NUR 684 Module 6 Lateral Integration Paper Example

Leading Without Authority: Lateral Integration for a Heel Pressure Injury Bundle

[Student Name]

Southern New Hampshire University

NUR 684: Clinical Nurse Leader Capstone

Module Six Lateral Integration Paper

[Instructor Name]

[Date]

Leading Without Authority: Lateral Integration for a Heel Pressure Injury Bundle

A clinical nurse leader on the orthopedic floor at Clearwater General supervises no one. Yet the heel pressure injury bundle depends on six groups changing what they do: emergency department nurses checking heels on arrival, unit nurses and assistants offloading and repositioning, physical therapists replacing boots after sessions, the dietitian seeing patients within a day, the wound nurse joining rounds and hospitalists responding to early skin changes. This paper describes how the CNL will integrate these groups laterally, drawing on research about microsystem teams, the CNL role and structured communication.

Interdependence in the Microsystem

Interdependence ran through the best front-line units Nelson et al. (2002) studied: staff understood how their work affected one another's, relied on each other and designed processes around the patient rather than around departmental boundaries. In lower-performing units, each discipline completed its own tasks without seeing how the handoffs between them shaped outcomes.

The unit's heel injuries show the second pattern. The emergency department's job ends at transfer; the therapist's session ends when the patient returns to bed; the dietitian works from a queue. Each does good work, but nobody watches the heel across those boundaries. The CNL's task is to make the interdependence visible and give the groups a shared routine.

The CNL as Lateral Integrator

Bender (2014) describes the CNL as a master's-prepared clinician who remains at the point of care and integrates care across disciplines and settings for a population of patients. In the studies she reviewed, CNLs improved outcomes largely by coordinating teams, translating evidence into practice and using data to hold processes accountable, not by supervising staff. The literature also identified challenges, including role confusion and a lack of protected time, when organizations did not define the role clearly.

For this project, lateral integration means three things. The CNL convenes a team that includes each group. The CNL translates the evidence into simple routines each group can own. And the CNL tracks and shares data so that each group sees its contribution to the outcome. The nurse manager has clarified the CNL's role at a staff meeting and protected four hours a week for project work, addressing the role confusion Bender describes.

Weekly Interdisciplinary Skin Rounds

The main integrating routine is a twenty-minute skin round every Tuesday and Friday morning. The CNL, the wound nurse, a physical therapist, the dietitian when available and the patient's nurse visit every hip fracture patient and anyone scoring 18 or below. At each bedside, the team looks at both heels, checks boot placement and straps, reviews the repositioning plan and nutrition status and agrees on one action if anything is off. The hospitalist is briefed afterward by message. Rounds replace, rather than add to, separate wound consults for early-stage concerns, which the wound nurse welcomed because it lets her cover four units more efficiently.

A Shared Language: SBAR for Heel Concerns

Haig et al. (2006) describe how a hospital adopted SBAR, a four-part way of laying out a concern, covering what is happening now, the relevant history, the speaker's judgment and a specific request, as a shared mental model for communication between clinicians. The structure came from high-risk industries and was intended to reduce the ambiguity that often surrounds nurse-to-physician calls. The hospital reported that staff perceived communication as clearer and that safety outcomes improved as SBAR spread alongside other changes.

The project adapts SBAR for heel changes. A nurse who finds non-blanching redness will say: the situation, a patient's right heel has a stage 1 injury; the background, hip fracture repair two days ago, Braden 13; the assessment, boot was off for four hours after therapy; and the recommendation, boot back on now, wound nurse review at next rounds, request to check pain control so the patient can shift position. Every nurse gets the script on a small card clipped behind the ID badge, and the team rehearses it at huddles.

Shared Ownership

Table 1 assigns each bundle element to a group. The aim is clarity rather than hierarchy: each group knows its piece and knows whom to call when another piece is missing.

Table 1. Bundle Elements and Owners

Note. Ownership was agreed with each group before launch.

Resolving a Real Conflict

The first conflict arose before launch. Physical therapists removed heel boots for sessions and, because boots were bulky, often left them off afterward so patients could practice getting up. Nurses saw this as undermining the bundle; therapists felt nurses were putting skin ahead of mobility, the goal both groups shared. The CNL brought one nurse and one therapist together, framed the problem as a shared patient goal, since a heel wound would delay walking more than a boot would, and asked them to design the fix. They agreed that therapists would replace boots at the end of each session and that the unit would stock a lighter boot style for patients working on transfers. The conflict became a small example of lateral integration: the solution came from the groups themselves, and the CNL provided the frame and the evidence.

Keeping the Team Connected

Integration fades unless it is maintained. The CNL will post a one-page summary after each skin round listing heels checked, boots in place and actions agreed, and will share a monthly chart of heel injuries and bundle completion with every group, including the emergency department. Each group will see its own element, such as boots replaced after therapy, alongside the outcome, so contributions are visible rather than assumed. Once a month the team will spend ten minutes of rounds on what is not working, which gives quieter members, such as nursing assistants, a regular opening to raise problems.

Conclusion

The CNL integrates the team through routines, language and data rather than authority. Skin rounds give the groups a shared time and place, SBAR gives them a shared way of raising concerns and the ownership table gives each group a clear piece of the bundle.

References

Bender, M. (2014). The current evidence base for the clinical nurse leader: A narrative review of the literature. Journal of Professional Nursing, 30(2), 110-123. https://doi.org/10.1016/j.profnurs.2013.08.006

Haig, K. M., Sutton, S., & Whittington, J. (2006). SBAR: A shared mental model for improving communication between clinicians. The Joint Commission Journal on Quality and Patient Safety, 32(3), 167-175. https://doi.org/10.1016/S1553-7250(06)32022-3

Nelson, E. C., Batalden, P. B., Huber, T. P., Mohr, J. J., Godfrey, M. M., Headrick, L. A., & Wasson, J. H. (2002). Microsystems in health care: Part 1. Learning from high-performing front-line clinical units. The Joint Commission Journal on Quality Improvement, 28(9), 472-493. https://doi.org/10.1016/S1070-3241(02)28051-7