Up to 98,000 hospitalized patients die each year, making hospital admission the fourth leading cause of death in the United States and costing the health care system more than $9 billion yearly (HealthGrades, 2004). The Institute of Medicine (IOM) began publishing materials related to patient safety in 2000 with To Err Is Human: Building a Safe Health System. Ten years later, nursing programs are still struggling with how to incorporate educational content and practice strategies to promote safe, quality care for patients seeking health care. The purpose of this pilot study was to test the effects of integrated classroom and clinical content related to safety and quality of health care systems versus classroom content alone on senior-level nursing students.
In the health care setting, nurses are responsible for the continual monitoring and management of care delivered to patients. They are the surveillance system responsible for early detection of patient complications and are in the best position to initiate actions to prevent negative outcomes. This role includes both response to unexpected changes in patients’ conditions as well as monitoring for and prevention of potential condition-related sequelae (Potter et al., 2005).
In 2004, the Agency for Healthcare Research and Quality published 140 articles that represented research conducted during since the publication of To Err Is Human. The conclusion drawn was that although progress has been made, problems still exist due in large part to several factors. Berwick (as cited in James, 2005) described four major barriers:
Most clinicians remain blind to care-associated deaths, injuries, and near misses, because of difficulties in recognizing, tracking, and summarizing these events.
A lack of appreciation of the true incidence and nature of patient injuries leads to “unscientific theories,” which result in “counterproductive responses to the problem.”
There is a lack of a business case for safety to justify and offset the large investments that may be necessary to make care safe.
Patient safety represents a difficult and complex problem. (¶ 4)
With recognition of these issues, multiple strategies have been implemented in an attempt to improve the quality and safety of care provided to hospitalized patients. In fact, patient safety has become the major focus area for all health care systems and their regulating bodies in the past 10 years (Hall, Moore, & Barnsteiner, 2008). Yet, hospital admission remains a leading cause of morbidity and mortality in the United States. There is no simple solution in our complex health care system.
Improving the quality and safety of care provided cannot be the task of only a quality committee or quality-based employees but rather must be the task of every hospital employee. The problem is that most current hospital employees were educated in a time when quality and safety were not an obvious part of the curriculum (Hall et al., 2008). To change how we practice, we must first change how we educate health professionals, in particular nurses, because education is the essential bridge to quality and safety improvements in health care (Aspden, Corrigan, Wolcott, & Erickson, 2004).
Nurses are the first line of defense against medical errors because of their constant bedside presence and surveillance responsibility (Durham & Sherwood, 2008). In an effort to change how nurses are educated with regard to safe, quality patient care, the Robert Wood Johnson Foundation provided financial support for a nationwide project entitled Quality and Safety Education for Nurses (QSEN). This national movement was designed to jump-start development and implementation of strategies for nursing education to support incorporation of the IOM competencies.
In recognition of the importance of incorporating these competencies into nursing curricula, the American Association of Colleges of Nursing (AACN) has made the IOM and QSEN competencies a substantial component of The Essentials for Baccalaureate Education for Professional Nurses released in 2008 (AACN, 2008). In addition, The Essentials for Baccalaureate Education for Professional Nurses has stated several assumptions regarding how baccalaureate graduates are prepared, including using clinical reasoning to address patient situations that range from simple to complex (AACN, 2008). Previous research has demonstrated that learners need interactive teaching that engages knowledge and skills in real-world situations (clinical experiences or simulations) (Durham & Sherwood, 2008) and that an experiential component augments the didactic component of learning (Stiernborg, Zaldivar, & Santiago, 1996), leading to a synergistic incorporation of knowledge and behavior (Fink, 2003), which is significantly greater than for those who have the didactic component alone.
However, few resources are available to help educators with strategies to support creating experiential components that augment and extend the didactic content rather than just repeat it. Finkelman and Kenner (2007) have identified clearly the content that must be incorporated into nursing education but have a less well-developed plan for clinical application to support incorporation of the IOM competencies into practice. This leaves educators with the task of discovering how to logistically place content in the classroom and identify the most effective ways to integrate learning activities within clinical experiences.
The specific research questions of this study were:
- What are students’ perceptions of their knowledge, skills, and attitudes (KSAs) related to selected quality and safety competencies?
- What is the effect of integrated classroom content alone on students’ perceptions of their KSAs related to selected quality and safety competencies?
- Is there a difference in the themes identified between students who have integrated classroom content only and students who have integrated classroom content and clinical discussions and projects related to safety and quality of a selected clinical case study?
A mixed-method quasi-experimental study was conducted using both repeated-measures analysis of variance (ANOVA) for the quantitative data and content analysis for the qualitative data. Previously established clinical groups were assigned to either control or intervention groups. The intervention was developed and implemented by faculty members who were actively participating in the QSEN project. Approval for the study was obtained from the university’s institutional review board. Written informed consent was obtained from participants before initiation of the study.
Participants in this study were baccalaureate nursing students in the senior-level adult medical-surgical course at a midwestern university. The college of nursing consists of four campuses across the state. Due to feasibility issues of distance and scheduling, only two of the four campuses were involved in data collection for this pilot study. The control group was recruited from one campus, and the two intervention groups were recruited from a second campus to avoid cross contamination between control and intervention groups. Both campuses are situated in urban settings. The majority of the students in the sample were white women between the ages of 20 and 25, with a graduating grade point average >3.0 (Table 1). Statistical analysis using t tests and chi square revealed no significant differences between the control and intervention groups.
Table 1: Characteristics of the Sample (N = 65)
The Student Perceptions of Safety and Quality Knowledge, Skills, and Attitudes Questionnaire was developed by the researchers for use in this study (Table 2). The tool is based on the KSAs identified in the QSEN competencies (Cronenwett et al., 2007). Cronbach’s alpha analysis for the pretest and posttest was performed to determine the internal consistency of the questionnaire items. Original assessment of internal consistency revealed low alpha estimates for both pretest and posttest scores, 0.398 and 0.596, respectively. The analysis showed removal of a particular item would increase the alpha estimates for both the pretest and the posttest. Following deletion of the particular item, estimates for Cronbach’s alpha increased to 0.584 for the pretest and 0.654 for the posttest. This moderate Cronbach’s alpha may be due to the fact that the instrument does not measure a single unidimensional construct, but rather the perception of KSAs of the multiple constructs of patient-centered care, teamwork and collaboration, and safety. The revised instrument used in this analysis consists of 10 statements about quality and safety competencies rated on a scale ranging from 1 (strongly disagree) to 7 (strongly agree). Items 6 and 9 are reverse scored for analysis. Total scores can range between 10 and 70.
Table 2: Quality and Safety Education Competencies
The intervention consisted of two phases (Table 3).
Table 3: Intervention
Intervention Phase 1. Deliberately integrated classroom content was delivered and discussed during a case study. Content related to patient-centered care, teamwork and collaboration, safety, and quality improvement was included. For example, when the cardiac patient in the case study was placed on a heparin infusion, students were directed to research and discuss this high-alert medication using national safety initiatives such as the Joint Commission’s National Patient Safety Goals, the Institute for Safe Medication Practices, the Institute for Healthcare Improvement’s 5 Million Lives Campaign, and the Agency for Healthcare Research and Quality. The KSAs identified in the QSEN project relating to patient-centered care were incorporated into the discussion surrounding patient and family choices, and end-of-life care. Both intervention group 1 (n = 24; classroom content only) and intervention group 2 (n = 8; classroom content and clinical projects), received this phase of the intervention.
Intervention Phase 2. Discussion and structured projects were incorporated into clinical experiences for only intervention group 2. The discussions and structured clinical projects were related to safety and quality health care systems as follows:
- A root cause analysis of a near miss.
- Determination and documentation of staff roles and responsibilities during a patient handoff and identification of procedures that ensure patient safety during a patient handoff.
- Monitoring adherence to a policy or procedure to identify workarounds.
- In preparation for these activities, students read articles and participated in clinical conference discussions related to these topics.
Data Collection Procedures
Students completed the Student Perceptions of Safety and Quality Knowledge, Skills and Attitudes Questionnaire at the beginning of the semester and again immediately after finishing structured classroom content. The content described above was delivered to only the two intervention groups. The posttest was administered prior to implementation of the clinical exercises used with intervention group 2. The control group received no structured classroom content, did not participate in structured clinical projects related to safety and quality, and did not participate in focus groups.
After completion of phase 2 of the intervention, both intervention groups were given a case study describing a paraplegic patient admitted to an acute care facility from a rehabilitation center. The patient experienced a distal fibular fracture during rehabilitation and ultimately required below-the-knee amputation while in acute care. Four focus group discussions regarding the case study were conducted. Intervention group 1 was divided into three separate focus groups (n = 8) and intervention group 2 (n = 8) comprised the fourth focus group. The discussions were facilitated by the researchers using predetermined guidelines.
Data from the Student Perceptions of Safety and Quality Knowledge, Skills, and Attitudes Questionnaire were analyzed with repeated-measures ANOVA using SPSS version 16.0 software (SPSS Inc, Chicago, IL). Partial Eta squared (η2) was calculated as an effect size. The following values for interpreting effect size were used: 0.01 = small; 0.06 = medium; and 0.14 = large, which are equivalent to Cohen’s f values of 0.10 (small), 0.25 (medium), and 0.40 (large). The level of significance was 0.05.
The focus group discussions of the case study were audiotaped and transcribed verbatim. Transcriptions were analyzed using content analysis as described by Stemler (2001). Transcripts were read several times and line-byline coding of case study analysis transcripts was completed. Related codes then were clustered into themes. Close examination of the data, sometimes looking at phrases or individual words, supported the developing themes.
Students’ Perceptions of Safety and Quality Knowledge, Skills, and Attitudes Questionnaire
The two intervention groups were combined for the ANOVA analysis due to the small sample size in intervention group 2. The time x group interaction was statistically significant, F(1, 63) = 7.635, p = 0.007, and resulted in a medium to large effect size (partial η2 = .108). The control group’s mean total scores increased 0.18 points (60.30 to 60.48), whereas the intervention group increased 2.81 points (58.84 to 61.66). When examining the means on each item, perceptions related to teamwork and collaboration (items 1, 5, 6, 7, and 8) exhibited a slightly greater increase in the intervention group than in the control group. The changes in perceptions related to patient centered care (items 2, 3, and 4) were similar in both groups. Perceptions related to safety, medical errors in particular (item 9), showed more change in the intervention group (Table 4). Overall, students’ responses reflected positive perceptions of their competencies related to the safety and quality competencies of QSEN.
Table 4: Students’ Perceptions of Safety and Quality Knowledge, Skills, and Attitudes Questionnaire by Group
Case Study Content Analysis
Several themes emerged from the content analyses of the case study discussion, and differences were revealed between intervention group 1 (classroom content only) and intervention group 2 (both classroom content and clinical projects) (Table 5).
Table 5: Content Analysis Themes by Intervention Group
Intervention Group 1. The themes identified from the focus group discussions for intervention group 1 included blaming, lack of communication, and resource seeking. Each of the focus groups focused heavily on blaming during their discussions. Comments such as “actually if PT [physical therapy] was doing any type of rehab they would have…,” “nurses should have communicated to the doctors…the ortho team should have followed up more closely…,” and “you’d think that doctors would assess that foot” dominated their discussions.
Lack of communication was another common theme, but with much less frequency than blaming. Comments that supported this theme included “communication obviously failed,” “if nobody documents it…they just keep thinking somebody else is going to look at it,” and “the biggest portion of this was breakdown in communication.” Seeking appropriate resources also was identified by comments such as “there’s something that they could have found about the Aircast® boot…like on the Internet of some type of research…” and “call PT with questions.”
Intervention Group 2. The themes that emerged from analysis of transcripts from this focus group included safety, problem solving systems, and lack of communication. The theme that was evidenced most frequently during analysis of this group’s discussion was safety. Comments such as “he fell forward so there were some sort of safety measures that weren’t looked at,” “preventing the fall was also something that could have been done,” and “he was on [vaso]pressors for 2 days” supported this theme.
Problem solving with a systems approach was another theme identified by this group. The group discussed patient transfers to floors or areas that are appropriate based on patient problems or conditions (“I wonder what floor he was transferred to…if he had transferred to ortho…”) and the need for adequate staffing to provide safe, competent care (“Was nursing short-staffed?”), as well as the need for system-wide education on devices and equipment used in patient care (“they just didn’t know how to do it”). This group also identified lack of communication as a common thread in this patient’s care trajectory as evidenced by comments such as “there’s just no communication going on” and “no one charted.”
Review of the results from the Student’s Perceptions of Safety and Quality Knowledge, Skills, and Attitudes Questionnaire used in this study indicate students perceived their KSAs related to safety and quality to be adequate or positive prior to receiving integrated classroom content related to these topics in a medical-surgical course. This could be an accurate reflection of their level of understanding as they were exposed to national quality and safety initiatives in courses such as health care policy and leadership and management. Because nursing has always valued safety and quality, faculty may have shared those values in prior courses that influenced student values and beliefs. However, it might be that students do not truly understand the depth and breadth of the QSEN competencies as outlined by Cronenwett et al. (2007). In fact, faculty also have reported they believe their understanding and inclusion of QSEN competencies is well developed in courses; however, when participating in faculty discussions on inclusion of the QSEN competencies, faculty discovered they did not truly understand or include QSEN competencies at the level required in light of today’s health care environment (Cronenwett et al., 2007; Smith, Cronenwett, & Sherwood, 2007).
Research has shown classroom content must be applied in clinical activities and projects to influence behavior of students (Durham & Sherwood, 2008; Stiernborg et al., 1996). However, safety and quality have remained primarily classroom topics, with the primary clinical focus placed on individual patient safety and quality care delivery to one or two patients. These study results reinforce the need to restructure clinical learning activities with broader perspectives of both safety and quality. Even in the small study sample, students who received classroom content only and those who received classroom content and participated in clinical projects demonstrated a significantly greater improvement in their perceptions of quality and safety compared to the control group students who had no integrated classroom content and no clinical projects. Those students who participated in clinical projects related to safety and quality in addition to classroom content viewed the case study analysis more from a systems perspective than students who had classroom content only. However, the small sample size prohibits drawing definite conclusions regarding the influence of classroom content alone on quality and safety KSAs. Further testing and refinement of the study questionnaire also is warranted.
The case study focus groups composed of intervention group 1 (classroom content only) students centered their case study analyses on blame. Blame was directed at medicine, nursing, and physical therapy groups, teams, or individuals involved in the patient’s care. Careful examination revealed these focus groups acknowledged no positive aspects of the case and spent minimal time in problem solving discussion that resulted in identification of the resource-seeking theme. Although advocacy was discussed by one of the focus groups, advocacy did not emerge as a major theme from intervention group 1.
The focus group composed of students who had participated in clinical quality and safety projects as part of the intervention (intervention group 2) devoted a great deal of their discussion on what they identified as gaps in safety that led to negative patient outcomes. Although they identified actions that were not taken, they did so with only minimal blame toward the medical team. Therefore, blame did not emerge as a theme for this focus group. They made several references to systems approaches for problem solving, such as adequate staffing based on patient care needs, system-wide educational needs, and patient transfers to appropriate inpatient units. In addition, they identified positive aspects to the patient care process such as communication between medical teams. They also noted the need for interprofessional collaboration with social work and psychiatry, which was appropriate for this case study. Failure to follow policy and procedures and personal and professional accountability also were discussed by this group, but with much less frequency than the identified themes.
A limitation of this study was the overall small sample size (N = 65), which threatens both internal and external validity. The extremely small size (n = 8) of intervention group 2, which received integrated classroom content and participated in clinical projects related to safety and quality, makes it impossible to generalize these results to other student groups. However, it appears students who engage in learning safety and quality concepts in both classroom and clinical settings have a greater in-depth understanding of these concepts. Their case study analysis indicates they acquired a broader view of safety and quality, and can approach gaps in safety and quality from a stronger systems perspective compared to those students who received only classroom content. Conducting a case study analysis with the control group would have strengthened the analysis of these data. Another limitation is lack of randomization to treatment groups. Finally, longitudinal practice behavior was not studied, so it remains uncertain if these types of educational activities actually influence practice over time. Further research in this area with larger sample sizes, randomization to groups, longitudinal study of practice behavior, and use of valid and reliable outcome measures is needed.
Implications for Nursing Education
High quality, safe patient care has taken center stage in health care in a way like never before (Gregory, Guse, Dicke, & Russell, 2007). In addition to receiving “local” level focus from clinicians, researchers, and managers in health care systems, national nursing organizations such as the AACN, National League for Nursing, and National Council of State Boards of Nursing are turning their attention to the IOM and QSEN competencies.
However, the punitive, person-centered approach, under which many people still operate in health care, hampers effective improvements in safety (Gregory et al., 2007). This is evidenced by the findings from the current study. Intervention group 1, those who had only classroom content on quality and safety competencies, was caught up in focusing on who to blame for the patient situation rather than moving to consideration of the system issues that might have contributed to the negative outcomes for the patient. The educational process and environment has not evolved to the point that what is taught matches what is needed clinically, and simply teaching it in the classroom also is inadequate. Integration of clinical experiences to support learning and application of quality and safety KSAs is a critical component for incorporation into the practitioner’s repertoire.
Ladden, Bednash, Stevens, and Moore (2006) cited three main reasons that health professions learners have not engaged with quality and safety issues in the past. First, only recently were these topics identified as educational priorities in the United States. Second, finding clinical faculty competent to teach this content is challenging because faculty do not feel confident about how to teach this content. Third, quality care and systems improvements have not made it to the front lines of clinical practice, specifically to the patient bedside. Educational strategies to train the trainers are imperative if we are to make headway in helping students apply the KSAs learned in didactic activities. Forming collaborative groups that consist of small numbers of faculty and practice partners is one way to begin. When this group feels ready to implement the strategies, they can be asked to each lead another collaborative group. In this way, we can work with our hospital partners to integrate quality and safety components into student clinical experiences.
The IOM calls for health professions education to make fundamental and transformative changes to assure safe, quality care (Greiner & Knebel, 2003). Workplace culture issues are important to providing an environment that promotes quality generally and patient safety more specifically (Stockwell & Slonin, 2006). Students need to be educated in a way that develops a culture of quality and safety in them in a substantial way so they take that culture into practice.
Nationally, faculty believe that the IOM and QSEN competencies are embedded in current curricula and that students are developing the desired competencies (Smith, 2007). In our institution, a similar review revealed the same results. However, data from the current study would support either there is not sufficient information embedded in our curricula or students are not able to integrate the content into clinical practice or to make the cognitive transformations required to implement the KSAs in clinical practice. Individual, task-oriented thinking is an important component of basic nursing education, but it is not sufficient for supporting student learning about systems issues and needs (Day & Smith, 2007). Perhaps implementing strategies such as focused didactic content along with focused clinical strategies to raise awareness of the content to a conscious level is necessary to actually create change or reinforce new learning.
Nursing prides itself on being the patient’s advocate and the keeper of quality and safety. We embrace the primary ethical principle that above all, we do no harm. In fact, as part of our advocacy role, we see ourselves as the entity that also prevents others from doing harm. We must change our nursing education programs so that this is not just a tagline for students, but is the basis for all aspects of their nursing practice. Although we give this much “lip service,” nursing academic programs have some stretching to do before this is reality.
- American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nurses. Retrieved January 15, 2009, from http://www.aacn.nche.edu/Education/pdf/BaccEssentials08.pdf
- Aspden, P., Corrigan, J.M., Wolcott, J. & Erickson, S.M. (Eds.). (2004). Patient safety: Achieving a new standard for care. Washington, DC: National Academies Press.
- Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J. & Mitchell, P. et al. (2007). Quality and safety education for nurses. Nursing Outlook, 55, 122–131. doi:10.1016/j.outlook.2007.02.006 [CrossRef]
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- Gregory, D.M., Guse, L.W., Dicke, D.D. & Russell, C.K. (2007). Patient safety: Where is nursing education?Journal of Nursing Education, 46, 79–82.
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- HealthGrades (2004). HealthGrades quality study: Patient safety in American hospitals. Retrieved March 18, 2009, from http://www.healthgrades.com/media/english/pdf/hg_patient_safety_study_final.pdf
- Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: National Academies Press.
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Characteristics of the Sample (N = 65)
|Variable||Control Group (n= 33)n(%)||Intervention Group (n= 32)n(%)|
| Female||29 (45)||28 (43)|
| Male||4 (6)||4 (6)|
| 20 to 25||20 (31)||18 (28)|
| 26 to 30||7 (11)||10 (15)|
| >30||6 (9)||4 (6)|
| White/Caucasian||32 (49)||28 (43)|
| Black/African American||0 (0)||2 (3)|
| Hispanic/Latino||0 (0)||1 (1.5)|
| Asian||1 (1.5)||1 (1.5)|
|Grade point average at graduation|
| 3.5 to 4.0||15 (23)||6 (9)|
| 3.0 to 3.4||14 (22)||20 (31)|
| 2.5 to 2.9||4 (6)||6 (9)|
Quality and Safety Education Competencies
|Student ID No.|
|Please indicate the degree to which you agree or disagree with the statement by drawing a circle around the number of the response that best expresses your understanding.|
|Strongly Disagree||Disagree||Somewhat Disagree||Neutral||Somewhat Agree||Agree||Strongly Agree|
|1. Patients would ultimately benefit if health care professionals worked together to solve patient problems||1||2||3||4||5||6||7|
|2. Providing patient-centered care includes comfort measures and easing pain, particularly in end-of-life care||1||2||3||4||5||6||7|
|3. I can identify multiple barriers to patients’ involvement in their care||1||2||3||4||5||6||7|
|4. I can assist patients in overcoming barriers to their active involvement in their own care||1||2||3||4||5||6||7|
|5. Effective communication with other health care professions is equally important as effective communication with patients||1||2||3||4||5||6||7|
|6. Functioning of health care teams has little overall effect on safety and quality of care||1||2||3||4||5||6||7|
|7. Team-working skills are essential for all health care students to learn||1||2||3||4||5||6||7|
|8. I have adequate understanding of scopes of practice and roles of health care team members||1||2||3||4||5||6||7|
|9. As a staff nurse, my only required response to a medical error is to file an incident report||1||2||3||4||5||6||7|
|10. I have a basic understanding of national patient safety resources, initiatives, and regulations||1||2||3||4||5||6||7|
|Intervention Group 1||O1||X1||O2||O3|
|Intervention Group 2||O1||X1||O2||X2||O3|
Students’ Perceptions of Safety and Quality Knowledge, Skills, and Attitudes Questionnaire by Group
|Competencies||Control Group (n= 33)Mean (SD)||Intervention Group (n= 32)Mean (SD)|
|1. Patients would ultimately benefit if health care professionals worked together to solve patient problems||6.64 (0.74)||6.64 (0.60)||6.53 (0.98)||6.88 (0.34)|
|2. Providing patient-centered care includes comfort measures and easing pain, particularly in end-of-life care||6.58 (0.71)||6.70 (0.47)||6.69 (0.64)||6.38 (1.48)|
|3. I can identify multiple barriers to patients’ involvement in their care||5.21 (1.27)||5.30 (1.55)||5.56 (1.24)||5.75 (1.16)|
|4. I can assist patients in overcoming barriers to their active involvement in their own care||5.70 (0.88)||5.79 (0.60)||5.59 (0.98)||5.66 (0.97)|
|5. Effective communication with other health care professionals is equally important as effective communication with patients||6.55 (0.79)||6.49 (0.67)||6.53 (0.84)||6.63 (0.55)|
|6. Functioning of health care teams has little overall effect on safety and quality of care||1.58 (1.12)||1.64 (0.78)||1.81 (1.28)||1.56 (0.67)|
|7. Team-working skills are essential for all health care students to learn||6.64 (0.70)||6.55 (0.56)||6.44 (0.91)||6.66 (0.48)|
|8. I have adequate understanding of scopes of practice and roles of health care team members||5.30 (0.95)||5.42 (0.90)||4.94 (1.01)||5.44 (0.91)|
|9. As a staff nurse, my only required response to a medical error is to file an incident report||2.21 (1.43)||2.00 (1.06)||1.97 (1.09)||1.47 (0.57)|
|10. I have a basic understanding of national patient safety resources, initiatives, and regulations||5.0 (1.15)||5.24 (1.20)||4.38 (1.21)||5.31 (0.86)|
Content Analysis Themes by Intervention Group
|Intervention Group 1 (n= 24)||Intervention Group 2 (n= 8)|
|Lack of communication||Problem solving systems|
|Resource seeking||Lack of communication|