NR 670 Week 3 Leadership Episode Analysis Example

Leadership Episode Analysis: A Fifth Admission Offered to a Night Shift at 03:00, the Minute Before the Choice and What I Now Do Differently

Student Name

College of Nursing, Chamberlain University

NR 670: Advanced Nursing Leadership Concluding Graduate Experience

Instructor Name

Month Day, Year

Leadership Episode Analysis: A Fifth Admission Offered to a Night Shift at 03:00, the Minute Before the Choice and What I Now Do Differently

The Situation, Compressed

Saturday 15 August 2026, night shift, a 36-bed adult medical unit. I was the charge nurse. Six registered nurses for 34 patients, one nurse already at five patients. At 02:55 the emergency department called to give report on an 81-year-old admitted with pneumonia and new confusion.

The Minute Before the Choice

What I knew: every nurse already had five patients except one, who had four, including a patient on a heparin drip and a patient withdrawing from alcohol who had needed medication twice since midnight. The emergency department was holding three admitted patients and had asked twice for beds. The house supervisor had told me at 01:00 that no float nurses were available.

What I guessed: that the confused patient would need frequent checks and might try to climb out of bed. That the alcohol withdrawal patient would settle by 04:00 because the last dose had been given at 02:20.

What I could not find out: whether the on-call nurse would answer, since our on-call list for that weekend had one name and that nurse had worked the previous night.

The live options, as I saw them then:

First, accept the patient to the nurse with four patients, making five, including the heparin drip and the withdrawal patient. Fast, but it would put the most unstable patients with the most loaded nurse.

Second, accept the patient and redistribute: move the heparin drip patient to another nurse, making that nurse six, and give the new patient to the nurse with four. Spreads the risk but breaks the ratio our unit had agreed to avoid.

Third, ask the emergency department to hold the patient until 07:00 and call the on-call nurse. Safer on the unit but leaves a confused 81-year-old in the emergency department for four more hours.

My Reasoning at the Time

I thought the withdrawal patient was the deciding factor. If that patient escalated, the nurse caring for them would be tied up, and a newly admitted confused patient on the same assignment would be unsafe. I thought a confused older patient was also at risk in a busy emergency department, where delirium tends to worsen. I believed, wrongly as it turned out, that the on-call nurse would not answer.

Who Actually Decided

I did, as charge nurse, though the house supervisor could have overruled me and the emergency department charge nurse influenced me by saying the patient was "pulling at lines." I chose the second option: accepted the patient, moved the heparin patient to a nurse with lighter patients, making that nurse six, and gave the new admission to the nurse with four. I told the house supervisor and documented the assignment.

What Happened

The new patient arrived at 03:40, confused but calm. At 04:15 the withdrawal patient became agitated and needed two nurses for twenty minutes. The nurse with six patients missed a 05:00 heparin level draw by forty minutes. No harm came to any patient. The on-call nurse, whom I called at 05:30 out of frustration, answered on the first ring and could have come in by 04:00.

A Fence Around Later Knowledge

I now know the on-call nurse would have answered and the withdrawal patient would escalate. I did not know either at 03:00. Judging the choice by what I learned at 05:30 would be unfair to the decision; judging the process is fair. The process had a gap: I acted on a guess about the on-call nurse instead of testing it, and the call would have taken one minute.

Revision, as Changed Practice

Since that night I call the on-call nurse before deciding, every time an admission would push any nurse past five patients, even if I expect no answer. I keep a note at the charge desk of who is on call and whether they worked the night before. Twice since August, the on-call nurse came in, and on both nights no nurse carried more than five patients.

I also changed how I weigh a patient in alcohol withdrawal: I now treat them as unstable until a full withdrawal score is low on two consecutive checks an hour apart, rather than judging from the time since the last dose.

What Others Would Say

The nurse who took six patients said afterward that the redistribution was fair but that they would rather have been asked than told. I have since asked before moving patients, which takes a minute and changed how the moves are received. Teams speak up more when leaders invite it (Edmondson, 1999).

What the House Supervisor Said

The house supervisor reviewed the night with me on 18 August. The supervisor said the redistribution was defensible but that a sixth patient should have triggered a call to the supervisor before, not after, and that the supervisor could sometimes find a nurse from another unit that a charge nurse cannot see. That became a line in the checklist I later drafted. It also showed me that my picture of the options was narrower than the hospital's: I listed three options, and the supervisor could have added a fourth.

How I Would Weigh the Options Now

With the on-call nurse tested, option three becomes realistic: hold the patient for under an hour and bring in help. Without that test, option two was a reasonable choice under uncertainty. The quality of the decision depended less on choosing well among the options than on widening the set of options before choosing. Leadership research links relational, consultative styles with better outcomes for staff (Cummings et al., 2018), and asking more people before deciding is a small version of that.

What This Episode Says About My Leadership

That I decide under time pressure without testing the assumption that matters most. The fix is procedural, not personal: test the cheapest unknown first. A one-minute phone call would have changed the options at 03:00, and the checklist I later drafted, with the night charge nurses, puts that call at the top so that no charge nurse has to remember it under pressure. Charge nurse decisions about assignments shape nurse workload and, through it, patient outcomes, which research on nurse staffing links to mortality (Aiken et al., 2014).

References

Aiken, L. H., Sloane, D. M., Bruyneel, L., Van den Heede, K., Griffiths, P., Busse, R., Diomidous, M., Kinnunen, J., Kózka, M., Lesaffre, E., McHugh, M. D., Moreno-Casbas, M. T., Rafferty, A. M., Schwendimann, R., Scott, P. A., Tishelman, C., van Achterberg, T., & Sermeus, W. (2014). Nurse staffing and education and hospital mortality in nine European countries: A retrospective observational study. The Lancet, 383(9931), 1824-1830. https://doi.org/10.1016/S0140-6736(13)62631-8

Cummings, G. G., Tate, K., Lee, S., Wong, C. A., Paananen, T., Micaroni, S. P. M., & Chatterjee, G. E. (2018). Leadership styles and outcome patterns for the nursing workforce and work environment: A systematic review. International Journal of Nursing Studies, 85, 19-60. https://doi.org/10.1016/j.ijnurstu.2018.04.016

Edmondson, A. (1999). Psychological safety and learning behavior in work teams. Administrative Science Quarterly, 44(2), 350-383. https://doi.org/10.2307/2666999