NURS 6053 Week 5: sample paper, in real form

Assessing the Work Environment of a 36-Bed Progressive Care Unit: Silence at Handoff, Its Retention Cost, and an Evidence-Based Response

Student Name

College of Nursing, Walden University

NURS 6053: Interprofessional Organizational and Systems Leadership

Instructor Name

Month Day, Year

Assessment of the Work Environment on a 36-Bed Progressive Care Unit

The unit assessed here is a 36-bed progressive care unit inside a 300-bed nonprofit community hospital that admits medical, post-surgical and step-down cardiac patients. Staffing is budgeted at 44.8 registered nurse full time equivalents across three shifts, with a target of one nurse to four patients on days and one to five at night. The assessment used two instruments the organization already owns: Clark's Healthy Workplace Inventory, a twenty-item scale scored one to five, and the items from the federal hospital survey on patient safety culture that address communication openness and handoffs (Agency for Healthcare Research and Quality, 2021; Clark, 2015). Both went to all 52 permanent staff members on the unit, nurses, nursing assistants and the unit clerk, over a two-week window in March, with responses collected anonymously and returned to a manager outside the unit.

Forty-one of 52 staff responded, a response rate of 79 percent, which is high enough that the results describe the unit rather than a vocal fraction of it. The Healthy Workplace Inventory composite was 61 of a possible 100. Three items carried the score down, and they cluster rather than scatter: staff feel free to speak up without fear of reprisal (mean 1.9), disputes are addressed rather than left to settle themselves (mean 2.0), and staff are treated respectfully by every discipline on the unit (mean 2.2). On the patient safety culture items, 38 percent of respondents here answered positively on communication openness, against 66 percent across the organization's five other inpatient units in the same reporting window. The unit is not failing at everything. Teamwork inside the shift scored 4.1 and orientation of new staff scored 3.8.

Turnover puts a number on what the survey describes. Over the twelve months ending June 30 the unit lost 15 registered nurses from a permanent roster of 44, a rate of 34 percent, while the organization turned over 16 percent of its nursing workforce. Nine of the 15 left within eighteen months of hire. Vacancy coverage ran at 6.4 travel nurse full time equivalents through the second half of that year at a contract rate near 1.8 times a staff nurse's loaded hourly cost. Exit interviews are the weakest evidence in this file, because they are self-reported and collected by the manager being evaluated, but eleven of the fifteen named the tone of the unit ahead of pay or schedule, and the anonymous survey gives that pattern a second and independent source.

The Problem the Scores Describe: Silence at Handoff

The organizational problem is not incivility in general. It is that handoff on this unit has stopped being a place where questions are asked. Nurse to nurse report happens at the bedside by policy, but the practice observed over four weeks is a shortened verbal summary at the station, and staff who receive an incomplete report say they do not raise it because the answer has been public correction more than once. That is the mechanism the low items are pointing at, and it is the reason a work environment belongs in a leadership course rather than in a satisfaction file. The behavior sits directly on the pathway where information about a deteriorating patient is supposed to move, at the one moment in the day when responsibility for that patient changes hands.

The professional literature settled long ago whether this is a morale matter. The American Nurses Association (2015) treats incivility, bullying and workplace violence as conditions the profession is obligated to interrupt rather than as personality friction, and it assigns responsibility to the employer and the individual nurse at the same time. The Joint Commission (2008) went further and named behaviors that undermine a culture of safety as a direct threat to error reporting, arguing that intimidating conduct teaches staff to avoid asking questions of the person most likely to hold the answer. Applied here the finding is uncomfortable and specific: the 38 percent positive response on communication openness is a measure of how often an uncertain nurse will ask, on a unit where nearly every patient carries a telemetry monitor.

Three conditions keep the pattern in place, and none of them is the character of any individual, which is the same reframing the National Academies of Sciences, Engineering, and Medicine (2021) applies when it treats nurse well-being as a property of the work system rather than a deficit in the nurse. First, handoff holds no protected time in the staffing model, so a nurse who slows report down is visibly costing a colleague the end of a shift. Second, the only route for reporting interpersonal conduct is the electronic form used for medication events, which travels to risk management and returns nothing to the person who filed it, so filing feels like an accusation with no reply. Third, charge nurses hold the assignment but no authority over conduct, which leaves the behavior owned by a manager who is present at 0900 and gone at 1900 when report happens.

An Evidence-Based Response and How It Will Be Measured

A civility campaign built on posters and a signed pledge is the response this organization would reach for first, and it should be refused, because it asks staff to behave differently while leaving every condition named above intact. Clark (2015) proposes something narrower and more testable: scripted cognitive rehearsal, in which staff practice a small set of specific replies to specific behaviors before the moment arrives, paired with language the receiving person can actually use in front of a patient. That fits the finding, because the survey did not report absent values. It reported the absence of a safe move at 1900. The plan below therefore pairs rehearsal with a change to handoff itself, since practicing a reply inside a workflow that punishes the question would only relocate the problem to a quieter hallway.

The plan runs six months. In month one the nurse manager and the four shift charge nurses complete four hours of rehearsal training, and the unit adopts a two-minute bedside safety check with a fixed four-item structure built on the escalation and read-back habits described in the patient safety culture guidance (Agency for Healthcare Research and Quality, 2021). Months two and three add 0.4 full time equivalents of paid overlap so that report sits inside paid time rather than being taken out of someone's evening, a line worth roughly $34,000 a year at the unit's blended rate and defensible against the replacement cost of a single nurse. In month four the conduct pathway is separated from the event report, given a named owner in nursing leadership and a five-day response commitment. Months five and six re-run both instruments on the same denominator.

Four measures carry the plan, and every baseline is already stated. The Healthy Workplace Inventory composite, baseline 61, is the outcome measure. Communication openness, baseline 38 percent, is the intermediate measure and sits closest to the mechanism. Twelve-month registered nurse turnover, baseline 34 percent, is the lagging measure and will not move inside six months, which is worth declaring in advance so that nobody calls the plan a failure in November. The balancing measure is shift-end overtime, baseline 41 minutes per nurse per shift, because a protected bedside handoff can push report past the end of a shift and convert a civility gain into an overtime problem. The decision that will test leadership here is not the training. It is whether the overlap money survives the first budget review, and transformational leadership becomes distinguishable from encouragement only at the moment a leader spends something (Bass & Riggio, 2006).

References

Agency for Healthcare Research and Quality. (2021). Surveys on patient safety culture (SOPS) hospital survey version 2.0: User's guide. U.S. Department of Health and Human Services.

American Nurses Association. (2015). Incivility, bullying, and workplace violence [Position statement]. American Nurses Association.

Bass, B. M., & Riggio, R. E. (2006). Transformational leadership (2nd ed.). Lawrence Erlbaum Associates.

Clark, C. M. (2015). Conversations to inspire and promote a more civil workplace. American Nurse Today, 10(11), 18-23.

National Academies of Sciences, Engineering, and Medicine. (2021). The future of nursing 2020-2030: Charting a path to achieve health equity. National Academies Press.

The Joint Commission. (2008). Behaviors that undermine a culture of safety (Sentinel Event Alert No. 40). The Joint Commission.