1

Care Setting Environmental Analysis: Wound Center

Alexandra Sanders

Capella University

NURS-FPX6210 Leadership and Management for Nurse Executives

Dr. Mary Ellen Cockerham

October 11, 2021

2

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

(SWOT) analysis.

Synthesizing Stories

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

3

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

4

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

5

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,

6

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

7

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

8

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.

Leadership Skills

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).

9

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

group

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.

Conclusion

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.

10

11

References

AI Commons. (2015). Appreciative inquiry commons – the appreciative inquiry commons. The

Appreciative Inquiry Commons. https://appreciativeinquiry.champlain.edu/

Amerine, J. P., Khan, T., & Crisp, B. (2017). Improvement of patient wait times in an outpatient

pharmacy. American Journal of Health-System Pharmacy, 74(13), 958–961.

https://doi.org/10.2146/ajhp160843

Caldwell, C. (2012). Moral leadership: A transformative model for tomorrow's leaders (strategic

management collection). Business Expert Press.

https://doi.org/https://www.businessexpertpress.com/books/moral-leadership-

transformative-model-tomorrows-leaders/

Halm, M. A., & Crusoe, K. (2018). Keeping the magnet flame alive with appreciative inquiry.

JONA: The Journal of Nursing Administration, 48(6), 323–328. https://doi.org/doi:

10.1097/NNA.0000000000000622

Hollingsworth, A., & Reynolds, M. (2020). The ED nurse manager's guide to utilizing SWOT

analysis for performance improvement. Journal of Emergency Nursing, 46(3), 368–372.

https://doi.org/10.1016/j.jen.2020.02.006

Indeed Editorial Team. (n.d.). Common weaknesses of transformational leadership and how to

avoid them. https://www.indeed.com. Common Weaknesses of Transformational

Leadership and How To Avoid Them

Le, V., Wagar, E. A., Phipps, R. A., Del Guidice, R. E., Le, H., & Middleton, L. P. (2019).

Improving patient experience of wait times and courtesy through electronic sign-in and

notification in the phlebotomy clinic. Archives of Pathology & Laboratory Medicine,

144(6), 769–775. https://doi.org/10.5858/arpa.2019-0139-oa

12

MacCoy, D. J. (2014). Appreciative inquiry and evaluation – Getting to what works. The

Canadian Journal of Program Evaluation, 29(2), 104–127.

https://doi.org/10.3138/cjpe.29.2.104

Strengths, weaknesses, opportunities, and threats. (2008). Journal of Oncology Practice, 4(2),

53–53. https://doi.org/10.1200/jop.0820501

Susan Trossman. (n.d.). Nursingald.com. nursingALD. https://www.nursingald.com/

Swysen, K., Lousbergh, B., Deneckere, S., & Vanhaecht, K. (2012). The use of a SWOT analysis

as a strategic management tool in mental health care. International Journal of Care

Pathways, 6(4), 146–151. https://doi.org/10.1258/jicp.2012.012009

The University of Alabama Huntsville. (n.d.). Transformational leadership in nursing.

https://online.uah.edu. https://online.uah.edu/articles/msn/transformational-

leadership.aspx

Trajkovski, S., Schmied, V., Vickers, M., & Jackson, D. (2013). Using appreciative inquiry to

transform health care. Contemporary Nurse, 45(1), 95–100.

https://doi.org/10.5172/conu.2013.45.1.95

Care Setting Environmental Analysis Scoring Guide

CRITERIA NON-PERFORMANCE BASIC PROFICIENT DISTINGUISHED

Synthesize stories and evidence about times when a care setting performed at its best with regard to quality and safety goals.

Does not list stories and evidence about times when a care setting performed at its best with regard to quality and safety goals.

Lists but does not synthesize stories and evidence, or fails to clearly relate stories and evidence to quality and safety goals.

Synthesizes stories and evidence about times when a care setting performed at its best with regard to quality and safety goals.

Synthesizes stories and evidence about times when a care setting performed at its best with regard to quality and safety goals. Identifies knowledge gaps, unknowns, missing information, unanswered questions, or areas of uncertainty (where further information could improve the synthesis).

Propose positive, attainable quality and safety improvement goals for a care setting.

Does not propose positive goals for a care setting.

Proposed goals are positive but not attainable, or will not lead to ethical and culturally sensitive improvement of organizational quality and safety, or are not clearly aligned with the care setting’s mission, vision, and values.

Proposes positive, attainable quality and safety improvement goals for a care setting.

Proposes positive, attainable quality and safety improvement goals for a care setting, and identifies assumptions on which proposed goals are based.

Conduct a SWOT analysis of a care setting, with respect to quality and safety goals.

Does not present the findings of a SWOT analysis of a care setting.

Conducts a SWOT analysis of a care setting that is not clearly focused on quality and safety goals.

Conducts a SWOT analysis of a care setting, with respect to quality and safety goals.

Conducts a SWOT analysis of a care setting, with respect to quality and safety goals, and impartially considers conflicting data and other perspectives.

Describe an area of concern identified in a SWOT analysis—relevant to a care setting's mission, vision, and values—that should be improved.

Does not describe an area of concern identified in a SWOT analysis that should be improved.

Describes an area of concern identified in a SWOT analysis, but does not show its relevance to a care setting's mission, vision, and values.

Describes an area of concern identified in a SWOT analysis—relevant to a care setting's mission, vision, and values—that should be improved.

Describes an area of concern identified in a SWOT analysis— relevant to a care setting's mission, vision, and values—that should be improved. Identifies criteria that could be used to evaluate such an improvement.

Compare the AI and SWOT approaches to analysis with regard to data gathering and interactions with others.

Does not describe data gathering and interactions with others.

Describes data gathering and interactions with others, but does not compare these activities using an AI and SWOT approach to analysis.

Compares the AI and SWOT approaches to analysis with regard to data gathering and interactions with others.

Compares the AI and SWOT approaches to analysis with regard to data gathering and interactions with others, and acknowledges one’s own assumptions and biases.

Analyze the leadership characteristics and skills most desired in the person leading potential

Does not analyze leadership characteristics and skills most desired in the person leading

Analyzes leadership characteristics and skills most desired in the person leading potential performance

Analyzes the leadership characteristics and skills most desired in the person leading p