ID Case File #4 - Sink or Swim
August 11, 2025
The Dilemma
I've just had an initial call with the Chief Nursing Officer at a major new potential client, St. Jude's Medical Center. Dr. Adrienne Sinclair has brought us what looks like a straightforward problem... there's a high rate of procedural errors among new nurses in the ICU.
Dr. Sinclair has data to back it up and she's already landed on a solution: a more robust, simulation-based onboarding 'bootcamp' to drill them on procedures until they can process patient cases with their eyes closed.
Now, in my experience procedural errors are often just the symptom of a deeper, systemic issue. A bootcamp might be the answer, but we can't propose a solution until we've validated the problem.
I've scheduled a 30-minute follow-up call for you with Dr. Sinclair. Your job is to go into that meeting, build on her initial analysis, and use your strategic questioning skills to either confirm her diagnosis or uncover the real root cause.
You're on the call with Dr. Sinclair, the CNO. After introductions, she immediately reiterates her position…
The Decision
This is the critical moment. You've successfully uncovered that the issue isn't a simple knowledge gap; it's a deep-seated cultural problem with a failing mentorship program, driven by the anxieties of the veteran staff. Now you must propose a path forward. Your choice will define the scope and focus of the entire project.
Which strategic path do you propose?
Select an option above or scroll down to view the debrief.
The Debrief
That conversation with Dr. Sinclair was a perfect example of how a simple training request can quickly evolve into a complex organizational problem. Your strategic questioning was excellent; you successfully moved past the surface-level symptom to uncover the root cause: a failing mentorship program and a stressed-out team culture.
Solving the cultural problem is the most ambitious and, in a perfect world, the 'right' thing to do. It's a strategy grounded in a deep Organizational Needs Assessment, attempting to solve the true cultural problem. By proposing to revive the human mentorship program, you're applying Social Learning Theory, which recognizes that the most valuable knowledge transfer often happens through observation and collaboration. However, as you saw, this path carries immense project risk. It requires a bigger budget and buy-in from a group of already stressed-out veteran nurses.
Solving the performance problem is the pragmatic choice. It's a brilliant example of working within constraints to deliver a tangible solution to the client's stated performance problem. This path focuses on a very targeted Task Needs Assessment, identifying the specific procedural skills the new nurses need and building an efficient solution to address that gap. The 'digital mentor' is a form of Just-in-Time Resource, providing support precisely when it's needed. The risk, of course, is that by creating an effective workaround, you may have inadvertently reinforced the 'sink or swim' culture, solving the symptom but not the disease.
So, how did you get from a request for an onboarding bootcamp to this complex discussion about hospital culture?
Uncovering the Root Cause
The first and most important principle is to always dig for the root cause. This is arguably the most valuable skill a consultant possesses. A client may come to you with a problem they've already diagnosed, but it's important not to take their word as the absolute truth. Their observations might be symptoms of a larger, underlying issue. Your job is to challenge that initial assumption, not by arguing, but by investigating.
In the conversation with Dr. Sinclair, the "procedural errors" were the symptom. A bootcamp would have been a treatment for that symptom. By asking a series of probing questions, you successfully dug deeper and uncovered the disease: a failing mentorship program and a toxic 'sink or swim' culture. You proved that the errors weren't the real problem; they were the result of the real problem.
This happens in every project, in every industry.
A client might say, 'Our sales team is bad at closing deals' (the symptom). A root cause analysis might reveal the marketing team is providing them with unqualified leads (an organizational problem).
A manager might say, 'My team doesn't know how to use the new software' (the symptom). The root cause might be that the software's user interface is confusing and unintuitive (a UX problem, not a training problem).
A call center might have 'low accuracy rates' (the symptom). The root cause could be something as simple as poor lighting in the office causing eye strain (an environmental problem).
The Art of Strategic Questioning
The primary tool for this investigation is strategic questioning. You didn't challenge Dr. Sinclair's 'bootcamp' idea directly. Instead, you used a series of open-ended and probing questions to help her uncover the deeper issue herself. This is what separates a consultant from a developer.
Active listening is the foundation of any successful consultation. It's more than just hearing words; it's about making the other person feel truly heard and understood.
A key technique here is paraphrasing, where you summarize the other person's point in your own words to confirm your understanding.
Probing questions are designed to dig beneath the surface of a problem. They are the "why" and "how" questions that move a conversation from a surface-level symptom to a potential root cause. After Dr. Sinclair identified the software as the issue, you didn't stop there.
You used a classic probing question to get more context: "In your experience, when do these errors tend to happen?" This moved the conversation from the "what" (the errors) to the "when and where," which was the key that unlocked the deeper problem.
Your most powerful move was your final question to Dr. Sinclair: "Putting yourself in the veteran nurses' shoes for a moment, what do you think their biggest concern is?" This is a great empathetic question.
It shifted the focus from a sterile discussion about procedural errors to a deeply human conversation about the fears and anxieties of her veteran staff, which was the final key to uncovering the true cultural issue. This is how you find the human-centered story behind the data.
Training Isn't Always the Answer
Finally, this situation highlights a critical and often misunderstood truth that all instructional designers must grapple with: 'more training' is not always the right solution.
Your discovery process revealed that the root cause of the procedural errors wasn't a knowledge gap in the new nurses; it was a systemic lack of support and a toxic culture. The 'bootcamp' idea would have been a 'band-aid on a bullet wound.' Both of the paths you could have chosen are a strategic response to this realization.
The 'digital mentor' is still a form of training, but it's a different kind. It's a highly targeted performance support tool designed to solve the immediate problem of procedural errors. This approach is like applying a tourniquet to stop the bleeding. It's a fast, effective, and often necessary first step to stabilize a critical situation. It solves the immediate performance issue, but the bullet (the toxic culture) is still in there. If left unaddressed, it can lead to a deeper infection down the road.
Fixing the mentorship program is the attempt to actually remove the bullet. It's a non-training solution focused on fixing the organizational problem itself: the broken mentorship and the burnout culture. This is the true long-term solution. However, non-training solutions are not always as simple as creating a job aid. A systemic fix like this is a form of organizational surgery. It's complex, it's costly, and it requires deep buy-in from multiple levels of the organization. There's a real risk that you can correctly diagnose the disease but find that the organization isn't ready for the cure.
The Bottom Line
An instructional designer's job isn't just to find the 'perfect' solution. It's to find the best possible solution within the given constraints. Your most important role in a complex discovery is to help the client see the full picture, the symptom and the disease, the quick fix and the long-term cure. You have to clearly articulate the risks and rewards of both the ambitious, systemic solution and the straightforward, pragmatic solution. The final decision depends on the client's budget, their appetite for risk, and their readiness for real organizational change. Your responsibility is to ensure they are making that choice with their eyes wide open.
An instructional designer's job isn't just to find the 'perfect' solution; it's to find the best possible solution within the given constraints. Our greatest value as consultants is our ability to see both the symptom and the disease.
This means we have a professional responsibility to present the client with the full picture. We must be able to offer the pragmatic 'tourniquet', the targeted solution that stops the immediate bleeding. But we must also present the case for the more difficult 'surgery', the systemic solution that will solve the underlying problem. We show them the full picture, the wound and the cure. The final choice of treatment is always theirs.
