vs. negative) x 2 (distractor: happy vs. sad face) mixed design ANOVA on accuracy was conducted. The results revealed main effects of valence, F (1, 77) = 27.60, p < .001, η 2 p = .26, distractor, F (1, 77) = 5.07, p = .03, η 2 p = .06, and group, F (1, 77) = 11.08, p = .001, η 2 p = .13. These main effects were qualified by a 3-way valence by distractor by group interaction, F (1, 77) = 5.26, p = .03, η 2 p = .06, with the depressed group recalling significantly fewer positive words superimposed on negative faces than the non-depressed group, t (50.97) = 3.48, p = .001, d = .80. There were no differences, however, between depressed and non-depressed groups in their recall for positive words superimposed on positive faces, t (40.65) = 2.07, p = .045, d = .48, negative words superimposed on negative faces, t (72.38) = .36, p = .72, d = .08 or negative words superimposed on positive faces, t (58.12) = 1.07, p = .29, d = .25.

Reaction time

A 2 (group: depressed vs. control) x 2 (valence: positive vs. negative) x 2 (distractor: happy vs. sad face) mixed design ANOVA found a main effect of group, F (1, 77) = 24.0, p < .001, η 2 p = .24, with the non-depressed group significantly faster at responding than the depressed group. We also found a significant valence by distractor by group interaction, F (1, 77) = 5.18, p = .03, η 2 p = .06, with the non-depressed group significantly faster at responding to positive words superimposed on positive faces, t (61.43) = 3.44, p = .001, d = .79, positive words superimposed on negative faces, t (71.42) = 3.14, p < .01, d = .71, and for negative words superimposed on positive faces, t (68.64) = 4.65, p < .001, d = 1.06 than the depressed group. There were no significant differences in reaction times between depressed and non-depressed groups for negative words superimposed on negative faces, t (75.17) = 1.25, p = .21, d = .28. We also did not find a significant effect of valence, F (1, 77) = 3.43, p = .07, η 2 p = .04, and distractor, F (1,77) = .42, p = .52, η 2 p = .01. See Table 3 .

https://doi.org/10.1371/journal.pone.0270661.t003

Flanker task

A 2 (group: depressed vs. control) x 2 (congruency: congruent vs. incongruent) mixed design ANOVA found a main effect of congruency, F (1, 77) = 16.35, p < .001, η 2 p = .18, with participants, overall, more accurate on congruent than incongruent trials. However, we did not find a significant main effect of group, F (1, 77) = .13, p = .72, η 2 p = .002, nor a group by congruency interaction, F (1, 77) = .39, p = .53, η 2 p = .005.

Reaction time.

A 2 (group: depressed vs. control) x 2 (congruency: congruent vs. incongruent) mixed design ANOVA found a main effect of congruency, F (1, 77) = 4.47, p = .04, η 2 p = .06. Overall participants were faster at responding to congruent than incongruent trials. However, we did not find either a significant main effect of group, F (1, 77) = .32, p = .57, η 2 p = .004, or a group by congruency interaction, F (1, 77) = .007, p = .93, η 2 p = .0.

The relationship between depression, rumination and social problem-solving

In order to determine whether there was a relationship between depression, rumination and social problem-solving, we conducted Pearson correlations. Our analysis failed to find significant correlations between depression, rumination and problem-solving abilities for the non-depressed control group; all tests p > .05. However, the correlations between depression, rumination, and the social problem-solving measures of relevant means (i.e., steps) and effectiveness for the depressed group were significant. These are presented in Table 4 .

https://doi.org/10.1371/journal.pone.0270661.t004

Regression analyses for relevant-means

Given that we found significant correlations between depression, rumination and social problem-solving ability in the depressed group, hierarchical multiple regression analyses were conducted in order to determine whether rumination and depression predicted performance on the problem-solving task.

The analysis found that in the baseline condition (i.e., when no consequences were generated) depression predicted the number of relevant means, Beta = .55, t(35) = 2.78, p = . 009, with a significant model explaining approx. 26% of the variance (F (2, 33) = 7.16, p = .003, R 2 = . 30, R 2 Adjusted = .26). Rumination, however, failed to predict the number of relevant means, Beta = .01, t(35) = .03, p = .98. In the resolved condition, depression was also found to predict the number of relevant means, Beta = .56, t(35) = 2.92, p = . 006, with a significant model explaining approx. 32% of the variance (F (2, 33) = 9.11, p = .001, R 2 = . 36, R 2 Adjusted = .32). Rumination, however, again failed to predict the number of relevant means, Beta = .05, t(35) = .27, p = .79. In the unresolved condition, we found that both depression and rumination predicted the number of relevant means, (depression, Beta = .49, t(35) = 4.08, p< . 001; rumination, Beta = .46, t(35) = 3.83, p = .001). A significant model found that both depression and rumination explained approx. 74% of the variance (F (2, 33) = 49.57, p< .001, R 2 = . 75, R 2 Adjusted = .74).

Regression analyses for effectiveness of solutions

Regression analysis revealed that for the baseline condition, depression predicted the effectiveness of the proposed solutions, Beta = .49, t(35) = 2.77, p = . 01, with a significant model explaining approx. 43% of the variance (F (2, 33) = 13.95, p< .001, R 2 = . 46, R 2 Adjusted = .43). Rumination, however, failed to predict the effectiveness of solutions, Beta = .24, t(35) = 1.38, p = .18. For the resolved condition, it was found that both depression and rumination predicted the effectiveness of solutions (depression, Beta = .44, t(35) = 2.67, p = . 01; rumination, Beta = .35, t(35) = 2.12, p = .04). A significant model found depression and rumination explained approx. 50% of the variance (F (2, 33) = 18.16, p< .001, R 2 = .52, R 2 Adjusted = .50). For the unresolved condition, it was found that both depression and rumination predicted the effectiveness of the proposed solutions (depression, Beta = .47, t(35) = 3.20, p< . 01; rumination, Beta = .38, t(35) = 2.59, p = .01). A significant model found that both depression and rumination explained approx. 59% of the variance (F (2, 33) = 26.58, p< .001, R 2 = . 62, R 2 Adjusted = .59). Taken together, these findings suggest whilst depression predicts the effectiveness of the proposed solutions in the baseline condition, both depression and rumination predict the effectiveness of solutions in the resolved and unresolved conditions.

Regression analyses for consequences generated

Regression analysis were also conducted for the consequences that were generated. It was found that for the baseline condition (e.g., when no problems were solved) depression predicted the number of consequences recalled, Beta = .60, t(35) = 3.11, p< . 01. A significant model was found to explaining approx. 32% of the variance (F (2, 33) = 9.16, p< .01, R 2 = . 36, R 2 Adjusted = .32). Rumination, however, failed to predict the recall of consequences, Beta = .004, t(35) = .02, p = .98. In the resolved condition, it was found that depression predicted the number of consequences recalled, Beta = .44, t(35) = 2.34, p = . 03, with a significant model explaining approx. 34% of the variance (F (2, 33) = 10.11, p< . 001, R 2 = . 38, R 2 Adjusted = .34). Rumination, however, failed to predict the recall of consequences, Beta = .23, t(35) = 1.20, p = .24. In the unresolved condition, however, we found that rumination predicted the number of consequences recalled, Beta = .510, t(35) = 2.46, p = . 02, with a significant model suggesting that rumination explained approx. 22% of the variance (F (2, 32) = 5.79, p< .01, R 2 = . 26, R 2 Adjusted = .22). Depression, however, failed to predict recall of consequences, Beta = .01, t(35) = .04, p = .97. Taken together, these findings suggest that whilst depression predicts the recall of baseline and resolved consequences, rumination predicts the recall of unresolved consequences.

Emotional Stroop performance & problem-solving abilities

As depressed and non-depressed groups showed significant differences in only one condition of the Stroop task (i.e., positive word/negative face condition), we correlated depressed participants positive word/negative face accuracy & reaction times with relevant means, effectiveness ratings and recall of consequences across all three conditions: baseline, resolved and unresolved. The analysis revealed that Emotional Stroop accuracy performance was significantly positively correlated with self-reported depression and rumination, as well as with the number of means and effectiveness scores on the problem-solving task and the recall of baseline and resolved consequences. Furthermore, a negative correlation was found for the reaction times to the positive word negative face condition and self-reported depression, self-reported rumination, number of steps generated in the resolved and unresolved conditions, as well as, the effectiveness in the resolved condition. See Table 5 . We also correlated non-depressed participants positive word/negative face accuracy & reaction times with relevant means, effectiveness ratings and recall of consequences across baseline, resolved and unresolved conditions. This analysis only found a significant relationship between positive word/negative face reaction times and recall of unresolved consequences, r (43) = -.31, p = .02; all other tests, p > .05.

https://doi.org/10.1371/journal.pone.0270661.t005

The impact of thinking about the consequences being resolved versus unresolved on social problem-solving

The aim of the current study was to determine whether thinking about the consequences of social problems being resolved or remaining unresolved would have different effects on social problem-solving in a depressed versus non-depressed sample. To this end, we presented participants with a hypothetical problem and asked them to generate consequences of the problem being resolved and remaining unresolved. We also took a baseline measure of social problem solving (i.e., where no consequences were generated). Our study found that the depressed group, compared to the non-depressed group was less effective at generating solutions and produced fewer relevant means in the baseline and unresolved conditions. These findings are consistent with previous research demonstrating that depression has a detrimental impact on social problem-solving [ 3 , 50 ]. The findings are also consistent with Noreen, Whyte & Dritschel [ 23 ] who found that generating the consequences of a problem remaining unresolved impaired social problem-solving in individuals scoring high in depression.

Interestingly, however, we found that there were no significant differences in the effectiveness of generating solutions and the number of relevant means between the depressed and non-depressed group in the resolved condition. Furthermore, we also found that depressed participants generated more relevant means and proposed more effective solutions to the problems in the resolved than baseline conditions. These findings are of clinical importance as they suggest that encouraging depressed individuals to think about the consequences of a problem being resolved prior to problem-solving enhances their ability to solve the problem. Given that research has found that positive problem orientation is an important factor for successful problem-solving [ 26 ], it is possible that thinking about consequences being resolved may naturally induce a positive problem-focused approach. Thus, this style of positive thinking may represent an effective strategy to improve social problem-solving in depression. Furthermore, the fact that depressed individuals were as able as non-depressed participants at generating effective solutions in this condition, suggests that depressed individuals may have intact social skills but, other cognitive-behavioural factors, such as excessive rumination or a negative-problem orientation may render them unable to select and implement these skills effectively.

Examining the relative contributions of depression and rumination on social problem-solving as a function of thinking about the consequences being resolved versus unresolved

The regression analyses revealed that whilst depression predicted the number of relevant means in the baseline and resolved conditions, both depression and rumination predicted the number of relevant means in the unresolved condition. These findings are partially consistent with Noreen, Whyte & Dritschel [ 23 ] who found that depression predicted the number of relevant means in the resolved condition, but only rumination predicted the number of relevant means in the unresolved condition. One reason for the discrepancy in findings may relate to depression severity. The present study consisted of participants that met the diagnostic criteria for clinical depression, whilst Noreen, Whyte & Dritschel’s [ 23 ] study consisted of dysphoric participants scoring high on measures of self-reported depression and rumination. Thus, it may be that more severe levels of depressive symptomology result in impairing social problem-solving abilities. This is consistent with research which has found that depressed individuals are less skilful then nondepressed participants in solving interpersonal problems and report significantly more difficulties in making decisions concerning interpersonal problems [ 4 , 51 – 53 ].

The fact that rumination predicted the number of relevant means in the unresolved but not resolved condition suggests that rumination, when triggered by negative thoughts or consequences, may represent an unsuitable problem-solving strategy in individuals with high levels of depression [ 54 ] and impair social problem-solving. This is consistent with research which suggests that although individuals believe rumination can help solve problems, i.e., by replaying the problem over in one’s mind and appraising it [ 55 ], when rumination is focused on negative thoughts, it can have a debilitating effect on social problem-solving [ 8 ] with individuals perceiving the problem as being more difficult to solve [ 14 ] and being less confident with the solutions they generate [ 56 ]. Thus, in the present study, when participants were asked to generate unresolved consequences, this may have triggered negative ruminative thoughts in the depressed group which led them to believe the problem was more difficult to solve. As a result, they took less steps to attempt to solve the problem.

The regression analyses also found that whilst depression was the only predictor for the effectiveness of the solutions generated in the baseline condition, both depression and rumination predicted the effectiveness of the solutions generated in the resolved and unresolved conditions. These findings are partially consistent with Noreen, Whyte & Dritschel [ 23 ] who found that whilst rumination predicted the effectiveness of the proposed solutions in the unresolved condition, only depression predicted the effectiveness of the solutions in the resolved condition.

One reason why rumination predicted the effectiveness of the proposed solutions in the resolved condition in this study but not Noreen, Whyte & Dritschel’s [ 23 ] study may relate to depression severity and the relationship between rumination and depressive symptoms. Research has found that rumination is associated with more severe and longer episodes of depression [ 57 ] and also predicts the onset of depressive episodes as well as their severity and duration [ 58 – 60 ]. It is important to mention that in Noreen, Whyte & Dritschel’s [ 23 ] study participants had moderate levels of depressive symptoms whilst in this study participants met a diagnostic criterion for depression. Therefore, it is possible that when individuals have moderate levels of depression, ruminative thinking is only triggered when negative information is presented. However, with more severe depression it is possible that both positive and negative information may trigger ruminative thinking. This is consistent with research which suggests that when currently depressed individuals recall positive memories their mood worsens [ 61 ], but when the positive memories are consistent with current view of the self then their mood improves [ 62 ]. Thus, recalling positive memories that are discrepant with current views of the self, worsens mood. It is possible that when depressed individuals think about the resolved consequences they might begin to ruminate about how positive resolution is discrepant with their current situation where they may have interpersonal difficulties. Future research should examine the self-relevancy of the problems to provide further insight on this issue.

The finding that rumination predicts the effectiveness of the solutions is consistent with a large body of research which has found that rumination hampers depressed individual’s problem orientation and problem-solving skills [ 14 , 63 ]; see Nolen-Hoeksema, Wisco & Lyubomirsky [ 64 ] for a comprehensive review). Lyubomirsky & Nolen-Hoeksema [ 12 ], for example, found that by manipulating dysphoric participants response style by encouraging them to focus on their mood state impaired their ability to solve problems on the MEPS compared to dysphoric participants who were distracted from thinking about their mood state [ 14 ]. Taken together, these findings suggest that rumination may account for the deficits in social problem-solving in individuals high in depression.

The fact that our study found that depression, independent of rumination impaired social problem-solving in the unresolved condition may relate to the severity of depressive symptomology. Previous research has found that rumination, rather than depression impaired social problem-solving in individuals with high self-reported levels of depressive symptoms (Noreen, Whyte & Dritschel, [ 23 ]). Given that individuals who took part in the present study met the diagnostic criteria for clinical depression, it is possible that generating consequences for a problem remaining unresolved impairs social problem-solving in only those individuals that have more severe levels of depression. This is consistent with research which suggests that increased severity of depression is related to greater impairments in overall cognitive ability [ 65 ].

Impact of consequence instruction on recall of consequences

We also found that depressed participants recalled significantly more consequences in the unresolved than resolved and baseline conditions. In contrast the non-depressed controls retrieved more resolved than non-resolved consequences. One reason for these findings may relate to the valence of the consequences generated. Participants generated more positive consequences of the problem being resolved and more negative consequences of the problem remaining unresolved. These findings are consistent with research on mood congruency effects which suggests that depressed individuals exhibit enhanced memory for negative material whilst healthy individuals demonstrate the opposite pattern with a memory bias for positive material ([ 66 , 67 ]; see also Matt, Vazquez & Campbell, [ 68 ]) for a review of the early work in the area).

Alternatively, it is possible that depressed individuals may recall more unresolved consequences and be impaired at social problem-solving due to impaired inhibitory control. Indeed, it is possible that generating the consequences of a problem remaining unresolved encourages depressed individuals to ruminate on these consequences. As a result, they may mentally fixate on these items which subsequently impedes the generation of appropriate solutions. This is consistent with research finding that problem-solving relies on the ability to generate appropriate solutions whilst inhibiting inappropriate responses [ 69 , 70 ].

The role of inhibitory control in social problem-solving

The role of inhibitory control in impairing problem-solving is supported by the present findings. Our findings on the Emotional Stroop task revealed that depressed participants were significantly slower and less accurate at responding in the positive word/negative face condition compared to non-depressed participants. Furthermore, we also found that in the depressed group accuracy in this condition was positively correlated with the number of relevant means and the effectiveness of solutions generated on the problem-solving task, as well as self-reported rumination and depression. For response times, however, the opposite pattern of findings was observed with reaction times negatively correlated with the number of relevant means and the effectiveness of solutions generated on the problem-solving task, as well as self-reported rumination and depression. Given that the Stroop task is a measure of sustained attention and the depressed participants showed impairments in the incongruent (positive word/sad face) condition, suggests that depression is associated with an impaired ability to inhibit negative interfering information.

Interestingly, we found no effects of depression on the flanker test which was a measure of inhibitory control of non-valanced material. These findings are consistent with research which has found that both depression and rumination are associated with impairments in tasks that require inhibition of affective content [ 36 , 71 , 72 ]. Indeed, according to Koster, De Lissnyder, Derakshan & De Raedt [ 73 ], difficulty disengaging from negative material increases one’s susceptibility to rumination. Thus, it is possible that impaired cognitive control in depression leads to individuals ruminating on unresolved consequences which subsequently impairs problem-solving and leads to enhanced recall of the unresolved consequences.

Clinical implications

It is important to highlight that our findings have potentially useful clinical implications. The fact that depressed participants showed no deficits at solving social problems compared non-depressed participants when resolved consequences were generated suggests that this may be an effective strategy to improve social problem-solving. Indeed, it is possible that generating resolved consequences results in a more a positive problem orientation style, which is a belief that social problems can be solved with a positive outcome. As positive problem orientation is conceptualised as an adaptive problem-solving strategy (see D’Zurilla & Nezu [ 26 ] for a review), these findings suggest that generating resolved consequences may aid social problem-solving in depression. Furthermore, the fact that positive problem orientation is significantly related to good psychological health, such as adaptive behaviour, positive mood, life satisfaction, and a higher level of subjective well-being [ 25 ], generating resolved consequences prior to problem-solving may actually help to reduce or alleviate sad mood in depression. Future research may wish to investigate the impact of generating resolved consequences on depressed participants subsequent mood and well-being in a therapeutic context. It is important to mention that there may also be other benefits of thinking about the problem being resolved prior to problem-solving. One possibility is that having a more positive problem orientation may encourage greater motivation in thinking about strategies for solving problems. Increasing motivation has been identified as an important factor for increasing engagement with coping strategies that can reduce depression [ 74 ]. Thus, it may be that focusing on thinking about the consequences of a problem being resolved positively increases motivation to engage in more active problem- solving strategies. Future research should look at changes in motivation for solving problems as a function of thinking about the consequences in depression. Another benefit of thinking about the generation of positive consequences is that it might encourage more positive goal-directed imagination. There is evidence that positive goal-directed imagination predicts well-being even after controlling for baseline levels of mental health [ 75 ]. Given that therapists often ask their clients to describe current problems, encouraging them to think about positive resolutions before they think about how to solve the problem could be important to improve not only social problem-solving specifically, but well-being more generally.

Furthermore, given that our findings suggest that poorer inhibitory control on the Stroop task is related to less effective problem solutions in the depressed group, it suggests that interventions such as mindfulness -based interventions (MBI) which influence inhibitory control might be useful for improving problem solving performance in depression. Mindfulness is a form of meditation that involves sustaining attentional focus on a chosen object (e.g., part of your body, sounds, specific thoughts or your breathing) and returning it to this anchor every time your mind starts to wander [ 76 ]. Research has found that mindfulness meditation is effective at enhancing executive control ([ 77 – 79 ]; for a review see Casedas, Pirrucio, Vadillo, [ 80 ]) with inhibitory control being the most consistent executive function that is improved by mindfulness mediation training [ 78 ]. With improved inhibitory control, depressed individuals may more effective at ignoring inappropriate and negative interfering thoughts from memory when trying to generate effective solutions to social-problems Future research should examine the impact of mindfulness on inhibitory control and its subsequent impact on social problem-solving.

Limitations

It is important to mention however that the study does have some limitations. Firstly, although the study used participants that met the diagnostic criteria for clinical depression on the MINI Plus, participants were not clinically diagnosed with depression by a medical professional. Therefore, it is possible that the present findings may not be generalizable to clinically diagnosed depressed individuals. It is, however, important to mention that the MINI Plus is a structured diagnostic tool that is compatible with the diagnostic criteria of DSM-5 and is commonly used in clinical research. Furthermore, the fact that our findings of impaired social problem solving are consistent with previous studies [ 8 ] that have used clinically diagnosed depressed patients also supports the notion that our participants disorder related level of impairment is comparable to clinically depressed patients. It is also worth noting that our participants were also largely university students and therefore may not represent the general population. This is especially true of our depressed sample. By using university students, however, our depressed and non-depressed participants did not differ significantly in age or level of education, thus any differences across groups for social problem solving or inhibitory measures cannot be attributed to these factors. It is also worth noting that there are significantly higher rates of depression in university students compared to the general population [ 81 ], thus, making this population important to study.

An additional limitation concerns determining the impact of depression on social problem-solving relative to other mental disorders. There is evidence that social problem -solving is also impaired by other mental health disorders, such as, social anxiety disorder [ 82 ], eating disorders [ 83 ] and schizophrenia [ 84 ], which can co-occur with depression. In the present study we could not address this issue as we screened our participants for other psychological disorders. Therefore, the present findings cannot be attributed to the presence of any comorbid disorders. Nonetheless, future research may wish to use a larger and more clinically diverse sample size to explore the impact of comorbid disorders on social problem solving. Another limitation of the current study is that we did not ask participants whether they were currently on any psychopharmacological treatments for their depression. Indeed, it is possible that psychopharmacological treatments for depression may lead to individuals demonstrating a different pattern of findings on social problem solving and rumination. Thus, future research may wish to report whether participants are on any treatments and whether this impacts rumination and social problem solving. A final limitation is that the study was not preregistered, however it is important to note that the study predictions were based on robust previous research findings (Noreen, Whyte & Dritschel, [ 23 ]).

In conclusion, our study has found that depressed participants have intact social problem-solving skills when solving problems that they have previously generated resolved consequences for. We also found that depressed participants recalled significantly more consequences in the unresolved than resolved and baseline conditions. These findings suggest that encouraging depressed individuals to think about the consequences of a problem being resolved may be an effective strategy to improve social problem-solving skills in depression. Furthermore, we also found that depressed participants had difficulty disengaging from negative interfering material on an Emotional Stroop task, providing support for an impaired inhibitory control account of social problem-solving in depression. These findings advance our understanding of social problem-solving in depression by providing a more nuanced understanding of the mechanisms underpinning social problem-solving difficulties and have implications for therapeutic interventions.

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• 18. Harvey AG, Watkins E, Mansell W, Shafran RCognitive behavioral processes across psychological disorders: A transdiagnostic approach to research and treatment. New York. Oxford University Press Inc; 2004.
• 19. Beck AT. Cognitive therapy of depression. New York: International Universities Press; 1976.
• 20. Beck AT, Rush AJ, Shaw BFEmery G Cognitive therapy of depression. New York, NY: Guilford Press;1979.
• 26. D’Zurilla TJ Nezu AM Problem-solving therapy: A positive approach to clinical intervention (3rd ed). New York: Springer Publishing;2007.
• 33. Hasher L, Zacks RT Working memory, comprehension, and aging: A review and a new view. In Bower GH (editor) The Psychology of Learning and Motivation, 22, New York: Academic Press. 1988; pp.193–225.
• 40. Beck AT, Steer RA Brown GK (1996 Manual for the beck depression inventory-II. San Antonio, TX: Psychological Corporation; 1996.
• 44. Spielberger CD, Gorsuch RL, Lushene RE. Manual for the state-trait inventory. Palo Alto: Consulting Psychologists Press: 1970.
• 45. Spielberger CD. State-Trait Anxiety Inventory: Bibliography. 2 nd Edition, Palo Alto: Consulting Psychologists Press; 1989.
• 47. Young AW, Perrett D, Calder A, Sprengelmeyer R, Ekman P. Facial expressions of emotion: Stimuli and tests (FEEST). Bury St. Edmunds: Thames Valley Test Company; 2002.
• 48. Ekman P, Friesen WV, Hager JC. Facial action coding system: Manual and Investigator’s Guide. Salt Lake City, UT: Research Nexus; 2002.
• 69. Smith SM (The constraining effects of initial ideas. In: Paulus PB, Nijstad BA, editors. Group creativity: Innovation through collaboration New York, NY: Oxford University Press. 2003; pp 15–31.

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‘There is no point in pouring staff into the funnel if they are not supported’

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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Social problem-solving might also be called ‘ problem-solving in real life ’. In other words, it is a rather academic way of describing the systems and processes that we use to solve the problems that we encounter in our everyday lives.

The word ‘ social ’ does not mean that it only applies to problems that we solve with other people, or, indeed, those that we feel are caused by others. The word is simply used to indicate the ‘ real life ’ nature of the problems, and the way that we approach them.

Social problem-solving is generally considered to apply to four different types of problems:

• Impersonal problems, for example, shortage of money;
• Personal problems, for example, emotional or health problems;
• Interpersonal problems, such as disagreements with other people; and
• Community and wider societal problems, such as litter or crime rate.

A Model of Social Problem-Solving

One of the main models used in academic studies of social problem-solving was put forward by a group led by Thomas D’Zurilla.

This model includes three basic concepts or elements:

Problem-solving

This is defined as the process used by an individual, pair or group to find an effective solution for a particular problem. It is a self-directed process, meaning simply that the individual or group does not have anyone telling them what to do. Parts of this process include generating lots of possible solutions and selecting the best from among them.

A problem is defined as any situation or task that needs some kind of a response if it is to be managed effectively, but to which no obvious response is available. The demands may be external, from the environment, or internal.

A solution is a response or coping mechanism which is specific to the problem or situation. It is the outcome of the problem-solving process.

Once a solution has been identified, it must then be implemented. D’Zurilla’s model distinguishes between problem-solving (the process that identifies a solution) and solution implementation (the process of putting that solution into practice), and notes that the skills required for the two are not necessarily the same. It also distinguishes between two parts of the problem-solving process: problem orientation and actual problem-solving.

Problem Orientation

Problem orientation is the way that people approach problems, and how they set them into the context of their existing knowledge and ways of looking at the world.

Each of us will see problems in a different way, depending on our experience and skills, and this orientation is key to working out which skills we will need to use to solve the problem.

An Example of Orientation

Most people, on seeing a spout of water coming from a loose joint between a tap and a pipe, will probably reach first for a cloth to put round the joint to catch the water, and then a phone, employing their research skills to find a plumber.

A plumber, however, or someone with some experience of plumbing, is more likely to reach for tools to mend the joint and fix the leak. It’s all a question of orientation.

Problem-Solving

Problem-solving includes four key skills:

• Defining the problem,
• Coming up with alternative solutions,
• Making a decision about which solution to use, and
• Implementing that solution.

Based on this split between orientation and problem-solving, D’Zurilla and colleagues defined two scales to measure both abilities.

They defined two orientation dimensions, positive and negative, and three problem-solving styles, rational, impulsive/careless and avoidance.

They noted that people who were good at orientation were not necessarily good at problem-solving and vice versa, although the two might also go together.

It will probably be obvious from these descriptions that the researchers viewed positive orientation and rational problem-solving as functional behaviours, and defined all the others as dysfunctional, leading to psychological distress.

The skills required for positive problem orientation are:

Being able to see problems as ‘challenges’, or opportunities to gain something, rather than insurmountable difficulties at which it is only possible to fail.

For more about this, see our page on The Importance of Mindset ;

Believing that problems are solvable. While this, too, may be considered an aspect of mindset, it is also important to use techniques of Positive Thinking ;

Believing that you personally are able to solve problems successfully, which is at least in part an aspect of self-confidence.

See our page on Building Confidence for more;

Understanding that solving problems successfully will take time and effort, which may require a certain amount of resilience ; and

Motivating yourself to solve problems immediately, rather than putting them off.

See our pages on Self-Motivation and Time Management for more.

Those who find it harder to develop positive problem orientation tend to view problems as insurmountable obstacles, or a threat to their well-being, doubt their own abilities to solve problems, and become frustrated or upset when they encounter problems.

The skills required for rational problem-solving include:

The ability to gather information and facts, through research. There is more about this on our page on defining and identifying problems ;

The ability to set suitable problem-solving goals. You may find our page on personal goal-setting helpful;

The application of rational thinking to generate possible solutions. You may find some of the ideas on our Creative Thinking page helpful, as well as those on investigating ideas and solutions ;

Good decision-making skills to decide which solution is best. See our page on Decision-Making for more; and

Implementation skills, which include the ability to plan, organise and do. You may find our pages on Action Planning , Project Management and Solution Implementation helpful.

There is more about the rational problem-solving process on our page on Problem-Solving .

Potential Difficulties

Those who struggle to manage rational problem-solving tend to either:

• Rush things without thinking them through properly (the impulsive/careless approach), or
• Avoid them through procrastination, ignoring the problem, or trying to persuade someone else to solve the problem (the avoidance mode).

This ‘ avoidance ’ is not the same as actively and appropriately delegating to someone with the necessary skills (see our page on Delegation Skills for more).

Instead, it is simple ‘buck-passing’, usually characterised by a lack of selection of anyone with the appropriate skills, and/or an attempt to avoid responsibility for the problem.

An Academic Term for a Human Process?

You may be thinking that social problem-solving, and the model described here, sounds like an academic attempt to define very normal human processes. This is probably not an unreasonable summary.

However, breaking a complex process down in this way not only helps academics to study it, but also helps us to develop our skills in a more targeted way. By considering each element of the process separately, we can focus on those that we find most difficult: maximum ‘bang for your buck’, as it were.

Continue to: Decision Making Creative Problem-Solving

See also: What is Empathy? Social Skills

Creative Problem Solving in Healthcare

CREATIVE PROBLEM SOLVING IN THE HEALTHCARE SETTING

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There are 5 primary strategies to use when looking for creative ways to solve problems in healthcare:

• Brainstorming
• Thinking hats
• Problem reversal
• Role-playing

We all have to deal with problems, not only at work, but also in our personal lives. Planning a wedding or a party, finding child care, paying bills, trying to arrange transportation for family members to get where they need to go…all of these are frequent problems that we have to deal with.

As a healthcare worker, your workplace is always changing. It is full of challenges and new clients. You must monitor your client’s condition and perform prescribed treatments. You must know when to inform health professionals about your client’s condition. You must help your clients to make decisions.

Problems can quickly arise and you will have to solve these problems. You need to know what to do and when to do it. Some of these problems will require creative solutions. Being able to creatively problem-solve is an important skill for today’s healthcare workers. Knowing the types of problems that can arise and planning for them in case they do happen will help you to deal with problems effectively.

ABOUT PROBLEM SOLVING

Problem-solving requires critical thinking skills and creativity. What is a problem? What does creativity mean? What is critical thinking?

A problem is a gap or difference in what the situation now is and what you would like it to be.

Creativity is basically the production of order out of chaos. Creativity is developing new, flexible, open-minded approaches or solutions to a problem.

Critical thinking is examining and reflecting on ideas and thinking. Then judgments are made and a course of action decided upon. By combining critical thinking and problem solving, the problem is identified, information is gathered, beliefs and ideas are challenged, and different options are examined creatively. Asking questions is the way to build critical thinking into problem solving.

CREATIVE PROBLEM-SOLVING STRATEGIES

Several strategies that you can use to solve problems creatively are brainstorming, thinking hats, problem reversal, S.W.O.T., and role playing.

Brainstorming Brainstorming is often used by groups, but can also be used by you alone. It is used to create as many possible solutions to a problem as possible. To be effective, the ideas must not be judged or evaluated in any way as they are being developed, no matter how bizarre they seem. Wild ideas are welcomed. Ideas can build on other ideas. New ideas can be created by changing ideas already mentioned.

The more solutions that can be created, the more likely you are to find an effective one. Also, the more variety there is in the solutions, the more likely you are to find an effective one. Once all possible ideas have been created, they are considered for possible consequences. A solution is then selected.

Consider for a moment Divide a square into 4 equal parts. How many possible ways can you think of to divide a square into 4 equal parts?

Below are 4 of the possible answers to this exercise. There are actually many different ways to divide a square into 4 equal parts. This exercise helps to develop your creative thinking skills. It also shows that there is often more than one right answer to a problem.

Thinking hats Thinking hats can also be used in groups, or by you alone. It was originally designed by Edward de Bono. It uses six colored (imaginary) hats. Each hat stands for a different way of thinking about a problem or issue. Using all of the hats will help you to consider the problem more creatively. You will be able to think about the problem from a different viewpoint than you usually take. If it is being used with a group, all members have on the same colored hat at the same time.

1. The white hat is neutral. Facts, figures, and information are examined. It helps to decide if more information is needed.

2. The red hat is for feelings, hunches, and intuition. There is no need to explain your feelings.

3. The yellow hat is for optimism and a logical, positive view of things. It looks at the benefits. It also helps during the evaluation of ideas.

4. The black hat is the logical negative. It uses caution and judgement. It does not encourage creativity. It helps during the evaluation of ideas. It is usually better to use the yellow hat before the black one, to look at the benefits first.

5. The green hat is for creative thinking and new ideas.

6. The blue hat is used to think about the problem-solving process. It ensures the process is being followed. It helps to decide what should be done next.

Problem reversal Sometimes, you will get a different view of a problem if you look at it from the opposite direction. State the problem in reverse. Change a positive statement into a negative one. For example, if there is a problem with a co-worker and you want to improve the situation, consider what would make the situation worse.

S.W.O.T. Analyzing the strengths, weaknesses, opportunities, and threats (S.W.O.T.) is another way of evaluating a problem. It can also be used when evaluating the solutions. What are the possible benefits? What strengths are present? What are the weaknesses? What new opportunities or situations can be created? How can we take advantage of these opportunities? What is the possible harm in the problem? What is the possible harm in the solution?

TIPS TO HELP WITH PROBLEM-SOLVING

1. Think before acting. Use a problem-solving process.

2. Think clearly – stay open-minded. Recognize the effects your emotions can have on your thinking. Separate facts from opinions. Look for errors in reasoning. Consider the evidence (information) – do not jump to conclusions. Don’t try to make the facts fit the solution you want to use.

3. Ask as many questions as you can. Make sure you are asking the right questions to find out what the problem really is. Find out all you can about the problem.

4. Get good ideas from everyone and from everywhere. Edward Land was taking photographs of his family on vacation. His daughter asked him, “Why do we have to wait to see the pictures?” Land thought about this and came up with the idea of instant photography and the Polaroid Camera.

5. Be selective. You cannot solve every problem. Make sure the problem is yours to solve.

6. If a problem seems to be overwhelming, break it into parts.

7. Make the best use of what you have. People often waste a lot of time and energy on “if only.” When you are solving problems, focus on what you have available and what you can change or fix. Spending time on “if only” will just waste time. Spending time and energy saying, “It wouldn’t be a problem if only we had twice as much money for equipment” does not solve the problem – especially if you know you are not going to get twice as much money. Gather the facts as they exist and develop realistic solutions.

8. Look for the opportunity in the problem. Developing creative solutions takes advantage of the opportunity in the problem. For example, a long-term institution for the elderly is looking at the possibility of having to lay-off employees. At the same time, there is a community need for daycare services for the elderly. Perhaps a creative solution would be to develop a daycare program for the elderly instead of laying the employees off.

9. Don’t wait for a problem to occur. If you can take action before a situation turns into a problem, do so.

10. Plan for problems before they occur.

11. Negotiate. Negotiation means that those involved have some of their needs met. This is usually a good strategy in problem-solving. Everybody gets something.

12. Ensure the solution fits the problem. Once the solution has been put into action, it is important to evaluate the plan to ensure the problem has actually been solved and not just hidden for a while.

13. Expect success. Believe in your ability. Work towards realistic goals rather than trying to save the world. Use your skills, time, and energy wisely.

14. Look forward, not backward. Don’t always count on strategies that worked in the past. Be curious. Have the self-confidence to try new things.

15. Although we would like to have all of our problems solved quickly, don’t expect to be able to solve every problem, especially with the first strategy used.

16. Keep your sense of humor.

17. Avoid judging during the gathering of information and development of ideas. The most important question in the creative process is “How might we…?” “We can’t because …” is a barrier to creative problem solving.

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I look upon the “Herb Interaction” book as a “quickie” for my pharmacy team, no need to get bogged down on the computer.

The book on “foot ulcers” spoke to me, I now understand the importance of foot care.

We forget sometimes the power of the patient for healing through compliance and self care habits. We should provide understandable information.

The Dr’ Guide books were a great door opener and relationship builder with the allergy medical team. Our reps loved them.

We had the highest BRC (business Reply Card) return rate of all time – it built up great customer goodwill and easier repeat calls.

The distribution of the Dr. Guide books was the most cost effective, most quickly integrated and best ROI program I have had in years – no committee development meetings, no sky high “creative” costs and so appropriate for our product / treatment messages.

• Dec 7, 2023

Problem Solving Challenges in Care Work: An Easy Guide

In the world of care work, problem-solving is a vital skill, akin to a necessary tool in a professional's toolkit. Whether you're a seasoned caregiver or just starting out, mastering the art of problem-solving is essential. Let's delve into the core of this skill and explore practical ways to identify and excel in problem-solving within the rewarding field of care.

Demystifying Problem-Solving To start, let's simplify the term 'problem-solving.' It's not about performing magic but more like unraveling a knot. It involves grasping the issue, finding imaginative solutions, and implementing them effectively.

Recognising Common Challenges in Care Work Before we get into the nitty-gritty of problem-solving, let's acknowledge some common challenges in care work. These can range from communication hurdles with patients and their families to managing time effectively and dealing with emotional exhaustion. Knowing the challenges is the first step.

Practical Tip #1 : Engage in Active Listening Have you ever heard the advice, "Understand first, then be understood"? In care work, active listening is the key. When you truly listen to patients and their families, you unveil the core of the issue, much like solving a puzzle by collecting all the pieces.

Practical Tip #2 : Foster Collaboration and Communication In problem-solving, two minds are often better than one. The same holds for care work. Don't hesitate to tap into your team's collective wisdom. Collaborate, share insights, and brainstorm solutions. Effective communication can turn a daunting challenge into a manageable task.

Practical Tip #3 : Prioritise and Stay Organised Care work can often feel like juggling multiple tasks. To prevent dropping the crucial ones, learn the skill of prioritisation. Identify the most urgent issues, create a to-do list, and tackle them systematically. Organization acts as your reliable guide in the expansive landscape of responsibilities.

Practical Tip #4 : Embrace Adaptability In care work, every day brings new challenges. Embrace the unexpected with open arms. Be flexible in your problem-solving approach. If Plan A falls short, there are 25 more letters in the alphabet – find the one that fits.

Practical Tip #5 : Commit to Continuous Learning Healthcare is a dynamic field, and so should your approach be. Keep your knowledge up-to-date, attend workshops, and seek opportunities for professional growth. The more tools you have at your disposal, the better equipped you'll be to tackle any challenge.

Applying Tips to Real-Life Scenarios: Tackling Emotional Burnout Now, let's put these practical tips to use in a real-life scenario – the prevalent issue of emotional burnout among caregivers.

Active Listening: Reflect on your emotions and listen to what they're telling you. Identify if you're feeling overwhelmed, stressed, or detached – this is the first step in addressing the issue.

Collaborate and Communicate: Share your feelings with your team or supervisor. They might provide valuable insights or suggest ways to lighten your workload.

Prioritise and Organise: Break down tasks into manageable parts, focusing on immediate needs. Organise your schedule to include breaks and self-care.

Embrace Flexibility: Understand that it's okay to adjust your approach. If a particular caregiving method isn't effective, explore alternatives. Flexibility is essential in overcoming emotional burnout.

Continuous Learning: Attend workshops on stress management and emotional well-being. Equip yourself with coping mechanisms that resonate with you.

By applying these problem-solving strategies, you can transform seemingly insurmountable challenges into manageable steps, fostering a more fulfilling and sustainable career in care work. Remember, problem-solving is a continuous journey of improvement. Happy caregiving!

To register your interest in CV Placement Ltd as a care business, please click HERE .

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• 3 Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
• Original Investigation Intervention to Improve Health Care Worker Well-Being During COVID-19 Lisa S. Meredith, PhD; Sangeeta Ahluwalia, PhD; Peggy G. Chen, MD, MHS, MSc; Lu Dong, PhD; Carrie M. Farmer, PhD; Kathryn E. Bouskill, MPH, PhD; Sarah Dalton, MA; Nabeel Qureshi, MPH, MPhil; Tara Blagg, MPhil; George Timmins, MPH, MPhil; Lucy B. Schulson, MD, MPH; Shreya S. Huilgol, BA; Bing Han, PhD; Stephanie Williamson, BA; Patricia Watson, PhD; Paula P. Schnurr, PhD; Monique Martineau, MA; Katie Davis, RN, MS-HSM; Andrea Cassells, MPH; Jonathan N. Tobin, PhD; Courtney Gidengil, MD, MPH JAMA Network Open

Burnout among US health care workers is an increasingly recognized problem. 1 General Social Survey data suggest that almost one-half of US health care workers experienced symptoms of burnout often or very often in 2022, up from less than one-third in 2018. 1 The Chief Medical Officer of the Centers for Disease Control and Prevention has said that “burnout among [health care] workers has reached crisis levels.” 2

In recent years, this burnout crisis has accelerated alongside the COVID-19 pandemic and broader workforce trends. The percentage of workers, both inside and outside health care, reporting often having sleep problems increased between 2018 and 2022 (from 21% to 27% for health workers, from 22% to 25% for other essential workers, and from 21% to 24% for all other workers). 1 This suggests that although health care workers have faced unique challenges during this period, there are other changes that have affected our whole society since the start of the COVID-19 pandemic. 1

Overall, US health care workers are now more burned out than they were before the COVID-19 pandemic. A national study of burnout in physicians by Shanafelt et al 3 found that 63% of physicians reported symptoms of burnout in 2021, 38% reported burnout symptoms in 2020, and 44% reported such symptoms in 2017. Burnout is a problem not only because of the suffering of our colleagues and their families, but also because of the repercussions for the health care system. For instance, clinicians who are burned out are more likely to consider leaving the practice of medicine. 4 In a national survey by Sinsky et al 4 in December 2020, 1 in 5 physicians and 2 in 5 nurses reported intending to leave medical practice within 2 years, and 1 in 3 health care workers reported intending to reduce their work hours. Both reduced work hours and clinician turnover due to burnout have substantial financial repercussions, with physician burnout alone thought to cost the US health care system an estimated $4.6 billion per year. 5 With the growing concern over health care worker shortages, the burnout crisis for health care clinicians is already likely contributing to a lack of availability of care for patients.

In this context, rigorous study of how to reduce physician burnout is essential. Meredith et al 6 examined the efficacy of a military-developed, evidence-based intervention to help individuals navigate highly stressful situations. Stress First Aid is an easily deployable framework for engaging in self-care and peer support through actionable coping skills, resilience building, and healing. Meredith et al 6 conducted a cluster randomized clinical trial by comparing the effects of the intervention vs usual care on a number of well-being measures, including posttraumatic stress disorder (PTSD) and psychological distress, for health care workers during the COVID-19 pandemic. Their survey-based study involved polling health care workers during the pandemic about symptoms of general psychological distress and PTSD before and after they received intervention support vs usual care (ie, no targeted support interventions). Although they found no treatment effect across the general study population, they found a clinically and statistically significant reduction in self-reported symptoms of both general psychological distress (approximately 4-point reduction on a 0-24 score; P  = .01) and PTSD (approximately 7-point reduction on a 0-80 score; P  = .04) in young health care workers (≤30 years old) in federally qualified health centers after intervention training. 6

These findings are notable for 2 primary reasons. First, from a research methods perspective, this is an example of a rigorous randomized clinical trial used to study psychological outcomes and burnout among health care workers. Given the importance of the burnout crisis, we need to have the most possible confidence about the efficacy of interventions. 7 Clinical trials are ideal to identify the causal treatment effect of interventions. The results of such trials are, thus, especially attractive to policymakers and health care leadership. 7 The fact that these authors were able to conduct their trial in health care settings through the COVID-19 crisis is particularly commendable. Second, their findings highlight that workplace interventions in health care have the potential to make meaningful reductions in burnout and potentially lead to more robust and resilient health care institutions.

By using peer-based support to navigate highly stressful circumstances, Meredith et al 6 highlight the importance of collegiality and mutual support in a cataclysmic crisis. On the basis of the results of their study, this may be especially meaningful for young health care workers who have yet to develop the most personally meaningful coping strategies, clinical confidence, and workplace community and networks that a longer career in health care may afford. Furthermore, as Meredith et al 6 suggest, peer-based skills acquired through programs may be especially important to teach early and nurture throughout the arc of an individual’s professional career.

More broadly, the results from their study suggest that strengthening peer-peer interactions in the workplace offers a potential target for reducing burnout in health care. Others have similarly found that workplace relationships can influence burnout. For instance, when Nigam et al 1 examined General Social Survey data, they found that the odds of experiencing burnout among those who felt their supervisors helped them were 26% that of those who did not feel their supervisors helped. Similarly, the odds of experiencing burnout among those who reported trust in their management were 40% that of those who did not. 1 These results suggest that if burnout is affected by workplace dynamics, whether peer-peer or between employees and supervisors, then focusing on these relationships and the improved workplace culture that can result is an important potential target for reducing health care burnout. 1

Together, these results highlight that continued worsening of the burnout crisis in health care is not inevitable. Although systemic changes are likely required to reverse the trend, the results from Meredith et al 6 and others highlight the potential role of workplace-culture interventions in starting to move the needle. As the authors suggest, organizational leadership may want to consider devoting resources for peer-based support initiatives to build workplace relationships and mitigate burnout. As we think about ways to help a generation of health care workers heal from the pandemic and its aftermath, focusing on peer-peer dynamics and workplace culture as the targets of intervention may be especially effective in reinforcing strong institutions, engaged health care workers, and robust community and collegiality in health care.

Published: April 30, 2024. doi:10.1001/jamanetworkopen.2024.4167

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 O’Kelly AC et al. JAMA Network Open .

Corresponding Author: Jason H. Wasfy, MD, MPhil, Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, GRB 800, Boston, MA 02114 ( [email protected] ).

Conflict of Interest Disclosures: None reported.

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O’Kelly AC , del Carmen MG , Wasfy JH. Learning How to Protect the Health System by Protecting the Caregivers. JAMA Netw Open. 2024;7(4):e244167. doi:10.1001/jamanetworkopen.2024.4167

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Social problem-solving partnerships with family caregivers

Affiliation.

• 1 University of Alabama at Birmingham, USA.
• PMID: 10754919
• DOI: 10.1002/j.2048-7940.1999.tb02192.x

The goal of this pilot study was to compare the effectiveness of home and telephone social problem-solving partnerships on primary family caregiver outcomes and to determine whether certain caregiver and stroke survivor characteristics influenced these outcomes. Thirty primary family caregivers were assigned to either a home visit, telephone contact, or control group. A registered nurse trained caregivers in the intervention groups in a series of seven telephone calls or home visits during a 12-week period to use social problem-solving skills in managing caregiving problems. Primary family caregiver outcomes were compared before the intervention, during the intervention (at 2 and 5 weeks after discharge), and after the intervention (at 13 weeks after discharge). Compared to the home and control groups, the telephone group had a significant reduction in depression, more positive problem-solving skills, and greater caregiver preparedness during the intervention, and improved, but nonsignificant depression, problem-solving, and caregiver preparedness scores postintervention. Race, age, and education were significant for selected outcomes.

Publication types

• Clinical Trial
• Comparative Study
• Randomized Controlled Trial
• Research Support, Non-U.S. Gov't
• Aged, 80 and over
• Caregivers / education*
• Caregivers / psychology*
• Community Health Nursing / methods*
• Family / psychology*
• Home Care Services / standards*
• Middle Aged
• Nursing Evaluation Research
• Pilot Projects
• Problem Solving*
• Professional-Family Relations*
• Rehabilitation Nursing / methods*
• Social Support*
• Stroke / nursing*
• Telephone / standards*

• Open access
• Published: 29 April 2024

The experiences and needs of older adults receiving voluntary services in Chinese nursing home organizations: a qualitative study

• Qin Shen 1 &
• Junxian Wu 1  

BMC Health Services Research volume  24 , Article number:  547 ( 2024 ) Cite this article

Metrics details

Older adults living in nursing home organizations are eager to get voluntary help, however, their past experiences with voluntary services are not satisfactory enough. To better carry out voluntary services and improve the effectiveness of services, it is necessary to have a deeper understanding of the experiences and needs of older adults for voluntary services.

The purposive sampling method was used to select 14 older adults from two nursing home organizations in Hangzhou and conduct semi-structured interviews, Collaizzi’s seven-step method was used to analyze the data.

Older adults in nursing home organizations have both beneficial experiences and unpleasant service experiences in the process of receiving voluntary services; Beneficial experiences include solving problems meeting needs and feeling warmth and care, while unpleasant service experiences include the formality that makes it difficult to benefit truly, lack of organization, regularity, sustainability, and the mismatch between service provision and actual demands. The needs for voluntary services mainly focuses on emotional comfort, Cultural and recreational, and knowledge acquisition.

Older adults in nursing home organizations have varied voluntary experiences, and their voluntary service needs are diversified. Voluntary service needs of older adults should be accurately assessed, and voluntary service activities should be focused upon.

Peer Review reports

Introduction

As a result of advancements in medical technology and improved sanitation conditions, the average life expectancy of Chinese people has increased significantly from 60 years in 1970 to 77.3 years in 2023. However, this has led to a growing number of older adults in China. According to the seventh population census conducted by the National Bureau of Statistics of China, there are now 260 million people over the age of 60 living in the country [ 1 ], The aging population in China is growing, and population balance is becoming a core challenge for the country in the long term. The increasing aging population has posed significant challenges and burdens to the state and society [ 2 ], China’s aging population challenges the current security system, requiring significant efforts from the state and society for improvement [ 3 ].

There are three main modes of old-age care in China: family old-age care, community old-age care, and institutionalized old-age care. Family old-age care is the most traditional form of old-age care in China, due to the reduction in family size and the formation of the “4-2-1” family model - which consists of four older adults, one couple, and one child - the traditional family model is no longer able to meet the growing demand for older adults care [ 4 ]; China’s community old-age care is still in the exploratory stage, facing challenges such as slow construction, insufficient staff, and lack of professional knowledge. As a result, it cannot provide meticulous care services for older adults [ 5 ]. Against this background, institutionalized older adult care has gradually become popular, it refers to older adults in social service organizations such as senior citizen apartments, welfare homes, and homes for older adults to spend their later life [ 6 ]. The challenges of population aging and the inadequacies of family and community support for older adults have resulted in a growing number of older adults opting to reside in nursing home organizations. This has undoubtedly placed additional burdens and challenges on these nursing home organizations. Due to multiple challenges such as late start, low quality, and lack of professional and technical talents, China’s nursing home organizations are still a long way from meeting the comprehensive needs of older adults in terms of health management, skilled nursing care, rehabilitation training, cultural and recreational services, psychological counseling, and social interaction [ 7 ]. To tackle the issue of an aging population in China and ensure that older adults have a high quality of life when choosing nursing home organizations, it is necessary to enhance the quality of older adult care services by engaging social forces, such as volunteer teams [ 8 ]. Voluntary services refer to the voluntary, unpaid public service offered by individuals, organizations, and voluntary service organizations to society or other organizations. The forms of voluntary services are diverse and can be either formal, planned, and long-term, or informal, spontaneous, and intermittent [ 9 ]. At present, volunteer groups in China’s nursing home organizations are mostly informal and consist of university students, healthcare workers, art workers, social workers, and others. These groups are invited by nursing home organizations or come to these institutions on their initiative to provide services for older adults. These services include a wide range of activities such as haircutting, cultural performances, spiritual comfort, hobby learning (e.g., paper-cutting, flower arranging), organizing festive activities (e.g., making rice dumplings on-site at Dragon Boat Festival, making mooncakes at Mid-Autumn Festival, etc.).

Voluntary services are a crucial aspect of long-term care and greatly complement the resources provided by the government,these nursing home organizations welcome volunteers who perform various non-medical activities associated with the daily lives of older adults [ 10 , 11 , 12 ]. Volunteers offer additional assistance and companionship to residents, provide support to employees such as nurses, nutritionists, and physical therapists, and potentially improve the overall quality of care, in China, these services have become increasingly popular and play a crucial role [ 13 , 14 ]. However, some problems have emerged in voluntary services, The voluntary services provided by volunteer organizations for older adults have certain functional defects and efficiency dilemmas, such as an unsound volunteer management system, high mobility of volunteers, and lack of a corresponding volunteer training system, which leads to the inability to provide high-quality services [ 13 ]. The above problems have undermined the effectiveness of voluntary services and affected the regular operation of nursing home organizations [ 15 ].

For effective services for older adults, it’s critical to understand the needs and experiences of older adults in nursing home organizations, there have been limited studies on how older adults feel about receiving voluntary services and if such services are suitable for their actual needs. One qualitative study documented the experiences of older adults who were helped by volunteers, but it was mainly focused on the volunteers themselves [ 16 ]. Another study looked into the benefits and experiences of receiving voluntary services, but it specifically focused on older adults who were confined to their homes [ 17 ]. There is no research available that sheds light on the emotions and requirements of older adults who receive voluntary services in nursing home organizations. To bridge this gap, we conducted interviews with older adults who have been accepted for voluntary services in two nursing home organizations in Hangzhou. The objective of this study is to gain a deeper understanding of the actual needs and experiences of older adults and use this information to guide promoting the effective growth of voluntary services and establishing a voluntary service system that is suitable for older adults in nursing home organizations.

This study adopts a qualitative descriptive approach to examine the experiences and expectations of older adults in nursing home organizations when receiving voluntary services. This study aims to gain a comprehensive understanding of the actual experiences and needs of older adults residing in nursing home organizations regarding receiving voluntary services and explore the types of voluntary services that are most suitable for the needs of older adults. To ensure accuracy and transparency, the authors followed the Consolidated Standards for Reporting Qualitative Research (COREQ) guidelines when reporting their findings [ 18 ].

Participants

During June-August 2023, the authors used purposive sampling to sample older adults residing in two nursing home organizations in Hangzhou, the inclusion criteria for the interview subjects were as follows:

they had to have resided in the nursing home organizations for more than a year;

they had to have received voluntary services;

they had to be conscious and able to express themselves effectively;

they had to have given informed consent and voluntarily agreed to participate in the study.

The number of people participating in the study was decided based on information saturation, this means the interviews were conducted until no new topics emerged and responses were repeated, the data from the twelfth interview indicated that saturation had been reached as confirmed by the other two interviews. This research principle was based on previous qualitative research studies [ 19 ]. A total of 14 older adults, coded N1-N14, were included in this study. All older adults who participated in the study agreed to the interview process, and none withdrew during the study. Detailed information can be found in Table  1 .

Interview outline

We developed an interview outline after thoroughly reviewing the literature sources and consulting with the research group [ 20 , 21 ]. We selected two older adults living in nursing home organizations to conduct pre-interviews, we adjusted the interview outline based on the feedback we received from the pre-interviews.

The interview will cover the following topics:

Please describe the voluntary services you have received in detail. How do you feel about receiving these services?

Are you satisfied with the voluntary service you have received? What aspects of the service make you satisfied?

What are your dissatisfactions with the voluntary service? Why do you feel that way?

What are your expectations and needs for the voluntary service’s content, form, and volunteers?

Is there anything else you would like to add to the discussion?

Data collection

A semi-structured interview method was utilized to gather data for this study. The main researcher, (a master’s degree nursing student) has been trained in qualitative research methods and has mastered the semi-structured interview techniques required to conduct interviews independently. Additionally, the researcher has participated in various volunteer activities in nursing organizations and has established a trustworthy relationship with the interviewees. Before conducting the interviews, the main researcher explained the study’s purpose and methodology to the interviewees and, after acquiring their consent, scheduled an appointment in advance. Face-to-face interviews were conducted with the respondents in a quiet, private, comfortable conference room. During the interview, the researcher recorded the entire process with the respondent’s consent without interrupting the respondent unnecessarily. The researcher confirmed the key concerns and the content that the respondent could not express clearly by repeating, asking follow-up questions, and asking rhetorical questions. The researcher also promptly recorded the respondent’s non-verbal information, such as movements, expressions, and tone of voice. Each interview lasted 30–45 min, and after conducting 14 interviews, no new information was obtained, indicating data saturation and ending the interview process. At the end of the interview, each interviewee was given a small token of appreciation.

Data analysis

The audio recordings of the interviews were transcribed into text within 24 h of completion, non-verbal information was noted in the transcript at relevant places. The transcribed information was then entered into the NVIVO 11.0 software (QST International, Cambridge, MA, USA) for data extraction, coding, and integration. Two researchers independently analyzed and coded the data, and the results were compared to identify common themes. Any discrepancies were resolved after the research team had discussed them to ensure that the data was complete and the analysis was accurate. Colaizzi’s seven-step analysis method was used to refine the themes from the interviews, which involved the following steps [ 22 ]:

Carefully read all the transcriptions of the interviews.

Analyze the significant statements made by the interviewees.

Code the recurring and meaningful ideas discussed in the interviews.

Gather the coded ideas and form the theme clusters.

Define and describe the themes from the coded ideas.

Identify similar ideas and sublimate the theme concepts.

Return the results to the interviewees for verification, and revision, and add the results based on the feedback from the interviewees. For detailed coding results, please see Table  2 .

After the data analysis was summarized, two main themes were identified: Experiences and Needs for volunteerism.

Theme 1: experiences

Beneficial experiences, solving problems and meeting needs.

Many older adults currently reside in nursing home organizations that are situated far away from their children and friends, they often face difficulties in getting help promptly when they encounter problems, which can affect their daily lives. For instance, in today’s rapidly developing society, many older adults own smartphones but lack the necessary knowledge to use them effectively. This, in turn, reduces their social participation and increases their sense of isolation. However, voluntary services have been instrumental in assisting them in overcoming these hurdles and leading a more fulfilling life.

N11: “When the volunteers come to teach me how to use computers, I ask them something that I don’t understand, and the teacher will explain it to me immediately.” N1: “I don’t know how to buy things online. Volunteers taught me little by little, and after a few teaching sessions, I learned how to do it so I don’t have to bother the caregiver every time. I can also do online shopping by myself, and I feel that life is much more convenient.”

Some respondents stated that volunteers could fulfill their needs. Professional volunteers also taught older adults Chinese medicine and health care and assisted with self-care.

N12: “I’m interested in Chinese medicine health care knowledge, and when students from the University of Traditional Chinese Medicine come over, and I ask them What are the functions of different acupoints, they tell me how to press them to make them work.”

Feel warmth and care

Many older adults live in nursing home organizations, away from their familiar environment and social network. This isolation can generate a sense of loneliness, making them more eager for emotional support. Volunteers provide services to add joy to the lives of older adults so that they feel cared for. Interviewees have mentioned that being taken care of on their initiative makes them feel warm and touched, increasing their overall sense of well-being.

N10: “I am delighted when I participate in volunteering, I feel that I have a group life again, I am pleased, I feel that someone cares about us.” N8: “Volunteers come to serve us, feel that people still care about us older adults, and now the country also cares about us, and society also cares about us, I am thrilled.”

Some respondents said that having someone to talk to and greet them would make them feel happy and that they were willing to communicate with young people and accept their new ideas.

N2: “As soon as I see you young people, I am happy, I feel the atmosphere of youth, my mood is different, I feel less lonely.”

Unpleasant service experiences

A formality that makes it difficult to benefit truly.

According to the interviewees, there are certain formalized phenomena in the domain of volunteering. Some volunteers engage in volunteering activities to obtain a certificate, such certificates can help them get extra points at work. Some volunteers participated in volunteering based on the mentality of the herd under the organizational arrangements of their schools or enterprises. These volunteers lack initiative, violate the principle of voluntarism, and cannot provide services that genuinely benefit older adults due to their single-mindedness and formalism during the service process. As a result, older adults have a poorer sense of experience.

N7: “Some volunteers are asked to serve by their companies, and they have to finish the job; some just go through a process.” N13: “Many volunteers come over to perform a show, then take photos and leave; the service time is very short, just like completing a task.” N5: “Some volunteers are very perfunctory; they come for a while and leave quickly.”

Lack of organization, regularity, sustainability

Many volunteers offer their services without compensation, while they have their formal jobs, which makes it difficult for them to provide services consistently. Additionally, volunteers may be more mobile, which can result in a lack of continuity in the services that are provided and the target groups that are served. However, older adults living in nursing home organizations often have monotonous and lonely lives, and occasional voluntary services may not be enough to meet their needs. As a result, some older adults may feel dissatisfied with the irregular and unsustainable nature of voluntary services.

N12: “Volunteers come on an ad hoc basis; they are not regular. Recently, a school teacher came to teach us how to sing, but unfortunately, they had to leave due to commitments and have not been able to come back.’’ N5: “Volunteers can’t come regularly; they come once in a while or not regularly and don’t have a plan.” N7: “Volunteers come to the nursing home occasionally, so they don’t want to bother them.”

The mismatch between service provision and actual demand

The voluntary services provided to older adults in nursing institutions were not able to match their real needs as the volunteers had no prior knowledge of their needs and did not make any advance preparations.

N4: “Last time, a volunteer came and asked me if I needed help with cleaning. However, I declined their kind offer because caregivers in the nursing home clean rooms every day, and the volunteers could not address the specific things I needed help with.”

The needs of older adults for volunteering can vary significantly based on their experiential backgrounds, and physiological and psychological conditions. Therefore, providing the same services to all older adults can lead to negative feelings towards volunteering among them.

N10: “Some volunteers come just to dance and sing, it feels very noisy. I don’t want to participate, I want the volunteers to talk to me peacefully and quietly.” N14: “I am not very good with my legs, so it is difficult for me to participate in activities organized by the volunteers downstairs. I would like to find activities I can participate in in my room, such as playing games or doing crafts.”

Theme 2 needs for volunteerism

Needs for emotional comfort.

Many older adults live in semi-closed institutions where they lack long-term support from their families and struggle to find someone to talk to. During the epidemic, nursing home organizations prohibited visitors to prevent the spread of the virus, leaving many seniors alone and cut off from the outside world. As a result, many older adults experience feelings of loneliness and depression. To help combat these negative emotions, volunteers can provide companionship and support, which can effectively reduce feelings of loneliness and promote emotional well-being.

N1: “I hope someone will come and chat with us; many older adults have no way to contact the outside world, so they have psychological barriers, they need psychological counseling, they need someone to come and chat with them to relieve their loneliness.” N10: “It’s better to have volunteers to come over to the service, to come and chat with me, to visit me.” N12: “I would like volunteers to communicate with us, tell us what is happening outside, tell us something new.”

Cultural and recreational needs

As people age, their social interactions tend to decrease, and they gradually tend to withdraw from daily life. This results in older adults having more free time after their retirement. Nursing home organizations can provide basic living care and medical assistance for older adults, which relieves them of the burden of cooking, cleaning, and shopping. This also means they have more free time than those who live at home or in the community. Many older adults wish to participate in cultural and recreational activities, such as singing, dancing, sports, and watching performances, to add excitement to their lives. They hope that volunteers can organize such activities to help them reduce their loneliness and spend their time in a meaningful way.

N14: “It’s good for volunteers to come and teach us how to dance, sing, and sing opera, and time passes a little faster when we all get together and learn.” N2: “It is popular for volunteers to bring cultural performances to our nursing home, we love to see young people performing programs, singing some classic old songs or Peking Opera, it is very popular.” N9: “We would like to play tai chi, it is a very suitable sport for us as it strengthens the body and the movements are softer, it would be nice if a teacher could teach us.”

Knowledge acquisition needs

According to Maslow’s Hierarchy of Needs Theory, individuals will naturally shift their focus toward higher-level pursuits once their basic and low-level needs are met. In the case of older adults residing in nursing home organizations, their basic material needs are taken care of, and as a result, their need for knowledge and learning becomes increasingly important. Many older adults require assistance in learning how to use electronic equipment, which can help facilitate their communication with the outside world and reduce feelings of isolation.

N1: “It’s become very convenient to buy things online, but I don’t know how to operate it myself and would like someone to teach me.” N2: “My daughter bought me an expensive Apple phone, but I am unfamiliar with how to use it. It would be great if someone could systematically instruct me on how to use the smartphone.” N8: “I don’t know how to use my smartphone, I don’t understand many functions, so I would benefit from having a teacher to guide me.”

As individuals age, their bodily and cognitive functions may deteriorate, adversely affecting their quality of life. Basic healthcare knowledge can be critical for older adults to maintain good health. Many older adults have a strong desire to learn about nutritional diets, rational exercise, and traditional Chinese medicine physiotherapy as a means of improving their health.

N9: “Volunteers can come and talk to us about medicine and how to predict dementia.” N13: “I have high blood pressure and cholesterol. I need advice on what to eat and what to avoid.”

To prevent any disagreements regarding the distribution of their assets among their heirs after they pass away, older adults seek the help of volunteers to assist them in drafting a will that is by national policies and regulations and has legal validity.

N12: “Volunteers can help us learn how to write a will effectively and can avoid unnecessary trouble and conflicts in the future.”

The current situation of voluntary experiences of older adults in nursing home organizations

Analysis of beneficial experiences.

The study’s findings indicate that individuals residing in nursing home organizations who are of advanced age have mixed experiences when it comes to receiving voluntary services. Most respondents conveyed the warmth and care emanating from the volunteers and the society towards older adults. Furthermore, they shared that volunteering offered them a means to engage in activities actively, create connections with fellow older adults, and foster mutual support and camaraderie. This social participation has the potential to enhance the mental well-being of older adults, thereby decreasing feelings of loneliness and depression [ 17 ]. Voluntary activities like smartphone training can help older adults acquire the necessary needed skills and adapt better to modern technology and life. Competent skills are crucial for older adults, particularly in today’s fast-developing technological society, where electronic devices such as smartphones are becoming increasingly popular. However, many older adults need more skills to operate these devices and thus cannot fully utilize them. Through training, older adults can learn how to use smartphones, including sending text messages, browsing the web, using social media, downloading applications, and more. Learning these skills not only improves the quality of life of older adults but also helps them stay connected with family and friends, thereby reducing loneliness.

Improved skills can assist older adults in accessing and utilizing health information, including online medical advice and health apps. This information can aid in managing their health status, preventing and managing chronic illnesses, and ultimately improving their quality of life. Volunteering is crucial in nursing home organizations. It provides numerous benefits to older adults, including enhancing their mental health and quality of life and receiving the necessary support and care by participating in voluntary activities [ 23 ].

Analysis of unpleasant experiences

During the interviews, some older adults shared negative experiences regarding the content, form, and frequency of voluntary services. They pointed out that volunteers did not understand their needs in advance, focusing too much on material assistance and neglecting their psychological and intellectual needs. Additionally, the service process is often too process-oriented and formalized, with less interaction with older adults, resulting in voluntary services failing to meet their expectations.

Research suggests that negative experiences of receiving voluntary services may impact older adults’ willingness to seek help and the effectiveness of voluntary services. Therefore, when providing voluntary services to older adults, it is essential to take the initiative to understand their experiences and continuously optimize the voluntary program. This approach is crucial to improving the quality of voluntary services [ 24 ].

The current situation of the demands for voluntary services by older adults

The study results show that nursing home organizations can provide comprehensive life care services to older adults, meaning they do not require many voluntary services for life care. However, this does not imply that older adults’ needs are met. Their need for emotional support, cultural recreation, and knowledge-seeking and learning is highly concentrated.

When older adults leave their familiar family environment to move into care institutions, they may experience feelings of loneliness and boredom due to the lack of regular interaction with their children, family members, and friends. This sense of isolation can harm their mental health, and they may seek more opportunities to communicate and interact with younger individuals to gain emotional comfort [ 25 ].

As people age, cultural entertainment and knowledge learning become essential for spiritual growth. After their basic living needs are taken care of, older adults desire more fulfilling recreational activities, such as calligraphy, painting, and singing, these activities enrich the spiritual life of older adults and benefit their physical and mental health [ 26 ].

In today’s rapidly developing society, the widespread use of smartphones and the popularity of online shopping have led to a digital divide among older adults. This phenomenon has, to some extent, hindered their social participation and increased their sense of isolation. Consequently, there is a growing demand for voluntary services that assist with smartphone use and can help them enjoy a convenient and fulfilling digital life.

The need for voluntary services for older adults has changed over time. While they still require help with their daily living, they also need emotional support, cultural engagement, and opportunities to learn new things. We should focus on meeting these needs to ensure our voluntary services are beneficial. By doing so, we can help older adults live fulfilling, healthy, and happy lives in their later years [ 27 ].

Suggestions and strategies for optimizing volunteerism

Accurately assessing older adults’ voluntary service needs.

The study results reveal that some older adults have negative experiences with voluntary services that fail to meet their actual needs, leading to unsatisfactory service outcomes. This highlights the need to accurately identify the real service needs of older adults to improve the quality and effectiveness of voluntary services.

To achieve our goal, we need to take a series of steps. Firstly, we must create appropriate tools for evaluating the needs of older adults for voluntary services. We should also clarify the assessment methods and strategies for assessing these needs, before launching voluntary services, relevant organizations and volunteers must understand older adults’ service experience and needs through qualitative and quantitative assessment methods [ 28 ].

To improve the quality and effectiveness of voluntary services for older adults, we can utilize big data technology to carry out precise reforms. This involves building a unified information platform for voluntary services that enables a quick match between the needs of older adults and the specialties of volunteers through the co-construction, sharing, and everyday use of resource information [ 29 ]. By doing so, we can provide multi-level, multi-category, and personalized voluntary services that cater to the actual needs of older adults, thus achieving the purpose of “precise service.”

In conclusion, we must prioritize the actual needs of older adults and provide them with more personalized and intimate voluntary services by continuously improving the assessment tools and information platforms with the orientation of precise services, the use of big data technology will play a key role in helping us realize the goal of efficient and accurate services.

Improving the quality management system of voluntary services

Volunteering quality refers to the quality of services volunteers provide, as perceived by the direct recipients. Research has shown that low-quality voluntary services fail to achieve their intended goals, moreover, negative experiences of receiving voluntary services may discourage older adults from seeking help in the future. The study highlights a significant gap between older adults’ experience of volunteering quality and their expectations, therefore, it is necessary to strengthen the management of volunteering quality to ensure that expectations are met.

To enhance the quality of volunteering, we need to implement measures. Firstly, we must optimize the recruitment and selection system for volunteers, this entails formulating recruitment plans and selection requirements that align with the voluntary services needs of older adults. We aim to create a stable and committed volunteer team skilled in services knowledge and job skills and willing to participate in voluntary services for an extended period [ 30 ].

To enhance the level and quality of service, it is important to provide regular and standardized training to volunteers. Volunteers should receive professional information support services, such as training on volunteer spirit, etiquette, communication skills, and the physiological and psychological characteristics of older adults. The main forms of training include information consultation, professional knowledge, technology lectures, sharing of previous volunteer experiences, summarizing stage-by-stage voluntary services, and experiential services. Volunteers should be provided with face-to-face or online interaction to help them improve their ability to assist older adults. The training for volunteering encompasses theoretical knowledge about volunteering, including its characteristics and principles, the rights and interests of service users, and respect for them. It also includes basic knowledge of social work, such as interpersonal communication methods and skills, as well as knowledge of health care for older adults. The latter includes the introduction of general knowledge about daily life care for older adults, such as diet, hygiene, and exercise, and the evaluation of the training’s effectiveness. Both voluntary service organizations and nursing home organizations should participate in the training process, only volunteers who have completed the training and assessment can engage in service activities [ 31 ]. It is essential to improve the evaluation mechanism of voluntary service quality. This can be done by creating a scientific evaluation index system involving older adults in evaluating their satisfaction with the voluntary service program and conducting a comprehensive analysis of the evaluation results. This analysis can help to optimize and improve the service program, additionally, tracking and evaluating the effectiveness of optimization measures to continuously enhance service quality is crucial [ 32 ].

Improving the quality of voluntary services is a comprehensive project that enhances various aspects, such as volunteer recruitment, training, and service quality evaluation. This systematic approach can help serve the nursing home organizations better and improve their overall quality of life.

Strengths and limitations

The paper’s strength lies in its focus on the experience of older adults in nursing institutions when receiving voluntary services and their need for such services. This study’s understanding of the real feelings and needs of older adults is beneficial for various organizations in society to provide better services in a targeted manner. However, the study’s limitation is that it mainly focuses on the more developed areas of Hangzhou, which affects the sample’s representativeness and makes it challenging to reflect the general situation of older adults in nursing home organizations. Additionally, the author’s subjective viewpoints may affect the analysis of the material during the data analysis process. Finally, the sample size of this study is relatively small, and there may be individual differences in personality, physical condition, and economic situation, among others. Therefore, expanding the sample size and the region’s scope to carry out more in-depth research is necessary.

This research explored the experiences and requirements of older adults who receive voluntary services in Chinese care homes. The study categorized their experiences into two groups: beneficial experiences and unpleasant service experiences, the needs of older adults who receive voluntary services include emotional comfort, cultural and recreational, and knowledge acquisition. It is crucial to have a timely and comprehensive understanding of the experiences and needs of older adults to create a targeted voluntary service model, standardized management, and training of volunteers in nursing home organizations.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. The datasets are not publicly available due to confidentiality and ethical restrictions.

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Acknowledgements

We want to express our heartfelt appreciation to the 14 older adults who participated in the interview and shared their experiences. We are also grateful to the administrators of nursing home organizations in Hangzhou, Zhejiang Province, for granting us access and allowing us to conduct the interviews at their facility. Their cooperation was invaluable in gaining insights into the needs of older adults.

This study did not receive any form of financial support.

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Li and Wu were responsible for data collection, sorting, and analysis, and Li wrote the paper. Shen directed and revised the article and approved the final version for publication. All authors read and approved the final manuscript.

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The study protocol was approved by the Medical Ethics Committee of Zhejiang Chinese Medical University (approval No. 20230814-2). Before the interviews, the participants were provided with information regarding the study’s purpose and procedures, the voluntary nature of their participation, and the confidentiality of their data. The interview data was stored securely, and only the research team could access it. The Ethics Committee of Zhejiang Chinese Medical University approved this study.

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Li, L., Shen, Q. & Wu, J. The experiences and needs of older adults receiving voluntary services in Chinese nursing home organizations: a qualitative study. BMC Health Serv Res 24 , 547 (2024). https://doi.org/10.1186/s12913-024-11045-5

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Health inequalities in 2040 Current and projected patterns of illness by deprivation in England

• Ann Raymond
• Hannah Rose Douglas
• Chris Kypridemos
• Laurie Rachet-Jacquet
• Publication
• Inequalities
• Long-term conditions
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Key findings

• On current trends, inequalities in health will persist over the next two decades: people in the 10% most deprived areas can expect to be diagnosed with major illness a decade earlier than people in the 10% least deprived areas.
• A small group of long-term conditions contribute to most of the observed health inequalities, out of which chronic pain, type 2 diabetes and anxiety and depression are projected to increase at a faster rate in the 10% most deprived areas by 2040. 
• These conditions are typically managed in primary care, underlining the need to invest in general practice, particularly in the most deprived areas, and community-based services and focus on prevention and early intervention.
• Inequalities in working-age ill-health is also projected to persist. 80% of the increase in the number of working-age people living with major illness between 2019 and 2040 (from 3 million to 3.7 million) will be concentrated in more deprived areas (deciles 1–5).
• Action focused on risk factors linked to major illness is essential but insufficient on its own to tackle health inequalities. Making progress on inequalities in major illness will also require long-term effort across government and the economy to address the underlying causes of health inequality, such as poor housing, low income and insecure employment.

This report is the second output from the REAL Centre’s programme of research with the University of Liverpool. Building on the projections in Health in 2040 , this report is one of the first studies to unpack patterns of inequalities in diagnosed illness by socioeconomic deprivation across England and project them into the future. 

Stark inequalities are projected to stubbornly persist up to 2040, with profound implications not only for people’s quality of life, but also their ability to work and the wider economy. The report also finds that health inequality is largely due to a small group of long-term conditions, with chronic pain, type 2 diabetes and anxiety and depression projected to increase at a faster rate in the most deprived areas.

Good health is an asset to society. The health inequality we describe in this report need not exist. Anticipating these trends gives policymakers an opportunity to act now to address these inequalities and increase economic growth.

Cite this publication

Raymond A, Watt T, Douglas HR, Head A, Kypridemos C, Rachet-Jacquet L. Health inequalities 2040: current and projected patterns of illness by level of deprivation in England. The Health Foundation; 2024 (https://doi.org/10.37829/HF-2024-RC01).

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