Nineteen Hours to the Right Mattress: A Systems Analysis of How One Community Hospital Moves a Pressure-Redistribution Surface to the Bedside
Student Name
American College of Education
NUR5043: Nursing Leadership: Organizational Systems
Module 1 Assignment
Instructor Name
October 12, 2026
The Organization
The organization analyzed here has 190 licensed beds, is nonprofit, and is one of four hospitals owned by a regional health system. It has a 34-bed emergency department, a 16-bed intensive care unit, five medical-surgical units and a small inpatient rehabilitation unit. Nursing is led by a chief nursing officer answerable to the hospital president, who in turn answers to the system's chief operating officer. Supply chain, finance and the equipment contracts sit at the system level, not in the hospital, and report through a system vice president of support services. That split matters for this analysis. Nursing units belong to the hospital, while much of what nursing units use belongs to the system. Neither the hospital nor its numbers are real; both were assembled for this paper to resemble organizations of this kind.
Most of the formal structure is familiar. Each nursing unit has a manager who reports to one of two directors, and the directors report to the chief nursing officer. A nursing quality council meets monthly and receives the hospital's pressure injury data every quarter. One certified wound, ostomy and continence nurse covers the whole hospital on weekdays from 0700 to 1530. Environmental services cleans and stores equipment, patient transport moves it, and a contracted vendor owns the specialty beds and mattresses and bills the hospital by the day.
One Process Read as a System
General systems theory treats an organization as a set of parts that exchange inputs and outputs with each other and with the environment, so that the behavior of the whole cannot be read from any single part (von Bertalanffy, 1968). Donabedian (1988) gave health care a version of the same idea when he separated structure, process and outcome and argued that quality has to be judged across all three. Read that way, getting a pressure-redistribution surface to a patient is not a nursing task. It is a system with its own inputs, throughput, outputs and feedback, and most of it runs outside nursing.
The input is a risk decision. A nurse scores a patient at 12 or below on the Braden scale, or finds an existing stage 2 injury, and decides the patient needs more than the standard foam mattress. The throughput begins when the nurse calls the equipment desk. Since a policy change two years ago, the desk cannot release a surface until the wound nurse approves it, so the request waits for her review. Once approved, the desk places an order with the vendor, whose regional depot is 40 miles away. The vendor delivers, transport takes the surface to the unit, and the nurse and a second staff member move the patient onto it. The output is a patient on the right surface, and the outcome the hospital cares about is a pressure injury that never develops.
Over a composite three-month review of 212 requests, the median time from the nurse's call to a patient on a new surface was 19 hours. Requests made after 1530 on a weekday, or at any time on a weekend, waited for the wound nurse, and those were the slowest: a Friday evening request typically waited until Monday morning for approval. The delay was not produced by any one department doing its job badly; every department in the chain was doing exactly what its own rules asked of it.
Where the Decisions Are Made
Placing each decision on the organization chart explains why the problem has lasted. The clinical decision that a patient needs a better surface is made by a staff nurse on a hospital unit. The approval decision is made by the wound nurse, who reports to a nursing director. The decision to require approval at all was made by system finance after rental spending for specialty surfaces ran 40% over budget in one year, and it was implemented by supply chain, which reports outside nursing entirely. The delivery time is decided by the vendor's contract, which supply chain negotiated and which specifies delivery within 12 hours of an order but says nothing about when an order may be placed.
So the people who feel the delay, the unit nurses and managers, do not own any of the decisions that create it. The chief nursing officer owns the wound nurse's hours but not the approval rule, and the system vice president of support services owns the rule but does not see pressure injury data. Senge (1990) described this pattern as a fix that fails: a solution applied to one symptom produces a consequence elsewhere in the system, often after a delay long enough that nobody connects the two. Finance solved a rental budget problem, and the cost of that solution was paid two years later in wound care, where it was counted as a nursing problem.
The Feedback Loop That Is Missing
Meadows (2008) argued that many system failures come from missing or delayed information flows: the part of a system that makes a decision does not see the consequences of that decision in time to change it. This hospital has two feedback loops, and they never meet. Rental spending is reported monthly to system finance, and it has fallen since the approval rule began. Hospital-acquired pressure injuries are reported quarterly to the nursing quality council, and over the same period the rate of stage 2 and deeper injuries on the medical-surgical units rose from 1.1 to 1.9 per 1,000 patient days in the composite data. Each group sees its own number move in the direction it wants or fears, but no group sees both numbers side by side.
The size of the hidden trade becomes clear when the two sides are costed. According to an estimate by Padula and Delarmente (2019), pressure injuries acquired in hospital may cost hospitals in the United States in excess of $26.8 billion annually, with roughly 59% of that total arising from the comparatively few stage 3 and 4 wounds. The evidence on surfaces themselves is less certain than practice assumes, but it points the same way: in a Cochrane overview and network meta-analysis, reactive air surfaces and alternating pressure air surfaces were both associated with lower pressure ulcer incidence than foam, with risk ratios of 0.46 and 0.63, although the certainty of that evidence was low (Shi et al., 2021). A few days of rental saved per patient is a small figure next to one full-thickness injury.
Where a Nurse Leader Could Intervene
Meadows (2008) ranked the places to intervene in a system from weak to strong: changing parameters such as numbers and budgets is the weakest, changing information flows is stronger, and changing the rules of the system is stronger still. That ranking suggests three interventions for this hospital, in order of strength.
The first is information. A single monthly report that shows rental days, rental spending and hospital-acquired pressure injuries on the same page, sent to both the nursing quality council and system finance, would close the missing loop at almost no cost. The second is a rule. A nurse-driven protocol that lets the bedside nurse order a surface directly when defined criteria are met, with the wound nurse reviewing the decision the next business day rather than approving it in advance, would remove the overnight and weekend wait while keeping a check on overuse. The third is structure: an interdepartmental group with members from nursing, supply chain and finance, given ownership of the whole process rather than of its parts. Dolansky and Moore (2013) argued that systems thinking is the competency that ties the rest of quality and safety education together, because it is what lets a nurse see that a local problem has a cause outside the unit. The strongest intervention here is not a better mattress; it is putting the two numbers that already exist in front of the same people.
Conclusion
The delay in getting a pressure-redistribution surface to a patient in this hospital is a property of the system, not of any person or department. It comes from a cost rule made where pressure injuries are not seen, an approval step that depends on one weekday role, and a contract that measures delivery from the order rather than from the need. A nurse leader who treated it as a unit problem would push staff to call sooner and change nothing. Treated as a system, it points to a shared report, a nurse-driven protocol and a group that owns the whole process, and it is the subject of the change work that follows in this course.
References
Dolansky, M. A., & Moore, S. M. (2013). Quality and safety education for nurses (QSEN): The key is systems thinking. OJIN: The Online Journal of Issues in Nursing, 18(3), Manuscript 1. https://doi.org/10.3912/OJIN.Vol18No03Man01
Donabedian, A. (1988). The quality of care: How can it be assessed? JAMA, 260(12), 1743-1748. https://doi.org/10.1001/jama.1988.03410120089033
Meadows, D. H. (2008). Thinking in systems: A primer. Chelsea Green Publishing.
Padula, W. V., & Delarmente, B. A. (2019). The national cost of hospital-acquired pressure injuries in the United States. International Wound Journal, 16(3), 634-640. https://doi.org/10.1111/iwj.13071
Senge, P. M. (1990). The fifth discipline: The art and practice of the learning organization. Doubleday.
Shi, C., Dumville, J. C., Cullum, N., Rhodes, S., McInnes, E., Goh, E. L., & Norman, G. (2021). Beds, overlays and mattresses for preventing and treating pressure ulcers: An overview of Cochrane Reviews and network meta-analysis. Cochrane Database of Systematic Reviews, 2021(8), Article CD013761. https://doi.org/10.1002/14651858.CD013761.pub2
von Bertalanffy, L. (1968). General system theory: Foundations, development, applications. George Braziller.
How this NUR 5043 Module 1 example is structured
NUR 5043 Module 1 typically asks for a systems analysis of one organization: its structure, its reporting lines and where nursing decisions are made; your classroom's instructions set the organization and the length. This example describes the hospital's structure first, then treats one process as a system with inputs, throughput, outputs and feedback, locates each decision on the organization chart, names the feedback loop that is missing, and ends with the places a nurse leader could intervene. The same problem carries through the later modules of this course on this site.
NUR5043 Module 1 questions, answered
What does NUR5043 Module 1 usually ask for?
NUR5043 Module 1 typically asks for a systems analysis of one organization: how it is structured, who reports to whom, where nursing sits and where the decisions that affect nursing are actually made. Many sections ask you to trace one process or problem across departments. Your classroom's instructions set the organization and the length.
Can I analyze my own hospital?
Yes, if your employer's policy allows it and nothing in the paper identifies patients or staff. Many students describe their organization's structure accurately but replace sensitive figures with composite ones and say so. The grade depends on the analysis, not on the real numbers.
Why trace one process instead of describing the whole hospital?
Because a systems analysis is judged on whether it shows how the parts affect each other. Following one ordinary request across departments reveals the boundaries, the owners and the missing feedback in a way a general description of the organization chart cannot.
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