Written assignment on nursing related challenges



Copyright ©2017 Capella University. Copy and distribution of this document are prohibited.

Impact Report to Senior Leadership

Learner’s Full Name

Capella University

Organizational and Systems Management for Quality Outcomes

Impact Report to Senior Leadership

May, 2017


Copyright ©2017 Capella University. Copy and distribution of this document are prohibited.

Impact Report to Senior Leadership

Nurse leaders play an important role in guiding nursing professionals to achieve a health

care organization’s quality and safety standards—standards that should help patients receive

high-quality care without negative outcomes on their health. Despite efforts to maintain these

standards, health care organizations across the United States of America have witnessed an

increase in the number of poor patient outcomes (that stem from unsafe care. According to the

Quality Interagency Coordination Task Force, the consequences of quality and safety issues in

patients have amounted to an annual loss of $29 billion (Huber, 2017).

The importance of maintaining patient safety standards in health care will be explored

based on the challenges faced by a well-known nursing facility in the United States of America.

Located in a major city, the facility provides 24-hour residential care to the elderly and people

with special needs who require customized care. The facility has been facing patient safety issues

connected to how its nursing professionals administer treatment and monitor patients.

Patient Safety as a Nursing Challenge in the Nursing Facility

Nursing professionals are the primary caregivers in any health care setting; they spend

the most time with patients as they administer treatment, detect signs of deterioration in patients,

and build caring relationships with them. Therefore, safety issues that cause any negative

outcomes in their patients can affect nursing professionals emotionally and hinder their career

development (Lawton, Carruthers, Gardner, Wright, & McEachan, 2012; Huber, 2017).

The nursing facility encountered safety issues caused by nurses when administering

medicines, patients falling or injuring themselves because of nursing negligence. These issues

Comment [A1]: Nice job identifying the challenge of providing patient safety care measures. Good inclusion of how unsafe practices leads to emotional and decreased career development in nurses as well as the impact of sentinel events for the organization. You stated that patients are negatively impacted and could further explain what is meant by that.


Copyright ©2017 Capella University. Copy and distribution of this document are prohibited.

are called adverse events because they occur in clinical practice and affect patients directly (U.S.

Food & Drug Administration, n.d.).

Following the perspectives of systems theory, which explain how smaller parts of an

organization affect the whole, the safety issues caused by errors in nursing practice can impact

the organization and its achievement of health care goals on a larger scale. In fact, adverse events

in nursing may have multiple consequences across the entire organization as different parts

interact symbiotically. For example, the safety issues have made the facility vulnerable to

sentinel events, which are patient-related events that result in death, permanent harm, or grievous

injury (The Joint Commission, 2017). Finding solutions to such challenges in nursing practice

requires nurses to grow into genuine systems leaders who can safeguard the goals of the

organization and nurture similar commitment in other nursing professionals (Senge, Hamilton, &

Kania, 2015).

The Impact of Safety Issues on the Organization

Since its inception, the nursing facility has always prided itself as a premier health care

organization that offers specialized physical, occupational, and rehabilitative therapies, aside

from medical services to the elderly and people with special needs. Through its mission, vision,

and core value statements, the facility has made a commitment to improve people’s lives, abide

by health care ethics, adhere to local and national health care standards, and provide affordable

services. The facility depends on skilled staff, nurses included, to carry out the goals mentioned

in its mission, vision, and core value statements.

However, the adverse events taking place in the facility and among its nursing

professionals are contradicting the mission, vision, and core value statements.. Systems theory

Comment [A2]: Excellent point and nicely

Comment [A3]: Excellent work explaining how unsafe practice issues conflict with the organization’s mission and vision of improving lives. Nice incorporation of systems theory.

Comment [A4]: Very true!


Copyright ©2017 Capella University. Copy and distribution of this document are prohibited.

states that organizations have inherent weaknesses—latent failures—that can cause adverse

events in patient care (Lawton et al., 2012; Huber, 2017).

Nurse leaders can ensure there is a culture of safety and quality through implementation

of continuous quality improvement and safety management initiatives. Organizational change

guided by systems theory plays a major role when introducing any quality improvement and

safety management initiatives. An effective safety culture in health care acknowledges change as

a common element in health care and can pre-emptively reduce the probability of adverse events

(Huber, 2017). The culture of safety incorporates systems thinking into patient-related decision-

making made by nurse leaders, which allows them and nursing professionals to consider how

actions can affect an organization as a whole.

SWOT Analysis of Organizational Factors

The nursing facility had experienced a number of changes that affected the nurses’ ability

to deliver safe care. The SWOT analysis helps the facility to focus on the changes that have had

the greatest impact on health care quality and patient safety.

Comment [A5]:

Comment [A6]: Nice work identifying the factors that impact the situation using a SWOT analysis, such as budget cuts and the lack of resources available to nursing leaders.


Copyright ©2017 Capella University. Copy and distribution of this document are prohibited.

Table 1

SWOT Analysis of Organizational Factors


 Specialized geriatric care and therapy

for people with special needs

 Strong market presence

 State-of-the-art infrastructure and


 Commitment to ethical standards

 Affordable and fair treatment for



 Budget cuts faced by the nursing


 Low number of experienced nursing


 Absence of organizational planning on

continuous quality improvement and safety

management initiatives

 Vulnerability to sentinel events

 Poor allocation of nursing professionals

across departments and gaps in staff


 Lack of communication between nursing



 Creation of a new nursing leadership

position to oversee patient safety and

quality care

 Efforts to become a Magnet hospital

 Increased public awareness about

geriatric care and therapy for people with

special needs

 Expansion and revision of nursing

competencies by national nursing



 Inadequate financial resources because of

federal budget cuts to health care programs

 Increased competition from other health

care organizations

Effective nursing leadership is crucial for the SWOT opportunities to be translated into

actions that facilitate organizational change. Leaders are change agents as they transform plans

into actions, motivate staff to align with the goals of the organization, and communicate details

of the change process to all stakeholders. Comment [A7]: Lots of great information here. Nicely written and well organized.


Copyright ©2017 Capella University. Copy and distribution of this document are prohibited.

Defining the New Leadership Position at the Nursing Facility

The new leadership position that will be created is the chief nursing officer (CNO). The

CNO will be responsible for planning, executing, and evaluating the strategies to improve safety

issues. The CNO will also be a part of the facility’s shared governance council and will head a

team that will analyze the organization for latent failures. Certain key competencies—

knowledge, skills, and attitudes—will define the broad nature of the CNO’s role and influence in

the organization.

Key Competencies for the Nursing Leadership Position

The American Organization of Nurse Executives (AONE, 2015) details five professional

leadership competencies that can help the chief nursing officer. The five competencies are

communication and relationship-building, professionalism, leadership skills, business skills, and

knowledge of the health care environment (AONE, 2015).

By developing these competencies, the CNO will gain (a) knowledge about global trends

in nursing and health care; (b) expert problem-solving and critical-thinking skills for making

decisions; (c) an understanding of patient safety and quality care; (d) an understanding of

organizational politics, authority, and power dynamics; (e) relationship-building and team-

building skills; (f) knowledge of systems theory and systems thinking; and (g) the trust of health

care professionals in the organization and the skills to adapt to organizational change.

Influence of Leadership Power in Patient Outcomes

Demonstrating appropriate power and authority is a prerequisite for productive nursing

leadership. Having this authority allows nurse leaders to recruit and retain a highly skilled

nursing workforce, which is a critical indicator of patient safety. They can also maintain the

Comment [A8]: Good identification of the skills required of a nursing leader which should consist of knowledge, leadership skills, and attitude. Nice explanation of how the nurse leader should approach change to allow for success by understanding systems theory and the organization’s dynamics as this will provide the nurse leader with the power to implement the change effectively.

Comment [A9]: Great assessment of how the nurse leader position will have the power to positively impact patient outcomes and stabilize the organization financially.


Copyright ©2017 Capella University. Copy and distribution of this document are prohibited.

productivity of nursing professionals by allocating training resources without management

interference. These empowered roles help stabilize an organization's financial performance,

thereby impacting the delivery of cost-effective and quality care to patients (Australian College

of Nursing, 2015).


Successful health care organizations are those that understand the role of nursing

professionals in patient outcomes and involve the workforce in addressing safety and quality

concerns. Such organizations demonstrate effective management that identifies latent

organizational factors behind adverse events and implements solutions accordingly. Nurse

leaders are crucial to this system as they communicate organizational and nursing goals to other

health care professionals in the organization. Acknowledging these nursing roles and

incorporating them into an organization's strategic planning help health care professionals adapt

to sudden environmental changes that affect safety and quality (Salmela, Eriksson, &

Fagerström, 2013).

Comment [A10]: Great job!

Comment [A11]: Very nice summary of what was discussed in the paper.


Copyright ©2017 Capella University. Copy and distribution of this document are prohibited.


American Organization of Nurse Executives. (2015). AONE Nurse Executive Competencies.

Retrieved from http://aone.org/resources/nec.pdf

Australian College of Nursing. (2015). Nurse leadership [White paper]. Canberra: American

College of Nursing. Retrieved from



Huber, D. L. (2017). Leadership and nursing care management (6th ed.). Philadelphia: W. B.

Saunders. http://dx.doi.org/10.7748/nm.21.6.13.s14

Lawton, R., Carruthers, S., Gardner, P., Wright, J., & McEachan, R. R. C. (2012). Identifying the

latent failures underpinning medication administration errors: An exploratory

study. Health Services Research, 47(4), 1437–1459. http://dx.doi.org/10.1111/j.1475-


Salmela, S., Eriksson, K., & Fagerström, L. (2013). Nurse leaders’ perceptions of an approaching

organizational change. Qualitative Health Research, 23(5), 689–99.


Senge, P., Hamilton, H., & Kania, J. (2015). The dawn of system leadership. Stanford Social

Innovation Review, 13, 27–33. Retrieved from


The Joint Commission. (2017). Sentinel event policy and procedures. Retrieved from https://



Copyright ©2017 Capella University. Copy and distribution of this document are prohibited.

U. S. Food & Drug Administration. (n.d.). What is a serious adverse event? Retrieved from

https:// fda.gov/safety/medwatch/howtoreport/ucm053087.htm

Comment [A12]: APA references looks great!