A Staff That Stopped Asking: Assessing the Practice Environment on Five Medical-Surgical Units, Measured With the PES-NWI
Student Name
American College of Education
NUR5043: Nursing Leadership: Organizational Systems
Module 3 Assignment
Instructor Name
October 26, 2026
Why Climate, and Why This Instrument
Culture is the set of shared assumptions that shape how people in an organization behave, and climate is the part of it that staff can describe and rate: how they experience support, resources and relationships at work. A nurse leader planning a change across departments needs to know the climate of the units that will carry it, because a plan that asks nurses to speak up about delays will fail where speaking up has taught them nothing changes. The question for this assessment is narrow and practical: what is it like to practice nursing on the five medical-surgical units of the composite hospital described in earlier modules, and does that climate explain why a 19-hour mattress delay became normal?
Lake's Practice Environment Scale (PES-NWI), derived from the Nursing Work Index, was chosen for three reasons. It was built from the organizational features of the original magnet hospitals, its five subscales were derived and tested for reliability at both nurse and hospital level, and confirmatory analysis in a sample of 11,636 Pennsylvania nurses supported its structure (Lake, 2002). It is also endorsed as a national nursing performance measure, which means results can be compared with published work. Its five subscales cover how far nurses take part in hospital affairs; the nursing foundations that support quality of care, such as a shared philosophy and ongoing education; the ability and support of the unit's manager; whether staffing and other resources are adequate; and how collegial the working relationships between nurses and physicians are.
What the Scores Show
Items on the scale are rated from 1, strongly disagree, to 4, strongly agree, so 2.5 is the midpoint between disagreement and agreement. Lake and Friese (2006) used that midpoint to classify hospital environments by how many subscales scored above it, and found that only about 17% of the 156 Pennsylvania hospitals they studied had favorable environments. The composite survey for this assessment had 141 responses from 208 eligible registered nurses on the five units, a response rate of 68%.
Across the five units, two subscales scored comfortably above the midpoint: nursing foundations for quality of care at 2.94 and collegial nurse and physician relations at 2.88. The manager subscale sat just above it at 2.61. Two scored below: staffing and resource adequacy at 2.21 and nurse participation in hospital affairs at 2.12. The pattern describes a staff that trusts its own clinical standards and its physician colleagues but does not believe the organization will give it resources or listen to it.
Unit differences matter as much as the averages. The two units with the highest pressure injury rates had the lowest scores on participation in hospital affairs, 1.94 and 2.03, and both had changed managers within the past year. The rehabilitation unit, where the manager meets monthly with supply chain about equipment, had the highest participation score at 2.46. The survey cannot say whether the manager's meetings produced the higher score or whether a more engaged staff made the meetings possible, but the difference points to where the change work should look first. It also suggests that participation is not fixed by the hospital's culture as a whole. It varies with what happens on each unit, which means a director can influence it directly, one unit at a time, rather than waiting for the organization to change around her. That is a hopeful finding for a leader with limited authority, and it shapes the recommendations below.
What the Survey Cannot See
A survey measures what nurses are willing to report about their environment. It does not show what they have stopped doing. Three kinds of observed evidence were gathered to test the scores. The first was the equipment request log. In the first month after the approval rule began, nurses on the five units made 118 requests for pressure-redistribution surfaces; in the most recent month they made 71, although the number of high-risk patients by Braden score had not fallen. Staff described the reason plainly: after 1530 on a Friday there was no point calling.
The second was the incident reporting system. Only four reports in the review period mentioned a delay in obtaining a support surface, while the equipment log showed dozens of waits longer than 24 hours. The third was the nursing quality council. Minutes from the past year contained no agenda item on equipment access, although pressure injury rates were reported at every quarterly meeting. The low participation score is not an abstract rating; it is visible as requests not made and reports not filed.
These observations fit the evidence linking environment to outcomes. In a meta-analysis of 17 articles reporting on 2,677 hospitals and 165,024 nurses, Lake et al. (2019) found that better work environments were associated with lower odds of poor safety or quality ratings, with an average odds ratio of 0.65, and of negative patient outcomes, with an average odds ratio of 0.93. Braithwaite et al. (2017) reviewed 62 studies across hospitals, general practices, aged care and other settings and reported that where cultures were more positive, patient outcomes tended to be better, among them lower mortality and fewer falls, although only four of the studies were interventional and none were randomized trials. Neither review can prove that this hospital's climate caused its injuries, but both make the connection plausible enough to act on.
What the Findings Mean for Change
The assessment changes the plan in two ways. First, any change to the equipment process has to repair participation before it asks for it. Nurses who have learned that calling after hours is useless will not start calling again because a new rule is announced; they will start when they see that a report produced a response. The first visible step should therefore be a small one that staff can watch happen, such as the director reporting back at each unit's staff meeting on every delay logged the previous week and what was done about it.
Second, the staffing and resource score is a warning about fairness. If a new nurse-driven protocol for ordering surfaces simply adds a task to nurses who already report inadequate resources, it will be read as more work rather than more authority. The protocol should remove steps as well as add them, for example by letting transport deliver and place the surface rather than asking nurses to find a second staff member. Climate is the soil the change is planted in, and on these units the soil needs attention before the seed.
Limitations
The survey is cross-sectional and self-reported, and a response rate of 68% leaves room for nurses who feel least heard to be the least likely to answer. Unit samples are small, so differences of a tenth of a point between units should not be overread. The observed evidence comes from records kept for other purposes; a fall in requests could partly reflect patients moved to other units. Repeating the survey after the change, with the same instrument and the same units, would show whether participation and resource scores move and would give the change work its own measure.
References
Braithwaite, J., Herkes, J., Ludlow, K., Testa, L., & Lamprell, G. (2017). Association between organisational and workplace cultures, and patient outcomes: Systematic review. BMJ Open, 7(11), Article e017708. https://doi.org/10.1136/bmjopen-2017-017708
Lake, E. T. (2002). Development of the practice environment scale of the Nursing Work Index. Research in Nursing & Health, 25(3), 176-188. https://doi.org/10.1002/nur.10032
Lake, E. T., & Friese, C. R. (2006). Variations in nursing practice environments: Relation to staffing and hospital characteristics. Nursing Research, 55(1), 1-9. https://doi.org/10.1097/00006199-200601000-00001
Lake, E. T., Sanders, J., Duan, R., Riman, K. A., Schoenauer, K. M., & Chen, Y. (2019). A meta-analysis of the associations between the nurse work environment in hospitals and 4 sets of outcomes. Medical Care, 57(5), 353-361. https://doi.org/10.1097/MLR.0000000000001109
How this NUR 5043 Module 3 example is structured
NUR 5043 Module 3 usually assesses organizational culture or climate with a named model and evidence from the setting; your classroom's instructions decide the model and whether survey data are required. This example chooses a validated instrument and says why, reports the composite results by subscale against a published cut point, compares units, adds observed evidence the survey cannot capture, and ends with what the findings mean for the change the course is building toward.
NUR5043 Module 3 questions, answered
What does NUR5043 Module 3 usually ask for?
NUR5043 Module 3 usually asks for an assessment of organizational culture or climate using a named model or instrument and evidence from a real or composite setting. Many sections ask what the findings mean for leading change. Your classroom's instructions decide the model and whether survey data must be used.
Do I have to run a survey myself?
Usually not. Many students use results their organization already collects, with permission, or describe composite results and say so. What matters is that the instrument is named and validated, the results are read against a published standard, and the limits are stated.
Can I use a culture model instead of a climate instrument?
Yes, if the prompt allows it. Models such as Schein's levels of culture or the Competing Values Framework suit qualitative assessments. Whichever you use, pair it with observable evidence from the setting so the assessment is more than a description of the model.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official American College of Education document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.