Abstract

‘Wicked’ problems, a term for complex, challenging issues, are inherent in healthcare, and it can be argued that they exist in all areas of life. From climate change to transport; food production to water provision; education to housing, such problems can appear insurmountable. Yet, it is possible to provide solutions to these problems by understanding the complex nature of inter-process communication, inter-professional collaboration and shared commitment, the successful application of which has the potential to bring about positive change.
 

Introduction

The NHS is faced with an ever-changing economic, political, social, cultural, and technological landscape. In this environment, healthcare leaders are expected to respond quickly to the increasing need for change, while navigating the complexity of service delivery, working relationships, patient needs and the mounting demand for continuous improvement.

Originally described by Rittel and Webber (1973), such ‘wicked’ problems contain 10 key characteristics that clearly define their structure (Box 1). Raisio et al (2019) argued that these problems are so multifaceted, interconnected and ambiguous that simply understanding them poses a significant challenge.

Box 1. 10 characteristics of wicked problems (from Rittel and Webber, 1973)

There is no definitive formulation of a wicked problem Wicked problems have no stopping rule Solutions to wicked problems are not true-or-false, but good-or-bad There is no immediate and no ultimate test of a solution to a wicked problem Every solution to a wicked problem is a ‘one-shot operation’, because there is no opportunity to learn by trial-and-error, every attempt counts significantly Wicked problems do not have an enumerable (or an exhaustively describable) set of potential solutions, nor is there a well-described set of permissible operations that may be incorporated into the plan Every wicked problem is essentially unique Every wicked problem can be considered to be a symptom of another problem The existence of a discrepancy representing a wicked problem can be explained in numerous ways. The choice of explanation determines the nature of the problem's resolution The planner has no right to be wrong

Furthermore, Grint (2010) argued that wicked problems are impossible to resolve because some of them, such as obesity and drug abuse, are also complex social problems that sit across multiple departments. Therefore, attempts to manage such problems through a defined organisational framework, such as the NHS, are flawed and essentially beyond our capacity to solve (Grint, 2010).
Danken et al (2016) found that wicked problems essentially consist of three inter-connected properties. They argue that these problems:

1. Resist a clear solution, over time becoming chronic problems
2. Fundamentally require a number of key stakeholders with varying values and interests to effectively collaborate to bring about positive change
3. Defy full appreciation and a clear definition of their nature and consequences.

Peters and Tarpey (2019) dispute such claims and maintain that by labelling such problems as wicked, or even super wicked (Levin et al, 2012), we may be limiting the willingness of policymakers to allocate time and money to a problem that is perceived as insurmountable.
 

Complex adaptive systems thinking

One way to manage these problems is to understand the concept of complex adaptive systems thinking. This focuses on the associations and interconnections between components of a system rather than the individual components themselves (Pype et al, 2018) and, in so doing, adopts a complex adaptive systems approach to their management. In relation to healthcare, this process requires NHS leaders to consider and analyse the complex patterns and interrelationships that exist (NHS Institute for Innovation and Improvement, 2005). 
Sapir (2020) defines complex adaptive systems thinking as: ‘a way of challenging taken-for-granted assumptions about how people, organisations and systems interact.’

Rather than continuing to maintain the norm, Sapir (2020) argues that we need to confront the assumptions that support the archetype, and replace them with something different, which has the potential to provide the results needed. An example of this might be to challenge the continued need for meetings for senior managers in the NHS – a phenomenon of which many readers will be painfully aware.
 

The role of leadership

The challenges faced by the NHS today require leaders and managers to act in a way that enables them to maintain their responsibilities as defined by Our Leadership Way (NHS Leadership Academy, 2021), a framework which requires frontline staff and senior leaders to work collaboratively to facilitate a compassionate, inquiring, and cooperative approach, while, according to Macdonald et al (2018) creating an environment in which people can work harmoniously in a mutually supportive culture. To do this requires understanding of the complex nature of systems leadership, which uses the skills and abilities of leaders to catalyse, enable and support systems-level change (Dreier et al, 2019).

There are three key elements of systems leadership:

1. The importance of leaders having insight into complex systems
2. The ability of leaders to build coalition and advocacy behaviours
3. The capacity of leaders to demonstrate collaborative leadership (Dreier et al, 2019).

Systems leadership emphasises the importance of collaborative working across organisations at different places in the system and at various levels (Ghate et al, 2013) to identify and manage wicked problems (Bolden et al, 2019).

Research by Silva et al (2022) also emphasised the importance of collective leadership, a process through which all employees take responsibility for organisational success and professionals share knowledge and expertise. This has the potential to not only influence team performance, but also to improve quality of patient care and staff wellbeing.
 

Blockers to change

A number of restraining forces often come with change, including competing demands, unstable leadership, scarce resources and resistance, which may hinder the success of any change initiative (Tappen et al, 2017).

Resistance to change is a complex phenomenon (Caliste, 2024), resulting in fear and discomfort (McElwaine, 2025). Although it should be considered a normal part of any change management process and so should be expected, fear of change can create significant opposition (Prosci, 2025). Effectively managing any challenges that ensue requires a high level of diplomacy – diplomacy being a characteristic associated with strong leadership, compassion, understanding, and respect (Alaba, 2017) and is a critical factor in establishing innovative solutions and quality service improvements within healthcare delivery (Prestia, 2017).

The key to the problem, according to Clark (2020), may be to understand the true reasons for resisting change and provide psychological safety to those who exhibit such a response, rather than marginalising them (Maddox, 2021).
 

Compassionate leadership

Demonstrating unconditional positive regard (Rogers, 1957), a process through which we demonstrate respect for each other, irrespective of behaviour, is a core condition for supporting change, according to Mullins and Kirkwood (2022). This is supported by Caprino (2019) who asserted that leaders who demonstrate a positive impact in the workplace value ideas, opinions and differing views while being deeply respectful and demonstrating compassionate behaviours towards everyone they meet.

West (2021) asserted that compassionate leadership is a process which requires the leader to focus on being present with, and taking the time to listen to, the experiences of others, while seeking to understand the distress and anguish suffered, so as to facilitate thoughtful and intelligent action in order to alleviate it.
Nurses are frequently at the forefront or on the receiving end of change, especially in the NHS, while being required to deliver high-quality patient care in an increasingly complex environment. One way to successfully manage this is for nurses to understand the importance of reflective practice, which: ‘encompasses the knowledge, skills, and critical thinking abilities required to analyse and address health-care challenges’ (Amir et al, 2023).

This is supported by Walton et al’s (2018) research on the importance of reflection in newly qualified graduate nurses’ ability to transition. They argue that incorporating reflection into assessment processes can encourage nurses not only to develop self-awareness, but also to foster critical thinking skills and emotional resilience. Moreover, having the ability to critically reflect requires the capacity to reject information that feeds existing biases and in so doing enables nurses to embrace opposition to their views, assuming a constant need to learn more (Wergin, 2020).

Central to this is the ability to empower oneself, which increases the capacity to effectively manage stressful situations (Pines et al, 2012), and to reframe negative experiences or stressors so they become an opportunity for personal growth (Gill and Orgad, 2018). Moreover, according to Wergin (2020), with increased clarity comes a greater level of understanding of the significant influences that exist.
 

Conclusions

Only when nurses adopt a critically reflective approach to the management of change, are they able to navigate the challenges that inevitably emerge. By recognising the complex nature of change, nurses can gain insight into whether change is actually needed or is simply a way in which to assert dominant forces on an already oppressed profession. Through this understanding nurses are then able to adopt a strong position and take the right course of action, whatever this is determined to be.

Perhaps, as it may well be suggested, change within nursing, as frequently as it occurs, could simply be another ‘wicked problem’—more akin to power and oppression, rather than democracy and freedom. This is an important issue to consider, and one which is not going away any time soon.
 

Acknowledgements

This article was developed from an assignment submitted as part of the NHS Rosalind Franklin Leadership Programme successfully completed in 2023.