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.
Community Insights
This section summarizes real-world feedback from instructional design practitioners polled on LinkedIn, Reddit, and other professional forums such as ONILP and Useful Stuff. We've highlighted their poll results, insightful comments, and alternative strategies to showcase diverse approaches to the dilemma.
Summary of Results
A strong 70% majority voted to solve the performance problem first, with comments highlighting the high-stakes medical context where errors can have critical consequences.
The prevailing logic was that while culture is the root cause, it's a systemic issue outside a contract ID's immediate scope; the pragmatic solution is to apply a "bandaid" performance fix now while advocating for a larger cultural initiative later.
Featured Comments
I'd apply a bandaid fix (option 2) while working on the deeper issue (option 1). Option 2 may give you a tiny bit of breathing room and/or plausible deniability with your leadership, but it sounds like the root issue can't be addressed by training alone. That's always a harder sell - but it is a more permanent fix.
- EL
If I could only do one, I would solve the performance problem. Turning company culture around is a herculean task, and you've got to have buy-in from the top down. Even if it's just one department out of many you've got to turn around, it's still a large task and can take months or years. In the meantime mistakes are still being made.
I work in a place that manufactures biologics. Strict Quality Assurance is embedded in what we do. Medical facilities outside of drug manufacturing often don't have the QA mindset you'd imagine they do. I say this because much of the software we use was designed by engineers, and UX was last on their list. I'm dealing with a situation now where mistakes are being made because of a software design that could easily be fixed. Luckily, it's designed in house so it can be tweaked, but that's not always the case.
As an ID you can't do anything about third party software, but it's something to consider. We have a testing lab that does much of the same thing, basically disease testing blood, and also doing very specific crossmatches for blood types when a hospital requests it. This is blood for transfusion, so that's why blood banks are so anal about only labeling tubes bedside with the donor, asking you to confirm your name etc. If you mislabel blood when drawing it's a major error, because everything down the chain will be compromised and tainted blood could enter the supply. I kind of consider myself a QA person who specializes in human factors.
I think it would also be useful for other IDs to study the concepts of engineering controls - basically setting up your machine or environment to force correct behaviors. A simple idea is the deadman switch lawnmowers have today. It won't stay on if you're not controlling it by keeping your hand on the bar. This may be a little scary, but most medical device training and the associated manuals are pretty poor across the board. The software UI/UX design is similarly poor. Enough that when I come across a good manual or training, it stands out. I deal mainly with automated disease/DNA testing machines, so it may be better in other domains.
- David Hendricks
Culture represents the behaviors that are allowed to exist and no amount of "culture training" is going to change that.
- Jane
The performance problem needs solving now, while the culture problem sounds more like it needs a company-wide initiative (or whatever the hospital equivalent is). That’s likely more under the purview of either management or human resources. My thoughts are on the “bootcamp” idea and whether it’s necessarily the best choice. Healthcare tends to be a fast-paced industry: would nurses really have the time to sit down and go through a training or learning module, let alone retain it?
I wonder if creating a job aid would be more effective, like a one page handout or a searchable library of microlearning modules so newer nurses could try to find the information on their specific questions quickly. They would probably master the database usage through the repetition of looking up some of the same questions over and over and be able to retain it more easily.
I think some message should be sent to the management about trying to get an initiative started to improve workplace culture, and then the instructional designer themself should focus on having a follow up meeting to determine project scope and set specific performance metrics to help guide the project.
- Erica Kauffman
Instructional Designer
In this medical context, it's performance hands-down! Error could mean a wrong diagnosis resulting in a fatal outcome. Culture would be too ambitious and complex going beyond your scope (and possibly interest/expertise).
- Super_Aside5999
