Ashley just accepted a job as nurse manager for the ortho-neuro unit of a large community hospital. She recently graduated with her master's degree in nursing with an emphasis on nursing leadership in healthcare settings. Excited about the new role and opportunities to influence positive changes on a nursing unit, Ashley was not at all concerned when the human resources officer mentioned that the last three managers on the ortho-neuro unit left the position after 12 to 18 months. Ashley had lots of clinical experience, and now armed with all that she had learned in graduate school, she was confident that she would be able to handle the management of the 32-bed unit with a staff consisting of 120 full- and part-time employees. The human resources officer had told her that half of the staff were long-term employees, but the other half were fairly new to the unit. There seemed to be a lot of turnover among newer employees, but the long-term employees had worked on the unit an average of 20 years. Ashley had aspirations of leading her unit in collaborative governance and hopefully influencing other directors and managers to begin the Magnet journey.

During her first few weeks in the role, Ashley discovered a lot of facts about the staff and the care delivery model. With a nurse-to-patient ratio of one nurse to four patients and one nursing assistant for every eight patients, the unit seemed to be reasonably staffed for the expected workload required for patient care. She also discovered that only 35% of the nurses were prepared at the baccalaureate level, 55% had attained an associate's degree, and 10% had a diploma in nursing. There was a strong ethnic mix as well, with nearly 30% of the nurses educated in foreign countries such as the Philippines (20%) and India (10%) and others who were second-generation immigrants from the Philippines (30%), the Middle East (10%), Canada (7%), and Germany (3%) educated in the United States. The remaining 20% were American born and educated. Ashley also discovered that the unit was experiencing a higher than hospital and national average rate for hospital-acquired infections (HAIs), patient falls, and medication errors. Nurse satisfaction levels were the lowest of all of the nursing units at the hospital, and if this was not enough, the patient and physician satisfaction levels were also lower than the hospital average. Ashley was surprised by these quality indicators, but she attributed the poor performance to the need for a consistent, strong, and visionary leader who would inspire the staff to work together and improve these quality indicators. She felt up to the challenge to transform this staff and voiced this commitment to excellence to nurses at her first staff meeting. After an energetic and inspiring "state of the union" address accompanied by her vision for the future, Ashley was a bit surprised that the staff remained absolutely stoic and had no response to her plans to develop a collaborative governance structure with unit councils providing staff input into decisions affecting nursing and patient care. Perhaps it was because she was new?

Over the course of a few months, Ashley tried to establish a Unit Practice Council (UPC) and a Research and Evidence-Based Practice (REBP) Council, but few of the staff volunteered to participate on either of the councils. Ashley sought a handful of nurses who she believed would be strong leaders and talked with them about her vision for empowering the nurses through council involvement. She was shocked to hear a resounding "no" from the nurses, who shared that they were afraid to participate. The repetitive answer from many of the nurses was "I only want to work my job and go home." As Ashley inquired more and more, she discovered that the staff were extremely fractionated into cultural groups who did not like to integrate or communicate any more than absolutely necessary with other cultural groups. Not only were the nurses in firm social cliques, but the more senior nurses on both shifts had first preference for scheduling, patient assignments, and lunch breaks. They refused to take assignments to orient new personnel or to be preceptors for nursing students. Because they were such a powerful group, they seemed to make the decisions for all of the staff. If any of the nurses from other cultural groups voiced a complaint, they were the ones who were canceled first for scheduled or overtime shifts or received the most difficult patients for an assignment.

Ashley learned that there was often open conflict among the nurses with name calling, accusations, threats, and retaliations. Evening shift nurses accused day shift nurses of being "lazy," not completing patient care assignments, or leaving the bulk of work to the evening/night shift nurses. Day shift nurses complained that night nurses were "sleeping on the job" and not properly assessing patients or documenting appropriately. To make matters worse, several of the physicians joined in with their own complaints and accusations that "these nurses are the worst of any unit in the entire hospital," "they don't know anything about ortho-neuro patients," and "they call all hours of the night for trivial things." After a few weeks of hearing all the complaints from multiple sources, seeing the negative unit quality indicators, and refereeing a number of conflicts among nurses and physicians, Ashley felt completely overwhelmed. She mentioned to a comanager, "I feel like the man in the circus who spins plates on a bunch of poles all at once. He has to keep dancing around just to keep a plate from falling down and breaking."

AShley tried many of the ideas she had learned in class about managing interpersonal conflict, using change theories as a framework for change and leading intergenerational and intercultural workgroups. She met with nurses individually and in groups. She tried todevelop a shared vision of what the future could be. She reread the chapter "Toxic Organizations and People" in Quantum Leadership and tried to remember class discussions of others who had witnessed similar situations in their clinical experiences. She remained confident that collaborative governance would be the best option for correcting many of the problems on the unit.

The entire unit of nurses seemed reluctant to change and seemed to have absolutely no interest in a collaborative governance structure. Because the hospital was under a union collective bargaining contract for nursing, the union shop steward, Angelina, asked for a meeting with Ashley.

Angelina explained that the nurses as a collective whole did not support moving to a collaborative governance structure, nor did they want input into unit decisions. "This is the job of management and not of staff nurses," Angelina explained, and she advised Ashley to cease from trying to change the unit.

Ashley faces huge and complex challenges with her new role as nurse manager. It is clear to her that change is critically needed to ensure optimal patient outcomes and to develop a work environment that is safe and healthy for the nursing staff.

1. How would you describe the various issues that complicate the case. How are these issues interrelated?

2. Try to Take on the role of Ashley, and describe how you might manage this situation and transform the unit.