NUR5043 Module 4 stakeholder and power analysis example

The Wound Nurse Holds the Key and the Budget Analyst Holds the Numbers: Mapping Stakeholders, Power and Informal Influence Around a Nurse-Driven Mattress Protocol

Student Name

American College of Education

NUR5043: Nursing Leadership: Organizational Systems

Module 4 Assignment

Instructor Name

November 2, 2026

The Proposed Change

The change under analysis would replace advance approval of pressure-redistribution surfaces with a nurse-driven protocol. A registered nurse caring for a patient with a Braden score of 12 or less, or with an existing stage 2 or deeper pressure injury, could order a reactive air or alternating pressure surface directly from the equipment desk at any hour. The wound, ostomy and continence nurse would review each order on the next business day and could discontinue a surface that did not meet criteria. Each month, one report would show nursing and finance together how many surface days were rented, what they cost and how many patients developed new pressure injuries. The change is proposed by the director of medical-surgical nursing in the composite 190-bed hospital analyzed in the earlier modules of this course.

Because the change touches a rule owned by system finance, a role owned by nursing and a contract owned by supply chain, it cannot be decided inside nursing. Bryson (2004) argued that attention to stakeholders is most needed exactly in situations like this, where no single party has the authority to act and where overlooking a party with power to block is the usual reason public and nonprofit changes fail.

Identifying the Stakeholders

Stakeholders were identified with the basic method Bryson (2004) recommends: a brainstorm of everyone affected by or able to affect the change, followed by a check of each candidate against the process map from Module 1 so that no step in the process was left without an owner. Eleven stakeholders or groups resulted: bedside nurses on the five units, the five unit managers, the wound nurse, the house supervisors, the chief nursing officer, the hospital president, the system vice president of support services, the system finance director, the budget analyst who prepares the monthly rental report, the supply chain contract manager and the vendor's account representative. Patients at risk of pressure injury and their families are stakeholders too, and their interest is the reason for the change, but they have no organized voice in the decision and are represented here through the outcome data.

Salience: Power, Legitimacy and Urgency

Mitchell et al. (1997) proposed that managers give attention to stakeholders according to three attributes: power to impose their will, legitimacy of their claim and urgency of that claim. Stakeholders who hold all three are definitive and must be engaged first; those with power but no urgent claim are dormant but can become decisive if provoked.

Rated this way, the system finance director is the definitive stakeholder. She has power over the rule, a legitimate claim because the approval step was her response to a real budget overrun, and urgency because a new overrun would be charged to her. The system vice president of support services has power and legitimacy but, so far, no urgency; he is dormant and the plan must avoid waking him as an opponent. The wound nurse has legitimacy and urgency, because the change alters her role and she has seen surfaces left on patients for weeks after they were needed, but her formal power is small. Bedside nurses have urgency and legitimacy and very little power. The vendor representative has power over delivery times through the contract but no legitimate claim over clinical criteria. Salience shows that the change will be decided in finance, argued in wound care and carried out at the bedside, and each of those places needs a different conversation.

Bases of Power and Informal Influence

French and Raven (1959) distinguished five bases of social power: legitimate power from a recognized position, reward power, coercive power, expert power from knowledge others need, and referent power from being admired or identified with. The distinction matters here because several stakeholders hold more influence than their position suggests.

The wound nurse is the clearest case. Her formal authority is limited to approval of surfaces, but her expert power is considerable. Unit managers, physicians and the chief nursing officer defer to her on pressure injury questions, and if she tells them the protocol will lead to surfaces being ordered for patients who do not need them, the change will stall regardless of what finance decides. Her likely concern is not status but workload and misuse: in the composite data, 22% of surfaces were still in place more than five days after the patient's risk score improved, and she was the only person who looked. The budget analyst holds a different kind of influence. She has no formal authority over the rule, but she built the monthly rental report the finance director trusts, and whatever she presents about the pilot will shape the finance director's view of it. Among bedside nurses, the night charge nurse on the unit with the highest injury rate holds referent power; staff on three units describe her as the person who knows whether a new process is worth the trouble. The three people most able to make or break this change do not appear on the organization chart as decision makers.

Engagement Plan in Order

The order of engagement follows from the analysis. The wound nurse comes first, privately, before any proposal is written. The protocol should be built with her, with criteria she would defend, a next-day review she can manage in her hours, and a rule that surfaces are reassessed when the Braden score improves, which answers her concern about misuse and gives her a stronger role than approval does. The budget analyst comes second, so that the monthly report combining rental spending and pressure injury data is designed with the person who will produce it, and so that she understands the cost of one full-thickness injury before she sees the first month of pilot spending.

The finance director comes third, with the wound nurse beside the director of nursing and the analyst's draft report in hand. The request should be for a 90-day pilot on the two units with the highest injury rates, with a spending ceiling that triggers review, because a bounded pilot answers her legitimate claim without asking her to give up the rule outright. The supply chain contract manager and the vendor representative come after the pilot is approved, to add a clause measuring delivery from the time of the nurse's order. The night charge nurse and the unit managers are engaged before the pilot starts, so that the first nurses to use the protocol hear about it from someone they trust. The vice president of support services is informed by the finance director, not by nursing, which respects the reporting line and keeps a dormant stakeholder from being approached as an adversary. Patients and families are engaged through the pilot's design rather than through a meeting: the unit's patient education sheet on pressure injury prevention will add a sentence telling families they can ask whether a special mattress is needed, which gives the people most affected a way to prompt the protocol and gives the pilot one more source of requests to count. The order matters more than any single conversation. A finance director who hears the proposal first from nursing, without the wound nurse's support and without numbers she trusts, is likely to see it as an attempt to undo a cost control, and her first reaction would be difficult to reverse.

References

Bryson, J. M. (2004). What to do when stakeholders matter: Stakeholder identification and analysis techniques. Public Management Review, 6(1), 21-53. https://doi.org/10.1080/14719030410001675722

French, J. R. P., Jr., & Raven, B. (1959). The bases of social power. In D. Cartwright (Ed.), Studies in social power (pp. 150-167). University of Michigan.

Mitchell, R. K., Agle, B. R., & Wood, D. J. (1997). Toward a theory of stakeholder identification and salience: Defining the principle of who and what really counts. Academy of Management Review, 22(4), 853-886. https://doi.org/10.2307/259247