NUR 5103 Module 4 Decision-Making Model Application Example

Six Closed Beds and a Phone Call From the ICU: Applying the Vroom-Jago Model and a Weighted Criteria Matrix to an LTACH Staffing Decision

Student Name

American College of Education

NUR5103: Leadership and Management Theory in Nursing

Module 4 Assignment

Instructor Name

March 23, 2027

The Dilemma

The long-term acute care hospital (LTACH) followed in this course, a 40-bed composite, has kept six of its beds closed for three months because it cannot staff them. Registered nurse turnover last year was 38%, and two new assistant manager positions, recommended in Module 2, have been approved but not yet filled. On a Monday morning, the chief medical officer of the host hospital calls the director of nursing. The host intensive care unit is at 96% occupancy, four ventilated patients who meet the LTACH's admission criteria are waiting, and the host hospital asks the LTACH to reopen the six beds within two weeks. The referral pathway identified as a strategic priority in Module 3 depends on the LTACH saying yes to calls like this one.

The decision has four credible options: contract six travel nurses for 13 weeks and open all six beds; keep the beds closed until the new managers are in place and permanent hiring catches up; open three beds using incentive overtime from current staff; or open three beds now with three travel nurses paired with experienced staff and open the other three once both assistant managers have started. Each option trades patient safety, staff stability, money and the relationship with the host hospital against one another.

Deciding How to Decide

A manager's first choice is often not which option to take but who should take part in choosing. Vroom and Jago (2007) describe a range of decision processes, from the leader deciding alone, through consulting individuals or the group, to facilitating a group decision or delegating it entirely. Which process fits depends on features of the situation, such as how significant the decision is, how important the team's commitment is, how much the leader knows, how likely the team is to support a decision made without them, whether the team shares the organization's goals and how much time is available.

Applied to this case, the decision is highly significant, and commitment matters greatly, because any option that adds patients depends on nurses who are already tired. The director knows the budget and the host hospital's position but not how much overtime staff will accept or how travel nurses would be received. Staff are unlikely to support a decision made without them; the last time beds were opened, through mandatory overtime, three nurses resigned within a month. The team broadly shares the goal of caring for ventilated patients well. Time is limited but not immediate. These features point to consulting the group: the director will bring the options to a meeting of charge nurses, respiratory therapy leads and the nurse manager, hear their views and then decide. Facilitating a full group decision was considered and rejected, because the financial and contractual terms cannot be shared in full and the director must answer for the result to the host hospital.

Criteria, Weights and Scores

Before the meeting, the director set four criteria and weights, and the group was asked whether they were right; they added nothing but asked that staff stability be weighted more heavily, which it was. Patient safety carries 35%, staff stability 25%, finances 20% and the host hospital relationship 20%. In the meeting, each option then received a rating for each criterion, with 1 meaning poor and 5 meaning strong. The ratings were discussed aloud until the group could live with each one, and where nurses and the director disagreed the lower rating was recorded.

Keeping the beds closed scored highest for safety (5) and well for staff stability (4) but poorly for finances (2) and very poorly for the relationship (1), for a weighted score of 3.35. Contracting six travel nurses scored 5 for the relationship and 3 for finances, since the full-rate patients would roughly cover the premium, but only 3 for safety, because travel nurses would need to learn the weaning protocol and equipment, and 2 for staff stability, because permanent nurses resent working beside colleagues paid far more; its weighted score was 3.15. Evidence on safety is more reassuring than staff feared. In a large study of hospitals, higher use of agency-employed supplemental nurses was associated with higher mortality only until the quality of the nurse work environment was taken into account, after which the association disappeared (Aiken et al., 2013). The finding suggests the risk lies less in the travel nurses themselves than in the environment they join. Incentive overtime scored 3 on every criterion, for 3.00, with fatigue as the main concern.

The phased option, three beds now with three travel nurses each paired with an experienced nurse for their first two weeks and the remaining beds opened once both assistant managers start, scored 4 for safety, 3 for staff stability, 3 for finances and 4 for the relationship, a weighted score of 3.55, the highest of the four. The winning option was not in the original list the director brought to the meeting; the charge nurses proposed pairing, and the matrix only confirmed that their version was better.

The Decision and Its Conditions

The director chose the phased option and told the host hospital that three beds would open in ten days and three more when two conditions were met: both assistant managers in post, and the breathing trial rate on the pilot unit at or above 70%. Travel nurses will be contracted only through an agency that can supply nurses with ventilator experience, will complete the weaning protocol orientation before their first shift and will be paired with named preceptors. The director will review falls, unplanned extubations, breathing trial completion and overtime hours every two weeks, and will close the three beds again if safety measures worsen. The decision was shared with all staff in writing, including the reasons and the scores, and night staff heard it from the director in person at their own huddle rather than second hand. The travel contracts include a clause allowing early release if permanent hires arrive sooner than expected, so the premium stops as soon as the LTACH no longer needs it.

The Limits of a Rational Model

Weighted matrices look precise, but the precision is partly an illusion. The weights and scores are judgments, and a small change in the safety weight would have changed the ranking of the travel nurse and overtime options. Simon (1955) argued that real decision makers do not maximize across every possible option but search until they find one that is good enough, because their information, time and ability to compute are limited. This decision fits his description: the director did not search for every possible staffing arrangement, and the option chosen was satisfactory rather than provably best. What the matrix did do was make the trade-offs visible, force the weights to be stated before the scores and give staff a clear account of why one option won. Those benefits, not the arithmetic, are the reason to use it.

References

Aiken, L. H., Shang, J., Xue, Y., & Sloane, D. M. (2013). Hospital use of agency-employed supplemental nurses and patient mortality and failure to rescue. Health Services Research, 48(3), 931-948. https://doi.org/10.1111/1475-6773.12018

Simon, H. A. (1955). A behavioral model of rational choice. The Quarterly Journal of Economics, 69(1), 99-118. https://doi.org/10.2307/1884852

Vroom, V. H., & Jago, A. G. (2007). The role of the situation in leadership. American Psychologist, 62(1), 17-24. https://doi.org/10.1037/0003-066X.62.1.17