Care Setting Environmental Analysis: Wound Center
NURS-FPX6210 Leadership and Management for Nurse Executives
Dr. Mary Ellen Cockerham
October 11, 2021
Care Setting Environmental Analysis: Wound Center
The Wound Center (WC) at Regional Medical Center (RMC) in Orangeburg, SC, was
one of the departments with the highest retention and satisfaction rates in the entire hospital.
Although it was one of the smaller departments in the hospital, it treated over 60 patients a day
in the clins=c and at least 2o inpatients a day. The WC staff was comprised of an infectious
disease/certified wound specialty physician, a certified wound, ostomy, continence nurse
practitioner, seven registered nurses all certified in would care with two also certified in ostomy
care, a physical therapist with two assists, a medical office assistant and front desk staff. The
clinic had long wait times and long hours, but the clinic had little to no team turnover. This paper
will analyze how the clinic kept its staff retention high by looking at the discovery and dream
phases of Appreciative Inquiry and conducting a strengths, weakness, opportunity, and threats
The center was an ambulatory care setting that saw patients from the community,
local nursing facilities, and transfers from other hospitals in the outpatient setting. The staff was
also responsible for treating any inpatient with a wound or needing specialized care from the
WOCN. With such a heavy patient load, there were times that the staff would work upwards of
14 hours a day, five days a week, and patients would leave without being seen due to the long
wait times in the clinic. A patient’s experience at a clinic can determine their perspective on their
treatment and experience overall (Le et al., 2019). Although the days were long and hard, the
staff retention in this department was 100%. How did a department that saw nearly as many
patients as emergency departments, work long hours, and rarely get breaks, manage to keep
100% retention? A survey was conducted that asked several questions regarding retention and
what made this clinic run so smoothly. Many of the employees stated that they stayed because of
the teamwork. When rooms got backed up, other staff would pitch in and lend a hand. The front
desk staff said that they would keep the patients in the waiting room updated on the progress in
the back and let them know how long their wait would be; they felt this helped to keep the
waiting room satisfied with their wait time if they knew how much longer they would be waiting.
One staff member decided that instead of having patients have their vital signs and questions
asked about updates in medicines and medical history done in the room with a nurse, she would
begin the process in an alcove in the clinic. She would check vital signs and blood sugars and
update medications and new problems before taking patients to rooms. This made the patient feel
like their visit had started, and they were one step closer to seeing the doctor or nurse
practitioner. It broke up the wait time and made it seem shorter since they had already had
contact with a staff member. Identifying these patient bottlenecks helps with workflow and
patient and staff satisfaction. By maximizing efficiency, health care systems have taken
principles f the LEAN Sigma Six strategies and adapted them to their setting (Amerine et al.,
2017). This method worked well in the clinic setting at RMC.
The team members stated that they felt like a family. They had all been working together
for about five years, and there was a genuine camaraderie among them. Their retention was so
high because they knew each other’s work ethic, and each member had their particular skill that
kept the team moving forward. They were all high achievers and hard workers. They thrived in
the chaos and business of the clinic. One staff member shared that the staff that works in the
clinic were handpicked. When inpatient rounds were made, the nurses would watch the floor
staff and see who made an effort to assist the clinic nurses, who would ask them questions about
the wound and ostomy care, how did the patients present: were they clean and dry, was their
dressing changed, was their room neat, little things that would tell the clinic nurses a little insight
in the floor nurses care. By handpicking the staff, they knew that they would get a high-caliber
team to work with, and by watching and interacting with staff, they got a feel for if the potential
staff would make a good fit in the clinic and if they would stay for years. Retention is dependent
on factors like workload, effective collaboration, professional solid practice roles, and a healthy
work environment (Susan Trossman, n.d.) RMC is having a significant nursing turnover and
issue with retention. They have requested an evaluation of how the WC could keep their nursing
staff and reduce turnover. The goal is to increase nursing retention on the units and increase staff
satisfaction. To effectively evaluate the possibility for the facility to increase nurse retention, the
use of Appreciative Inquiry (AI) and SWOT analysis will be used to review nursing turnover
rates and facilitate ways to improve nurse retention and recruitment. Upon completion of the
analysis documentation, the results will be submitted to upper management for review and
presentation to the board.
Appreciative Inquiry Discovery and Dream
What is Appreciative Inquiry (AI)? AI creates change by asking intentional questions
focusing on discovery, dream, design, and destiny (MacCoy, 2014). AI looks for the best in
people, the organization, and the strengths (AI Commons, 2015). The first two phases of AI were
used in assessing the WC. During the discovery phase, it was found that the WC had high
retention rates of their staff. The staff cared for more than 60 patients a day that included
inpatients and outpatients. All the clinical team is board-certified, and ancillary staff all had
previous experience in a clinic setting. Patient care safety is a number one goal for all health
care facilities. Having a high nurse retention rate shows that the staff you have The WC is
known for its excellent care, and the only advertisement it receives is word of mouth from
present and former patients. Hospital Consumer Assessment of Healthcare Providers and
Systems (HCAHPS) data, provided by facility management, shows this department, clinic, has
been in the top percentile for patient and staff satisfaction for the past ten years. As mentioned
above, staff find that their teamwork and innovative ideas keep them at the clinic and keep
patients happy. The team has the skill of engagement; they are compassionate, energetic, and
love their job. They are fully vested in their work. The WC staff reported the following positive
engagement experiences: 1) I understand what is expected of me from my supervisor; 2) We
deliver high-quality care and are rewarded for such;3) the employees in this department have
mutual respect for one another and their opinions and protect one another, and the patients;4) the
physician and nurse practitioner value my opinion and are ever ready to teach and give
constructive criticism; 5) I enjoy working with my team; 6) I am encouraged to grow
professionally through education, research, and publications.
Nursing managememt at RMC must formulate an action plan to promote nursing
retention throughout the hospital and use the WC as a model. All nursing staff needs to make an
effort to stay informed and express their ideas and desires to help with retention. This can be
done by attending and contributing to monthly staff meetings, attend council meetings, read
nursing bulletin boards, and participate in upcoming continuing education, to name a few.
All healthcare institutions have similar missions, to care for their community, but the WC
also has a mission related to their staff. Their mission is to make everyday fun while working
together as a team and teach something new every day, whether to staff or patients. The dream
phase of the AI approach leads to several opportunities to create a mission for the RMC staff as a
whole and increase nurse retention at the facility. Nurse retention is a current problem for RMC,
even before COVID. The dream phase includes bonuses for nurses who have been at the facility
for five or more years, in-house continuing education to meet state education requirements,
tuition reimbursement, and merit/ Press Gainey raise increases every year. Using AI, the facility
will identify what is working well, define why it is working well, and clarify how to continue it
(Halm & Crusoe, 2018).
Strengths, Weakness, Opportunities, and Threats(SWOT)Analysis
There are four elements to the SWOT analysis approach: strengths, weaknesses,
opportunities, and threats (Hollingsworth & Reynolds, 2020). Strengths and opportunities are
internal factors that help the WC achieve the goal of 100% retention. Weaknesses and threats are
external factors that prevent goals from being completed.
Leadership should conduct a SWOT analysis on a yearly or even as-needed basis. It
should occur when nurse retention and recruiting, patient satisfaction, or safety issues are
identified ( Hollingworth & Reynolds, 2020). The assessment usually includes managers and
other stakeholders, like nursing, physicians, and clerical assistants in this setting who have a
vested interest in the organization. A SWOT analysis can ensure a valuable and correct
connection between management and the internal and external environment of the healthcare
setting (Swysen et al., 2012).
Leadership wants nurse retention to improve and has seen that high retention is possible
at RMC, as evidenced by the 100% retention rate of the WC. A SWOT analysis was conducted
during a strategic planning meeting to decide if this was a workable plan. The strengths were
noted as 1) the WC has been around since 1998 and has only added staff, 2) the community
needs RMC as it is the closest hospital 3) the hospital has an affiliation with the local technical
school and therefore has access to new nurse graduates, and 4) the WC traits can easily be
reproduced to assist with nurse retention. The weaknesses identified by the team include 1)
RMC does not have the best reputation for patient care due to nursing shortage, 2)there are no
competitive wages to keep nurses, 3) the benefits program does not include an appealing
retirement process, 4) there is little promotion from within to keep nurses from wanted to climb
the ladder. Even though these weaknesses are significant, the opportunities are ample. The
identified opportunities are 1) use the new graduates to fill nursing positions as they have done
their clinicals here and are familiar with the culture, 2) add a sign-on bonus plan and competitive
wage program and referral bonuses to entice staff to come and stay, 3) include state retirement as
the hospital is affiliated with the county and state government, and 4) implement a program to
teach staff about the management positions in the hospital and promote from within the hospital.
Lastly, the threats that may impede this plan are as follows: 1) larger hospitals are 30 minutes
from RMC and already offer higher wages and bonuses, 2) Fewer students are applying for
nursing school at the local college, 3) the new CEO and CNO are not from this area and have not
learned the RMC way, and 4) former employees are getting bonuses to get new hires to the other
hospitals and taking staff from RMC.
It is essential to focus on the positives of this analysis and consider the implications for
safety and quality. Patient safety is the most prominent area of concern. Having issues with nurse
retention comes the risk of patient safety, staff burnout, and increased nurse-to-patient ratios that
are not attractive to potential employees. Leadership must decide if it is fiscally and financially
possible to give raises and sign-on bonuses. If these areas cannot be implemented, nurses will go
elsewhere, mainly because low staffing means higher ratios.
AI and SWOT Comparison
Both AI and SWOT work to create improvements in processes and outcomes. AI focuses
on positivity and increased value. It can be used to promote workforce engagement and learning
within the organization and promote positive change in a health care context (Trajkovski et al.,
2013). Focusing on what is working can help promote positive change. AI involves interviewing
the involved persons and collecting data using open-ended questions (MacCoy, 2014). SWOT
analysis is a systematic way of thinking and exploring areas for development in your field,
resource usage (including physical, personal, and intellectual resources), and areas of
vulnerability needing improvement or expansion (“Strengths, Weaknesses, Opportunities, and
Threats,” 2008). While both tools use specific and relevant components for data collection, AI
focuses on positivity. SWOT only looks at factors at a certain point in time and times change the
SWOT analysis does not allow for the changes.
Transformational leadership is one of the most used styles in healthcare (The University
of Alabama Huntsville, n.d.). Transformational leadership can be defined as “an ethically-based
leadership model that integrates a commitment to values and outcomes by optimizing the long-
term interests of stakeholders and society and honoring the moral duties owed by organizations
to their stakeholders (Caldwell, 2012). Transformational leaders are proactive, seeking mutually
beneficial opportunities for both the organization and the individual team members. They seek to
promote success in the workplace by making changes. Transformational leaders are excellent at
influencing others, which makes it easy for people to manipulate a situation, and since they
spend a lot of time helping team members, they can be seen as showing favoritism, also
transformational leaders focus on long term goals and may lose sight of the details along the way
(Indeed Editorial Team, n.d).
The AI approach, which focuses on positive and affective aspects of a project, and the
transformational leadership style that focuses on an individual’s knowledge and expertise are
both supportive and innate combinations. The transformational approach looks at the group as a
whole while also giving attention to individuals as needed. Transformational leaders engage the
For the SWOT approach, transformational leaders can be influential as they look at
strengths and weaknesses, opportunities and threats for a project that requires open
communication. With a mutual goal of satisfying the stakeholders, SWOT analysis and
transformational leaders work well.
While AI and SWOT analysis are different assessment tools, they share the common goal
of pursuing growth opportunities. Both assessments are sources of truth during the strategic
planning process; however, over-emphasis for either evaluation may lead to a skewed prediction.
A skilled transformational leader can evaluate existing or planned programs using analytical
tools and effectively design a financially viable plan and supportive of high-quality outcomes.
Using the WC as a model for nurse retention, RMC should recruit nurses and retain those nurses
for years to come.
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Appreciative Inquiry Discovery and Dream
Strengths, Weakness, Opportunities, and Threats(SWOT)Analysis
AI and SWOT Comparison
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