Mary Carroll, MSN, RN, is new to the organization. She self-identified as a servant leader and was a little anxious abou

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Mary Carroll, MSN, RN, is new to the organization. She
self-identified as a servant leader and was a little anxious about
her new role as the director of the critical care unit of the
hospital. Two years after she earned her master’s degree in health
system nursing leadership, she was determined that she was up to
the challenge and would be successful, but she was experiencing
some trepidation. When Mary Carroll interviewed with the new chief
nursing officer (CNO), who already envisioned the organization to
be on the Magnet journey, she recognized that the CNO was
relationship centered and was also a transformational leader. When
she reviewed the monthly budget and nurse-sensitive indicators,
Mary Carroll noted the high turnover and vacancy rates (20% and
30%, respectively) on her unit, the high number of falls and
hospital-acquired pressure ulcers, the high cost of overtime, and
the use of traveling nurses. The mean age of the few seasoned
nurses was in the upper sixties. The high number of nurses with
less than 2 years of bedside experience alarmed Mary Carroll.
Recognizing that the literature supports improved outcomes among
nurses with higher education, Mary Carroll reviewed the number of
diploma-, associate-, and baccalaureate-prepared nurses on the
unit. She found that 30% of the nurses were diploma prepared, 45%
were associate’s degree prepared, and 25% were baccalaureate degree
prepared. Mary Carroll recognized that, without some major changes,
it would be difficult to bring additional new associate-degree
nurses from the local community colleges into the current hospital
environment; with the current percentage of such nurses, a high
turnover and vacancy rate, and poor nurse-sensitive indicators, the
hospital environment was not conducive to enhancing the strength of
the nursing workforce. Patient complaints were frequent, and
physician dissatisfaction was high. The quality and risk managers
were demanding to meet with Mary Carroll regarding quality issues,
patient complaints, and current litigation. Prior to the first
staff meeting, Mary Carroll spent time learning about the unit,
dealing with daily operational issues, and formulating a plan to
involve staff members in enhancing care on the unit while
decreasing turnover and vacancy and improving patient experiences.
As she observed staff members on the unit, she noted that some were
cool and noncommunicative, others were frantic and claimed they
were too busy to talk, and others ducked into rooms to avoid having
a conversation with their new director. The first unit meeting was
sparsely attended by a few seasoned nurses and several newer
nurses. When she asked the attendees why they thought the meeting
was poorly attended, they said that administration keeps cutting
resources, everyone is exhausted, and many were out looking for
positions at other hospitals. As Mary Carroll continued to ask
staff members to identify issues and discuss solutions to improve
the critical care unit, many barriers to patient care were
identified and potential solutions were listed. As she focused on
positive topics after identifying issues and seeking solutions,
nurses began telling their stories of why they had chosen a nursing
career and how important they felt they could be in improving
patient outcomes. Some of the seasoned nurses rolled their eyes
during the storytelling, and others made negative facial
expressions. Mary Carroll applauded the nurses who spoke up about
the possibilities for nursing and the services they could improve
on their unit. Mary Carroll asked for volunteers to begin working
on improving a variety of aspects on the unit. She also asked staff
members what kinds of teams they thought might be helpful in
dealing with the current issues they had listed and how those teams
could facilitate some of the solutions that were suggested. As the
meeting adjourned, the nurses expressed excitement about potential
improvements and the unit issues that could be improved under the
direction of their new leader. As Mary Carroll left the meeting,
she maintained hope that she could empower the nurses to own their
unit and improve the work environment, nurse satisfaction, the
patient experience, and nurse-sensitive outcomes. She began to
think about what resources she would need to engage them further.
Case Study Questions 1. Identify stakeholders who should be
included in performing a needs assessment to help further identify
core issues on the unit that must be addressed prior to
transforming the unit culture. 2. Identify why each stakeholder
should be included in the improvement process. 3. Discuss methods
for identifying which stakeholders to engage, inform, and
influence. 4. What are the issues in the case study? 5. What
literature and theories can support resolution of the issues in the
critical care unit? 6. What resources might Mary Carroll call upon
to assist her in resolving the issues in the critical care unit? 7.
What leadership and change theories might be helpful to Mary
Carroll as she thinks about ways to improve the nursing work
environment and the nurse-sensitive indicators?