NR 703 Week 7 Diagnostic Case Paper Example

Diagnostic Case Paper: Two Years of Station Report at the 07:00 Handoff on a Telemetry Unit, Three Competing Accounts and the One the Evidence Favors

Student Name

College of Nursing, Chamberlain University

NR 703: Applied Organizational and Leadership Concepts

Instructor Name

Month Day, Year

Diagnostic Case Paper: Two Years of Station Report at the 07:00 Handoff on a Telemetry Unit, Three Competing Accounts and the One the Evidence Favors

The Pattern

The problem is old, specific and well documented. Since at least the 2023 rollout of the bedside report policy, the telemetry unit's night-to-day handoff has happened mostly at the nurses' station, while the day-to-night handoff has happened mostly at the bedside. Two re-education campaigns, in 2023 and 2025, did not change it. A request for paid overlap time in 2024 stalled. A 90-day paid overlap pilot began on 14 September 2026.

Evidence, Before Any Reading

The evidence comes from audits, overtime reports, interviews and the unit's own history, each dated. Audits, clinical nurse specialist: 2023 after rollout, 07:00 bedside report in 9 of 40; 2025 after re-education, 10 of 40; summer 2026, 11 of 50. 19:00 bedside report in the same audits: 34 of 40, 35 of 40, 42 of 50.

Six unplanned overlap days in September 2026, when day nurses came early for orientation: 07:00 bedside report in 9 of 14.

First four weeks of the paid pilot, 14 September to 11 October 2026: 07:00 bedside report in 25 of 40 audited handoffs.

Overtime report: night nurses' average minutes past 07:30 were higher on days with any bedside report.

Newcomer accounts: new night nurses told to let patients sleep and to leave promptly.

Workflow: the morning medication pass and first laboratory draws begin at 07:00.

Three Competing Accounts

Each account below is stated in its strongest form before any is preferred. Culture. Night shift holds an assumption that letting patients sleep and leaving on time outrank bedside report, transmitted to newcomers and reinforced in night-only spaces (Schein & Schein, 2017). For: newcomer accounts, the whiteboard and card, re-education's failure. Against: nurses who work both shifts follow both rules depending on the handoff, which suggests the situation, not a shift identity, drives behavior.

Incentive. The organization counts overtime and not bedside report, so the behavior that protects the counted measure persists (Kerr, 1975). For: overtime minutes rise when bedside report happens, and bedside report rose sharply when overlap removed the overtime cost, both on unplanned days and in the pilot. Against: the pilot reached 25 of 40, not 40 of 40, so something besides overtime still holds the behavior back.

Workflow. The 07:00 medication pass and laboratory draws compete for the day nurse's attention, so report moves to where it is fastest. For: day nurses report being pulled away within minutes. Against: the pilot did not move the medication pass, yet bedside report rose, so workflow alone cannot explain the pattern.

The Part Where It Decides

A diagnosis has to choose, or it is only a list of possibilities. The incentive account holds most of the evidence. When the overtime cost was removed, without any change in culture or workflow, bedside report at 07:00 more than doubled, from 22% to about 62%. Re-education, which addressed culture directly, did not move it. The culture account explains why the remaining 38% persists: newcomers are still told not to wake patients, and that assumption did not change with the overlap. The workflow account explains part of the remainder too. The diagnosis is that the incentive is primary and the culture secondary, reproducing a behavior the incentive first produced. Workflow is a real but smaller contributor, and of the three it would cost least to change, explaining some of the handoffs that stayed at the station even with paid overlap, especially on days with early laboratory draws.

A Diagnosis That Can Fail

If, over the remaining weeks of the pilot, bedside report at 07:00 stays near 62% or falls, the incentive account explains less than claimed and culture or workflow carries more. If it rises above 75% without any further change, the incentive account is strengthened. If the pilot ends and bedside report falls back to the summer level within a month, the incentive account is confirmed and culture is shown to have followed, not led. Each outcome can be checked against the clinical nurse specialist's weekly audits, which will continue through the pilot and for one month after it ends. The final month's audits will be unannounced, so that the figures are less likely to reflect nurses performing for an observer.

What Has Already Been Tried, and What It Tells Us

Re-education in 2023 and 2025 targeted culture and knowledge; both left the 07:00 figure where it was. The 2024 overlap request targeted the incentive but never reached a decision. The 2026 pilot targeted the incentive and moved the figure. The pattern of what has and has not worked is itself evidence for the incentive account, since the only intervention that moved behavior was the one that changed the cost.

Why Three Accounts and Not One

A diagnosis that considers only one explanation usually confirms what the investigator already believed. Organizational problems are rarely explained by a single cause, and choosing an account before considering rivals risks the familiar error of fixing what the investigator already believed was wrong. Each account here has real support. The paper commits to one as primary because the evidence points there most strongly, not because the others are wrong. A reader who weighs the pilot's early figures differently could reasonably put culture first, and the paper's prediction about what happens when the pilot ends is the way to settle that disagreement.

What Would Change the Leader's Action

If the incentive account holds, the leader's first action after the pilot is to decide whether to fund the overlap permanently. If culture holds more than expected, the first action is work with the night nurses themselves on what bedside report at 07:00 should look like when patients are asleep, such as a brief visual check with both nurses rather than full report. If workflow holds more, the first action is to look at the medication pass time with pharmacy. Each action is reasonable; the diagnosis decides which comes first and saves the unit from trying all three at once.

What the Paper Does Not Claim

That bedside report at 07:00 improves outcomes on this unit; that is a separate question, though evidence from elsewhere suggests benefits for patient perceptions (Sand-Jecklin & Sherman, 2014). That the pilot should be made permanent; that is a decision, not a diagnosis.

References

Kerr, S. (1975). On the folly of rewarding A, while hoping for B. Academy of Management Journal, 18(4), 769-783. https://doi.org/10.2307/255378

Sand-Jecklin, K., & Sherman, J. (2014). A quantitative assessment of patient and nurse outcomes of bedside nursing report implementation. Journal of Clinical Nursing, 23(19-20), 2854-2863. https://doi.org/10.1111/jocn.12575

Schein, E. H., & Schein, P. (2017). Organizational culture and leadership (5th ed.). Wiley.