NUR 860 The Nurse Executive: Hot Seat Case Study

  Nursing workforce = 25% of employees.

  Rising COVID cases in the community and staff infections.

  Diversion status with patients transferred out of area.

  14 ICU beds and 62 acute care beds unstaffed.

  Travel nurse funds depleted, minimal applicants available.

  Administrative nurses reassigned to bedside care.

  Unsafe patient-to-staff ratios discussed in daily huddles.

Haddad, L. M., Annamaraju, P., & Toney-Butler, T. J. (2023). Nursing shortage. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK493175/

National Academies of Sciences, Engineering, and Medicine. (2021). The future of nursing 2020–2030: Charting a path to achieve health equity. National Academies Press. https://nap.nationalacademies.org/catalog/25982/the-future-of-nursing-2020-2030-charting-a-path-to

• Nurse executives must build trust through clear communication and relationship-building.
• Ethical decision-making ensures safe staffing during crises.
• Staff engagement and retention are priorities for workforce stabilization.

Haddad et al. (2023)

• Nursing shortages are driven by burnout, aging workforce, and pandemic-related stressors.
• Retention strategies such as flexible scheduling and professional development are effective.
• Nurse executives should advocate for policies addressing systemic staffing issues.

National Academies (2021)

• Nurse leaders should engage in policy advocacy to strengthen workforce sustainability.
• Partnerships with academic institutions expand the nursing pipeline.
• Evidence-based staffing models protect patient safety and staff well-being.

• Advocate for safe staffing ratios even when financial pressures push for opening more beds without adequate personnel.
• Communicate transparently with staff, executive leaders, and the community about diversion status and the risks of unsafe care.
• Support frontline nurses experiencing burnout by pushing for wellness resources and fair workloads, despite budgetary constraints.
• Resist short-term, cost-driven solutions that compromise patient safety or diminish quality of care.
• Balance competing priorities from leadership, staff, and community stakeholders while remaining guided by ethical obligations to patients.
• Uphold integrity by making difficult decisions that prioritize safety and quality over political or financial convenience.

  Patient population consists entirely of privately insured individuals, with no charity care accepted.

  The organization performs mostly elective and orthopedic surgeries, averaging 112 surgical cases daily across 14 bays.

  A patient undergoing hip replacement reported experiencing inappropriate and unprofessional conduct by both the surgeon and nursing staff.

  This is not the first complaint involving the same surgical team, indicating a repeated behavioral concern.

  The Nurse Executive has met with HR multiple times, but no performance improvement plan has been implemented.

  HR is viewed as the subject matter expert on employee management, and owners rely heavily on HR’s recommendations.

  Patient satisfaction scores are declining, creating concern for financial stability and reputation.

  Facility owners and the Nurse Executive share a common concern but differ in their authority to enforce corrective action.

  Leadership – Strong leadership is essential to confront unprofessional behaviors directly, clearly set expectations, and consistently model accountability.

  Knowledge of the Healthcare Environment – Understanding how patient satisfaction influences reimbursement, accreditation, and reputation is critical.

  Professionalism – The Nurse Executive must demonstrate integrity and ethical practice in holding staff accountable to service standards.

  Business Skills and Principles – Recognizing how declining satisfaction scores may affect the hospital’s market competitiveness guides decision-making.

Frampton, S. B., Guastello, S., & Hoy, L. (2021). The evolving role of nursing leadership in patient experience. Patient Experience Journal, 8(1), 12–18. https://pxjournal.org/journal/vol8/iss1/5

Press Ganey. (2022). Improving patient experience through leadership engagement. Press Ganey. https://www.pressganey.com/resources/improving-patient-experience-through-leadership-engagement

• Nurse executives must address staff accountability and professionalism to protect patient experience.
• Strong communication and relationship-building are required when dealing with physicians, HR, and owners.
• Ethical leadership ensures alignment between staff behavior and organizational values.

Frampton, Guastello, & Hoy (2021)

• Nurse leaders shape patient experience through culture, professionalism, and respectful communication.
• Transparency in addressing complaints reinforces trust between patients and providers.
• Aligning nursing leadership priorities with patient satisfaction goals improves long-term outcomes.

Press Ganey (2022)

• Leadership engagement directly impacts patient experience scores and organizational reputation.
• Coaching and feedback for staff are effective tools in addressing unprofessional behaviors.
• Failure to act on behavioral complaints undermines loyalty and financial success.

  Address inappropriate behaviors directly with the surgical team, including high-performing physicians, while maintaining professional boundaries.

  Communicate honestly with facility owners about the risks of ignoring patient complaints, even if it creates tension.

  Uphold patient-centered values by insisting on respectful, professional conduct as a non-negotiable standard.

  Accept the possibility of pushback from influential surgeons but remain firm in prioritizing patient experience and organizational integrity.

You review the most recent organizational data and uncover some concerning patterns.

·         Medication errors have increased 3% over the last year.

·         Patient falls are up from a hospital average of 3.2 falls/1000 patients to 5.3 falls/1000 patients.

·         A recent nurse satisfaction survey reports that a significant percentage of nurses did not feel heard by their manager.

·         Patient satisfaction scores have declined.

·         Quality metrics have not changed significantly but do demonstrate a small but concerning downward trend universally.

·         The percentage of nurses employed with less than 1 year of experience has increased from 25% to 35%.

·         First the first time, the organization is pursuing international nurse staffing solutions to address their workforce shortage

  Staff required to work overtime to cover high patient loads and surgical schedules.

  Continuous PPE use contributes to staff fatigue and burnout.

  Nurse-to-patient ratios on non-critical floors increased from 1:4–5 to 1:6–7.

  Workplace division over COVID-19 vaccine mandate fuels tension among staff.

  Medication errors increased by 3% over the past year.

  Patient falls rose from 3.2 to 5.3 per 1000 patients.

  Nurse satisfaction survey indicates staff feel unheard by management.

  Patient satisfaction scores have declined.

  Quality metrics demonstrate a small but concerning downward trend.

  Percentage of nurses with less than one year of experience increased from 25% to 35%.

Current financial performance and budget flexibility to support workforce interventions.

Comparative benchmarking data on patient outcomes with similar hospitals.

Specific feedback from nurses about communication gaps with managers.

Orientation and support structures are in place for novice and international nurses.

Staff absenteeism rates and overtime patterns.

Patient safety incident reviews beyond falls and medication errors.

Evaluation of leadership visibility, engagement, and support during the pandemic.

• Advocacy: The nurse executive must advocate for staff well-being and patient safety to the board and executive team, especially when financial priorities conflict with safe staffing practices.
• Collaboration: Building strong partnerships with HR, ancillary staff, and international recruitment agencies is essential to stabilize the workforce and support new hires effectively.
• Systems Thinking: The leader must evaluate how staffing, morale, patient safety, and quality outcomes are interconnected, ensuring interventions address root causes rather than isolated issues.
• Knowledge Management: Leveraging organizational data on errors, falls, and satisfaction surveys enables evidence-based decisions that improve patient outcomes and staff engagement.
• Change Management: Guiding staff through transitions, such as onboarding novice and international nurses or adjusting to new workforce models, requires structured change leadership to minimize disruption.

Shanafelt, T., Ripp, J., & Trockel, M. (2022). Understanding and addressing sources of anxiety among healthcare professionals during the COVID-19 pandemic. JAMA, 323(21), 2133–2134. https://jamanetwork.com/journals/jama/fullarticle/2764380

Lasater, K. B., Aiken, L. H., Sloane, D. M., French, R., Martin, B., Reneau, K., & McHugh, M. D. (2021). Chronic hospital nurse understaffing meets COVID-19: An observational study. BMJ Quality & Safety, 30(8), 639–647. https://qualitysafety.bmj.com/content/30/8/639

• Nurse executives must address staff engagement, retention, and patient safety.
• Communication and trust-building are critical to morale recovery.
• Ethical decision-making ensures staff and patient needs are balanced fairly.

Shanafelt et al. (2022)

• Healthcare workers’ anxiety stems from fatigue, safety concerns, and lack of support.
• Leadership presence, clear communication, and wellness resources reduce burnout.
• Listening to staff concerns directly improves resilience and trust.

Lasater et al. (2021)

• Chronic understaffing worsens patient outcomes, increasing falls and medication errors.
• Higher nurse-to-patient ratios correlate with reduced safety and satisfaction.
• Investing in adequate staffing directly improves patient outcomes and nurse morale.

  Address staff concerns openly, even when vaccine mandates or policy issues create division.

  Confront declining patient outcomes with transparent communication to executives and the board, regardless of reputational risks.

  Stand firm in supporting novice and international nurses through robust orientation, even if it requires resource allocation.

  Make difficult decisions to balance patient safety with organizational constraints, prioritizing ethical practice over expediency.

The county median age is 38.5, and the median household income is $66K.

The organization’s economic impact on the community is:

·         432 employees (direct [257] and secondary [175])

·         $32.84M (direct [$25.5M] and secondary [$7.3M])

Current services offered:

The facility is part of a more extensive integrated network, with the tertiary facility located 100 miles away. In addition, there is a four-year degree-granting university in the community with a nursing program that graduates approximately 15 nursing students a year.  Agriculture and oil are the primary industries. The public school district has approximately 4000 K-12 students.  The community is mainly homogenous, with nearly 80% of the population of Caucasian descent, with Hispanic and African American ethnicities representing 10% and 6% of the population, respectively.

While ED visits have remained stable, organizational leaders have recognized a slow but notable downward trend in the market share of outpatient visits to ambulatory, outpatient settings. To add to this finding, leaders have uncovered that a more significant number of patients presenting to the ED have no identified primary care provider. Many patients presenting to the ED identify their primary care provider as a local competing healthcare organization. To further complicate the issue, the payor mix for ED visits includes a shrinking percentage of privately insured, a steady rate of Medicare/Medicaid, and a growing rate of self-pay patients.

• Market share decreased by 8% in one year.
• Declines concentrated in orthopedics and elective procedures.
• Patient satisfaction surveys show lower scores compared to competitors.
• Outpatient centers attract patients with convenience and shorter wait times.
• Decline in case volumes threatens financial viability of certain service lines.
• Physician dissatisfaction is increasing due to reduced case volumes.
• Staff morale is impacted by uncertainty about organizational stability.

Patient demographics and reasons for choosing other facilities.

Insurance provider contracts and referral patterns that may impact patient volumes.

Financial projections under current trends versus potential improvement strategies.

Physician alignment and referral practices.

Current marketing strategies and community outreach efforts.

Capacity to expand outpatient or telehealth services.

• Business Skills and Principles: Analyze market data, financial performance, and competitive positioning to inform decision-making.
• Knowledge of the Healthcare Environment: Understand local healthcare market trends and consumer expectations.
• Communication and Relationship-Building: Collaborate with physicians, staff, and community stakeholders to strengthen reputation and engagement.
• Strategic Leadership: Guide innovation in service delivery models, including outpatient and patient-centered care, to compete effectively.
• Professionalism: Maintain integrity and patient-centered focus while balancing financial and competitive pressures.

Porter, M. E., & Lee, T. H. (2021). The strategy that will fix health care. Harvard Business Review. https://hbr.org/2013/10/the-strategy-that-will-fix-health-care

Wolf, J. A., Niederhauser, V., Marshburn, D., & LaVela, S. L. (2021). Defining patient experience. Patient Experience Journal, 8(1), 7–19. https://pxjournal.org/journal/vol8/iss1/3

• Nurse executives must align patient experience strategies with organizational goals.
• Strong business and financial acumen is essential for market competitiveness.
• Collaboration with stakeholders builds trust and sustainability.

Porter & Lee (2021)

• Healthcare organizations must compete on value, not just volume.
• Integrated practice units and patient-centered outcomes drive competitive advantage.
• Transparent reporting of outcomes strengthens market trust.

Wolf et al. (2021)

• Patient experience is defined by respect, communication, and coordinated care.
• Improving patient experience is directly linked to improved market share.
• Nurse leaders play a central role in shaping patient perceptions of quality.

• Advocate for patient-centered initiatives even if they require short-term financial investment.
• Challenge leadership and board members if strategies prioritize profits over patient experience.
• Address physician dissatisfaction constructively while holding providers accountable for professionalism.
• Be transparent with staff about challenges and opportunities, even when morale is low.
• Support innovation in care delivery, despite resistance from stakeholders invested in traditional models.

  The resident population includes 40 long-term care and 10 hospice patients.

  Fall occurred in a resident with DNR/DNI status, leading to neurological changes and significant injury.

  Fall precaution bundle was not in place at the time of the incident.

  Incident meets criteria for a Sentinel event and requires mandatory compliance reporting.

  Root cause analysis revealed inconsistent implementation of safety bundles across residents.

  Safety lapses raise the risk of litigation, regulatory penalties, and reputational damage.

  Highlights systemic issues in patient safety and compliance monitoring.

• Staff adherence and compliance data with fall and safety bundles across all residents.
• Staffing ratios, overtime trends, and training records related to fall prevention and patient safety.
• Previous incident history involving patient falls or safety breaches.
• Details on internal auditing processes for monitoring compliance with care bundles.
• Policies regarding Sentinel event reporting and follow-up corrective actions.
• Communication and documentation practices between frontline staff and leadership.
• Family and resident satisfaction surveys regarding safety and quality of care.
• Financial and legal resources available to address litigation risk and compliance oversight.

  Communication and Relationship-Building: Essential for transparency with staff, residents, and families about safety concerns and corrective actions.

  Knowledge of the Healthcare Environment: Understand regulatory and compliance requirements related to Sentinel events in SNFs.

  Business Skills and Principles: Evaluate legal, financial, and operational implications of safety failures.

  Leadership: Guide culture change to make patient safety a shared responsibility across all staff levels.

Agency for Healthcare Research and Quality (AHRQ). (2022). Fall Prevention in Hospitals: A Toolkit for Improving Quality of Care. AHRQ. https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit.html

Joint Commission. (2021). Sentinel event policy and procedures. Joint Commission. https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event

• Nurse executives must integrate safety priorities into organizational culture.
• Competencies require ethical leadership in transparent reporting of adverse events.
• Building accountability and trust with staff supports consistent policy implementation.

AHRQ (2022)

• Standardized fall prevention bundles reduce variability in care delivery.
• Ongoing staff education, monitoring, and audits sustain compliance.
• Leadership engagement is critical in implementing sustainable fall prevention programs.

Joint Commission (2021)

• Sentinel events require immediate investigation and reporting.
• Root cause analysis identifies system vulnerabilities rather than individual blame.
• Corrective actions and sustained monitoring must be documented to maintain compliance.

• Report the Sentinel event transparently, despite potential reputational and financial consequences.
• Hold staff and managers accountable for noncompliance, even when it may cause conflict.
• Advocate for additional resources or staffing adjustments to support consistent safety bundle implementation.
• Communicate openly with families about safety concerns and corrective actions, maintaining trust in difficult circumstances.
• Lead culture change toward a proactive rather than reactive approach to patient safety, despite resistance or pressure to minimize issues.

• The setting is a large multi-state, faith-based level II trauma health system with ten hospitals and over 160 physician clinics.
• A newly graduated nurse (only 1.5 years out of nursing school) was promoted to Unit Manager for the neurology/neurosurgery unit.
• Initial mentorship from the outgoing supervisor was cut short due to her early departure.
• The Unit Manager lacks leadership experience and formal preparation for managing a team.
• The team of ten registered nurses has shown disregard for her authority.
• Morale and unit effectiveness have declined.
• The Unit Manager attempts to be approachable by joking, helping with tasks, and fulfilling schedule requests but struggles to balance authority and rapport.
• The Director has intervened due to concerns about conflict and team dysfunction.

  Information on team culture and the history of conflict within the unit prior to the leadership change.

  Clarity on organizational expectations for a Unit Manager role in terms of authority, accountability, and performance metrics.

  Data on patient outcomes, staff turnover, and unit-specific quality measures since the leadership transition.

  Availability of internal or external leadership development resources, such as coaching, AONL programs, or mentorship opportunities.

  Understanding of the Director’s support plan and resources allocated for new leaders.

  Communication and Relationship-Building: Establishing credibility and trust through professional communication, active listening, and consistent follow-through.

  Professionalism: Modeling integrity and accountability in decision-making and conflict resolution.

  Knowledge of the Healthcare Environment: Understanding how leadership decisions directly affect morale, team functioning, and ultimately patient care outcomes.

  Business Skills and Principles: Applying time management, staffing strategies, and organizational tools to balance patient needs with staff dynamics.

Cummings, G. G., Tate, K., Lee, S., Wong, C. A., Paananen, T., Micaroni, S. P. M., & Chatterjee, G. E. (2021). Leadership styles and outcome patterns for the nursing workforce and work environment: A systematic review. International Journal of Nursing Studies, 115, 103842. https://doi.org/10.1016/j.ijnurstu.2020.103842

Shirey, M. R. (2022). Building leadership capacity in novice nurse managers: Essentials for success. Journal of Nursing Administration, 52(4), 187–193. https://doi.org/10.1097/NNA.0000000000001126

• Nurse leaders must build credibility through clear communication and consistent accountability.
• Competencies highlight the balance between relationship-building and authority in leadership roles.
• Developing staff engagement fosters improved morale and performance.

Cummings et al. (2021)

• Transformational leadership is associated with better staff morale, retention, and patient outcomes.
• Authoritarian approaches often increase conflict and decrease satisfaction.
• Supportive leadership styles improve collaboration and trust within teams.

Shirey (2022)

• Novice nurse managers need structured mentorship and professional development to succeed.
• Role clarity, feedback, and skill-building are critical in early leadership transitions.
• Leadership capacity grows through intentional reflection and ongoing learning opportunities.

  Advocate for leadership development resources despite possible financial or time constraints.

  Address staff resistance directly by setting expectations for professionalism and respect toward the Unit Manager.

  Uphold accountability when performance issues arise, balancing fairness with support for novice leaders.

  Demonstrate integrity by prioritizing patient care and team function over convenience or avoidance of conflict.

You will help facilitate discussion and an action plan, but it will be the committee’s responsibility to put the action plan in place. What suggestions, opportunities, and ideas for education will you provide to the committee?

  Vacancy rates have caused unsafe staffing ratios in several units.

  Reliance on agency and travel nurses has strained budgets.

  Patient satisfaction scores are trending downward.

  Morale among permanent staff is low, with reports of burnout and limited support.

  Competing hospitals in the region are aggressively recruiting with higher pay and flexible options.

  Detailed breakdown of unit-specific vacancy and turnover rates.

  Financial impact of turnover, including recruitment, training, and agency costs.

  Effectiveness of current retention initiatives such as mentorship programs, tuition reimbursement, and career advancement pathways.

  Data on overtime, absenteeism, and staff injury rates.

  Feedback from staff on desired incentives or workplace improvements.

  Leadership: Creating a supportive culture that values staff contributions and emphasizes professional growth.

  Knowledge of the Healthcare Environment: Understanding workforce trends, market competition, and generational differences in nursing.

  Professionalism: Modeling integrity and accountability in addressing turnover transparently.

  Business Skills and Principles: Analyzing costs of turnover and building a financial case for investing in retention programs.

Sharma, N., & Rani, R. (2022). Nurse retention strategies: A review of current practices. Journal of Nursing Management, 30(5), 1121–1130. https://doi.org/10.1111/jonm.13569

Brook, J., Aitken, L., Webb, R., MacLaren, J., & Salmon, D. (2021). Characteristics of successful interventions to reduce turnover and increase retention of early career nurses: A systematic review. International Journal of Nursing Studies, 115, 103834. https://doi.org/10.1016/j.ijnurstu.2020.103834

• Nurse executives must lead initiatives that align workforce stability with patient care quality.
• Effective communication with staff fosters trust and retention.
• Retention strategies must integrate financial stewardship with staff well-being.

Sharma & Rani (2022)

• Flexible scheduling, recognition programs, and career development opportunities improve retention.
• Mentorship and supportive leadership reduce turnover among new nurses.
• Positive work environments encourage loyalty and reduce burnout.

Brook et al. (2021)

• Structured orientation, preceptorship, and residency programs reduce turnover in early-career nurses.
• Supportive leadership is consistently linked to higher retention rates.
• Interventions that combine education, career pathways, and mentorship are most successful.

  Confront systemic issues such as poor scheduling practices or unsupportive work culture, despite resistance.

  Be transparent with staff about challenges while committing to meaningful solutions.

  Hold managers accountable for fostering supportive environments that prioritize nurse well-being.

  Balance the need for financial stewardship with the ethical responsibility to protect staff morale and patient safety.

  Resident with dementia and Parkinson’s disease wandered outside unsupervised due to back door being left ajar.

  Staff reported as “grumpy,” inattentive, and too busy to answer call lights.

  Chronic short staffing is identified by family members.

  Reports of night nurses sleeping during shifts and spending time outside smoking.

  The resident described the facility as “a miserable place to exist,” reflecting a poor perception of quality of life.

  Family dissatisfied with communication and concerned about poor quality of care.

  Nurse executive had directed removal of the resident without fully investigating the incident.

  The daughter plans to report concerns to state regulators, which could raise the risk of compliance citations, reputational damage, and litigation.

  Internal incident reports related to resident elopement, staff misconduct, or quality-of-care complaints.

  Documentation of prior family complaints or grievances.

  Details of training for dementia and Parkinson’s disease care.

  Facility policies for elopement prevention, call light response, and staff accountability.

  Food service and nutrition quality review records.

  Leadership communication processes and documentation of family interactions.

  Data on prior state inspections, survey deficiencies, and corrective actions.

  Communication and Relationship-Building: Rebuild trust with families and staff through transparency and engagement.

  Professionalism: Model accountability and integrity by addressing failures openly.

  Knowledge of the Healthcare Environment: Understand state regulatory expectations and the implications of family complaints.

  Leadership: Drive culture change to prioritize resident dignity, safety, and staff professionalism.

Agency for Healthcare Research and Quality (AHRQ). (2022). Nursing home patient safety culture survey. AHRQ. https://www.ahrq.gov/sops/surveys/nursing-home/index.html

The Joint Commission. (2022). Comprehensive accreditation manual for nursing care centers. The Joint Commission. https://www.jointcommission.org/standards/nursing-care-center-standards/

• Nurse executives must hold staff accountable for professionalism and quality of care.
• Communication with families and regulators is essential during safety crises.
• Leadership is required to align organizational culture with patient safety priorities.

AHRQ (2022)

• Safety culture surveys help identify weak areas in nursing home care.
• Staff engagement and leadership support improve compliance with safety protocols.
• Strong safety culture reduces incidents of harm and increases family confidence.

The Joint Commission (2022)

• Accreditation requires systems to prevent elopement and ensure resident dignity.
• Facilities must have processes to investigate, report, and correct safety failures.
• Leadership accountability is central to compliance and quality improvement.

  Report the incident accurately to regulators, despite potential financial or reputational harm.

  Communicate transparently with the resident’s family and acknowledge system failures.

  Advocate for resources to improve staffing, training, and safety systems despite cost pressures from ownership.

  Lead a cultural shift away from tolerance of unprofessional behaviors toward accountability and respect for residents.

Cybersecurity was a topic of concern brought forward by a member of the hospital governing board at a recent hospital board meeting.  This member had read briefly about recent increases in cybersecurity threats to healthcare organizations and the consequences of disrupted business operations, data leaks, monetary loss, and patient safety issues. Overall, leadership had limited insights to offer regarding the point of cybersecurity during the meeting.  The member’s superficial understanding of cybersecurity threats in healthcare raised concerns about the strengths, weaknesses, opportunities, and threats of cybersecurity within the organization and a desire to know more about the topic in general and related to the organization specifically.

The topic of the meeting was leaked to the press, and you are fielding calls from the media requesting a statement on the presumed inadequacies of your organization’s ability to keep health and financial documents secure from hackers.

• The organization is a large, not-for-profit, integrated healthcare system with 4,700 employees, 550 providers, and a 304-bed hospital.
• System includes multiple clinics across a tristate area and seven additional communities.
• COVID-19 pandemic increased remote work and telehealth visits, creating new vulnerabilities.
• A hospital board member has raised cybersecurity risks after reading about national healthcare breaches.
• Leadership demonstrated limited awareness or preparation to address cybersecurity during the board meeting.
• The Board has requested a comprehensive report on cybersecurity at the next meeting.
• The topic was leaked to the media, raising reputational risks and external pressure.
• Concerns include potential threats of data breaches, financial losses, disrupted operations, and patient safety.

  History of attempted or successful cyberattacks within the organization.

  Benchmarking against best practices and national standards (HIPAA, NIST, HHS guidance).

  Vendor management practices, including telehealth platforms and electronic health record systems.

  Staff training and compliance rates with cybersecurity protocols.

  Resources allocated for IT security, including budget and staffing levels.

  Insurance coverage for cyber incidents.

  Media and communications plan for handling external inquiries.

• Knowledge of the Healthcare Environment: Understanding regulatory standards, compliance requirements, and risks related to data security.
• Leadership: Guide organizational awareness and prioritize cybersecurity as a patient safety and quality issue.
• Communication and Relationship-Building: Collaborate with IT, executives, staff, and board members to strengthen trust and align strategies.
• Professionalism: Maintain transparency and integrity when engaging with staff, patients, and the media.
• Business Skills and Principles: Balance cybersecurity investments with organizational financial stewardship while demonstrating the cost of inaction.

U.S. Department of Health and Human Services (HHS). (2023). Health industry cybersecurity practices (HICP): Managing threats and protecting patients. HHS. https://405d.hhs.gov/public/materials/hicp

Ponemon Institute. (2023). The impact of ransomware on healthcare during the COVID-19 pandemic and beyond. Proofpoint. https://www.proofpoint.com/us/resources/white-papers/ponemon-ransomware-healthcare

• Nurse executives must recognize cybersecurity as an essential component of patient safety.
• Collaboration across executive teams ensures coordinated responses to system vulnerabilities.
• Leaders must maintain professionalism in responding to crises that impact trust and safety.

HHS (2023)

• Five key threat areas include phishing, ransomware, loss/theft of equipment, insider threats, and attacks against connected medical devices.
• Leadership must prioritize cybersecurity awareness and workforce education.
• Cybersecurity is directly tied to patient safety, care continuity, and compliance.

Ponemon Institute (2023)

• Ransomware attacks in healthcare have increased significantly since COVID-19.
• Cyber incidents result in care delays, increased mortality risk, and financial losses.
• Strong security frameworks and investments reduce long-term costs and operational disruptions.

  Advocate for increased investment in cybersecurity infrastructure despite budget constraints.

  Confront gaps in leadership knowledge and initiate education at the executive and board level.

  Hold staff accountable for cybersecurity training compliance, even if there is resistance.

  Acknowledge the organization’s vulnerabilities openly while committing to corrective action, despite reputational risks.

The organization utilizes a contracted agency for security services. The security office is located in the emergency department, which is a locked unit. There are two security officers on duty during business hours and one security officer after hours. The security officers are unarmed with responsibilities to the whole hospital campus.

Several incidents of workplace violence have been reported over the last two years.  These incidents have included:

·         A patient who was denied a prescription for narcotics waited outside the ED in a vehicle with two other individuals until the nurse practitioner who had evaluated the patient had ended her shift and departed the building. The patient and other individuals rapidly approached, from their car, the nurse practitioner as she was walking across the parking lot. They were shouting and demanding an explanation.  In this instance, the provider convinced the discharged patient to return to the ED. She provided a prescription for a small number of hydrocodone which satisfied the patient and dissipated the situation.

·         A patient was evaluated for chronic low back pain. The provider assessed the patient, left the room to review the medical record, and returned to the patient’s room to find the patient cleaning out his fingernails with a 10-inch blade knife. The patient was not aggressive but otherwise manipulative in demanding that he require pain medication. The patient was discharged with a prescription for a muscle relaxant and #10 hydrocodone.

·         A young woman was brought to the ED after a witnessed cardiac arrest and was pronounced dead after nearly an hour of resuscitative efforts. When the nurse went to the waiting room to bring the family back to the department, the mother punched the nurse.

·         An estranged partner of a single postpartum woman presented unannounced on the maternal-child floor after evening change of shift.  He became belligerent and loud when the nursing staff refused to disclose which room the patient and baby were located. He proceeded to knock papers and technology off counters and started banging on patient doors up and down the hall. Security was paged, and by the time they arrived 5 minutes later, the enraged visitor had vacated the building.

·         A nurse reports to the unit manager that she has received repeated accusatory communications from a peer recently fired from her position. In these communications, the disgruntled past employee is faulting the nurse for the events leading up to her termination. The tenor of each communication escalates and eventually becomes threatening. The terminated nurse presents to the hospital front desk, is warmly greeted, and subsequently welcomed to visit the hospital floor where she was terminated. Once on the floor, she begins visiting patient rooms and presenting herself as a nurse until staff recognizes her presence and behavior.  When asked to leave, she became agitated and shouted out, “I will be back to take care of you all”. After which, she left the floor, and her whereabouts were unknown for several hours. Eventually, security staff observed from a surveillance tape that she had left the hospital’s front doors two hours after the incident. However, it is unknown where she was within the facility for two hours after the verbal exchange and before she departed from the facility.

·         An ED physician was recently attacked by a patient under the influence of illicit drugs and nearly “choked out” before colleagues recognized the altercation and intervened.  The physician had no long-term physical implications as a result of the incident.

A bill introduced to the state legislative assembly to attack a healthcare worker as a felony was recently defeated.

  Rising staff injuries and sick leave related to violent encounters.

  Higher turnover rates linked to unsafe work environments.

  Reports of lateral violence and bullying among staff.

  Declining morale and patient satisfaction tied to unsafe conditions.

  Lack of consistent reporting and follow-up on incidents.

  Minimal staff training on de-escalation techniques and violence prevention.

• Incident reporting data: frequency, severity, and locations of violent events.
• Review of staff safety policies, security presence, and current training programs.
• Benchmark data on workplace violence in comparable hospitals.
• Employee perception surveys regarding safety and organizational support.
• Legal, OSHA, and regulatory requirements for workplace safety compliance.
• Financial costs associated with staff turnover, injury claims, and liability.
• Community crime statistics and their impact on patient and visitor behavior.

  Communication and Relationship-Building: Foster transparent communication channels for staff to report safety concerns without fear.

  Knowledge of the Healthcare Environment: Apply evidence-based practices for violence prevention and understand OSHA/regulatory compliance requirements.

  Professionalism: Demonstrate accountability and integrity in prioritizing staff and patient safety.

  Business Skills and Principles: Allocate financial resources to enhance security, training, and staffing for violence prevention.

Occupational Safety and Health Administration (OSHA). (2021). Guidelines for preventing workplace violence for healthcare and social service workers. OSHA. https://www.osha.gov/workplace-violence/healthcare-social-service

The Joint Commission. (2022). Workplace violence prevention standards. The Joint Commission. https://www.jointcommission.org/standards/workplace-violence-prevention-standards

• Nurse executives must lead in building a culture of safety and accountability.
• Communication and engagement with staff strengthen reporting and compliance.
• Professional integrity requires consistent follow-through on safety initiatives.

OSHA (2021)

• Healthcare workers face the highest rates of workplace violence among U.S. industries.
• Prevention requires environmental controls, staff training, and administrative policies.
• Strong reporting systems support risk identification and mitigation.

The Joint Commission (2022)

• Hospitals must implement workplace violence prevention programs as part of accreditation.
• Standards emphasize leadership accountability, incident reporting, and staff support.
• Training in de-escalation and response strategies is essential for compliance and safety.

  Confront cultural tolerance of bullying or lateral violence among staff.

  Communicate transparently with staff and patients about safety concerns while demonstrating accountability.

  Report unsafe practices and incidents openly to regulators, despite reputational risks.

  Support staff who experience violence, ensuring their voices are heard and acted upon.

The nurse presents in her work uniform and tearfully reports that she was unsure of what to do with her information about the share. She says that a patient, who was well-established with the physician she works with, presented for an appointment this morning. This patient has a stage IV colon cancer diagnosis, lives alone, and has been declining in the last three months.  He requested assistance with dying. The physician agreed she would help him and instructed him to have prescriptions available for him at his pharmacy tomorrow. The physician ordered the nurse to complete the necessary paperwork for her to sign and subsequently for the nurse to fax to the pharmacy. At this point of the discussion with the CNO, the nurse is overridden with emotion and reports she cannot follow this physician order because of her moral convictions. What is your immediate course of action and subsequent plans of action?

  Colorado is a state where medical aid in dying (MAID) is legal under the End-of-Life Options Act.

  The patient is a stage IV colon cancer patient, lives alone, and has experienced significant decline.

  The physician ordered the nurse to complete paperwork to facilitate MAID, but the nurse refused due to moral convictions.

  The nurse escalated her concerns to the CNO, expressing emotional distress and moral conflict.

  There is a direct conflict between state law (permitting MAID) and the Catholic health system’s ERDs (prohibiting participation in assisted dying).

  The incident raises risks of regulatory, legal, ethical, and reputational consequences.

  Clarification of Colorado’s End-of-Life Options Act requirements and protections for providers who opt out due to conscience.

  Ethics committee guidance on how to handle cases involving requests for assisted dying in a Catholic-sponsored hospital.

  Information on whether the physician’s actions align with hospital policy and national system guidelines.

  Documentation of communication with the patient, including informed consent, prognosis, and palliative options discussed.

  Emotional and professional support resources for the nurse who reported moral distress.

  Risk assessment of potential media, legal, or regulatory scrutiny.

  Leadership: Provide guidance in navigating ethically complex cases involving conflicting moral, legal, and religious frameworks.

  Communication and Relationship-Building: Collaborate with the ethics committee, medical staff, and leadership to ensure clarity and support.

  Knowledge of the Healthcare Environment: Understand state laws on MAID, federal regulations, and Catholic directives.

  Advocacy: Support nurses experiencing moral distress while balancing organizational and patient care priorities.

National Catholic Bioethics Center. (2022). Ethical and Religious Directives for Catholic Health Care Services. United States Conference of Catholic Bishops. https://www.ncbcenter.org/resources

Colorado Department of Public Health & Environment (CDPHE). (2023). End-of-Life Options Act. CDPHE. https://cdphe.colorado.gov/end-of-life-options-act

• Nurse executives must lead with professionalism and uphold organizational values.
• Ethical leadership is required in situations of moral conflict.
• Relationship-building fosters trust between leadership, clinicians, and staff in sensitive cases.

National Catholic Bioethics Center (2022)

• Catholic health care facilities are prohibited from participating in medical aid in dying.
• Alternative care options such as palliative and hospice care must be provided.
• Leadership must safeguard the conscience rights of staff aligned with Catholic values.

CDPHE (2023)

• MAID is legal in Colorado under strict eligibility criteria.
• Participation is voluntary; providers and institutions may decline involvement.
• Patients must still have access to information and referral pathways if care is declined at a specific institution.

  Confront the physician’s directive if it violates Catholic ERDs and hospital policy, even if it causes professional conflict.

  Communicate clearly with the ethics committee, executive leadership, and staff about the hospital’s stance and legal responsibilities.

  Uphold the integrity of Catholic values while ensuring the patient receives appropriate care, such as referral to non-Catholic providers who can legally provide MAID.

  Balance transparency with sensitivity when addressing potential concerns from regulators, patients, families, and the public.