NR 446 Week 3: sample paper, in real form

Hierarchy and Interruption at Bedside Handoff: An Interprofessional Communication Analysis on a Medical-Surgical Unit

Ava R. Delgado

Chamberlain University, College of Nursing

NR 446 Collaborative Healthcare

Professor K. Iverson, DNP, RN, CNL

Week 3

March 15, 2026

The Situation on 4 West

4 West is a 32-bed medical-surgical and telemetry unit inside a 240-bed community hospital, staffed at one nurse to five patients on days and one to six on nights. On a Tuesday night early in the session, a 68-year-old patient two days out from an open cholecystectomy showed a respiratory rate of 26, a heart rate of 112, and urine output of 15 milliliters per hour across two consecutive hours. The night nurse paged the on-call hospitalist, described the patient as looking tired, and asked whether anything should be ordered. The hospitalist said to keep monitoring. Three hours later the patient met rapid response criteria and moved to step-down with early sepsis. No order was ever refused, and no policy was broken.

What failed was not knowledge. The nurse had the numbers and had already run them against the unit's early warning criteria, which the patient met at the time of the call. What failed was the shape of the exchange. The concern went out as a description of appearance rather than as a set of measurements attached to a request, and when the hospitalist declined to act, the concern was not raised a second time. In a debrief three days afterward, the nurse said she had worked with that hospitalist for two years, had been told before that she called too often, and made a quiet calculation that a second call would cost her more than it would buy the patient.

The pattern is not confined to one night. Across four weeks the unit's shared governance council observed 96 bedside handoffs and found that 61 of them, or 64 percent, were interrupted at least once by a call light, a phone, or a passing colleague, and that a standardized format was used in only 38 of the 96. On the unit's most recent culture survey, 52 percent of nurses answered positively to the item asking whether staff feel free to question the decisions of those with more authority, down from 68 percent the year before. The rapid response that Tuesday was one event. The conditions that produced it are the unit's ordinary working conditions.

Naming the Barrier: An Authority Gradient the Handoff Process Does Not Correct

The barrier is an authority gradient that the unit's communication process leaves uncorrected. An authority gradient is the perceived distance in standing between two people in an exchange, and it predicts whether the person with less standing will restate a concern after a first refusal. The Joint Commission's review of handoff failures describes this same pairing of an unstructured exchange with a culture in which the receiver's answer ends the conversation (The Joint Commission, 2017). The gradient itself is not removable. Physicians and nurses carry different accountabilities and different training, and no unit policy will flatten that. What is removable is the silence the gradient produces when nothing in the process obliges a concern to be repeated in a form the receiver has to answer on the record.

Read against the collaborative practice competencies, the failure sits in communication rather than in roles or in values. Those competencies describe communicating with other health professionals in a responsive and responsible manner that supports a team approach, and they treat expressing one's own knowledge and opinions with confidence and respect as a trained behavior rather than a personality trait (Interprofessional Education Collaborative, 2023). The night nurse held the clinical picture and did not convert it into an assertion the hospitalist could decline only in writing. That is a skill gap the unit has never taught, not a character flaw, and skill gaps respond to structure in a way that character does not.

Two structures exist for exactly this and neither is in routine use on 4 West. The first is a standardized handoff format, which hands the receiver situation, background, assessment, and recommendation in a fixed order and closes with the sender stating plainly what is being requested (Agency for Healthcare Research and Quality, 2023). The second is a graded assertion script, which gives the sender permission to escalate language in steps and to say outright that a patient is unsafe when the first attempt does not land. Where both are trained and audited, the patient safety literature reports that breakdowns shift away from missing information and toward disagreements that at least surface in real time (O'Daniel & Rosenstein, 2008).

The Change I Am Committing To

My commitment is narrow on purpose. Starting this week, I will use a standardized format on every escalation call I make and close each one with an explicit request and a read-back, in this order: here is what I am seeing, here is what I believe is happening, here is what I am asking for, and please repeat back what we have agreed. I am not committing the unit to anything, because I do not have the standing to do that. I am committing the one behavior I control, on every call, and I have asked my charge nurse to hold me to it at our weekly check-in for the six weeks left in this session.

The second half of the commitment is the harder half. When a request is declined and my own reading of the patient has not changed, I will state the concern a second time in the language our escalation policy already supplies, that I am uncomfortable and that I believe this patient is unsafe, and if the second attempt does not move the plan I will activate the rapid response team, which our policy permits any nurse to do without a physician order. Fixing the words in advance matters more than it looks. In the debrief, the barrier was not that the night nurse lacked authority to escalate. It was that at two in the morning she had no sentence ready.

I will know whether this worked from three numbers I can collect myself. The first is the share of my own escalation calls that end in a read-back, which I will log for eight weeks and expect to hold above 90 percent. The second is the count of second attempts I make after a first decline, which needs only to be greater than zero to prove the script survives contact with a real night. The third is the unit's next culture survey item on questioning authority, which I will read as a unit signal and not a personal one. One nurse changing one behavior does not repair an authority gradient. It does establish at the bedside that a second attempt is normal.

References

Agency for Healthcare Research and Quality. (2023). TeamSTEPPS 3.0 pocket guide. U.S. Department of Health and Human Services. https://www.ahrq.gov/teamstepps-program/index.html

American Nurses Association. (2015). Incivility, bullying, and workplace violence [Position statement]. American Nurses Association. https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/

Interprofessional Education Collaborative. (2023). IPEC core competencies for interprofessional collaborative practice: Version 3. Interprofessional Education Collaborative. https://www.ipecollaborative.org/

O'Daniel, M., & Rosenstein, A. H. (2008). Professional communication and team collaboration. In R. G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses. Agency for Healthcare Research and Quality. https://www.ncbi.nlm.nih.gov/books/NBK2637/

The Joint Commission. (2017). Inadequate hand-off communication (Sentinel Event Alert No. 58). The Joint Commission. https://www.jointcommission.org/resources/sentinel-event/sentinel-event-alert-newsletters/