NURS 626 Week 1 Blog 1 on Defensive Practice and the Nurse Administrator Example

Blog 1: Fear, Accountability and the Culture a Nurse Administrator Builds

NURS 626 Nursing Administration IV: Nursing Administration Capstone, Blog 1

Thread by [Student Name]

The practicum unit, the event described and the classmates replied to are composites written for a model blog.

Two months ago, a family on the medical floor that hosts my capstone practicum filed a complaint claiming their mother had gone four hours without being checked. The record showed hourly rounding checkmarks, but the family insisted no one had come in. Nothing was proven either way, yet the unit changed. Within a week, nurses were writing a narrative note for every round, calling the covering physician about blood pressures that would never have prompted a call before, and asking a second nurse to witness routine conversations with families. One nurse told me, "I chart for the lawyer now, not for the next shift." The extra work was not making patients safer. It was making nurses feel safer, and it was costing them time they had previously spent at the bedside. By my rough count, the narrative rounding notes alone added about forty minutes of charting to each twelve-hour shift, and the night nurses told me they were now finishing their documentation after the end of the shift.

That behavior has a name. Defensive nursing practice describes actions nurses take mainly to protect themselves from blame or legal exposure rather than to meet a patient's need. El-Sayed et al. (2026) studied it among 486 oncology nurses in four cancer centers in Egypt, measuring legal consciousness, perceived just culture and defensive practice with validated scales. Nurses who were more conscious of legal risk reported more defensive practice, while nurses who perceived a stronger just culture reported less. The interaction mattered most: a strong just culture weakened the link between legal awareness and defensive behavior. Nurses with prior legal involvement or legal training reported more defensive practice, while those with postgraduate education reported less. Because the nurses were surveyed once and all worked in oncology in a single country, the findings cannot be generalized with confidence, but the pattern fits what I saw. The complaint raised the nurses' sense of legal risk, and nothing in the unit's response told them they would be treated fairly if something went wrong.

Our reading describes quality and risk management as work that protects both patients and the organization (Roussel et al., 2020). Defensive practice shows what happens when those goals pull apart. As a nurse administrator, I would respond to a complaint like this one by meeting the staff within days, explaining how the review will be conducted and what fair treatment looks like, and then auditing whether the new charting habits add anything for patients. Practices that only protect the nurse should be retired openly, with the manager's support behind the decision. I would also bring the family's concern back to the staff as a question to solve together, perhaps through visible rounding boards in the room, so that the answer to a complaint is better communication rather than heavier documentation.

Scripture says that "there is no fear in love, but perfect love casts out fear" (English Standard Version Bible, 2001/2016, 1 John 4:18). A unit governed by fear will spend its time protecting itself, while a unit that trusts its leaders can spend its time on patients. Building that trust is part of the administrator's calling.

Reply to Lauren

Lauren, you wrote that your hospital's just culture program is working because incident reports rose by a third after it launched. I want to challenge whether more reports prove a better culture. McGonigal et al. (2026) described a just culture program in the intensive care units of an academic medical center and found a statistically significant rise in safety event reporting from 2023 to 2024, while the response to error domain of the patient safety culture survey rose from 54.58% to 59% between 2023 and 2025. Those are encouraging results, but notice that the culture measure moved modestly while reporting moved sharply. Reporting can rise for several reasons: easier forms, a new expectation from managers, or even fear that failing to report will itself be punished. Only the culture survey tells us how nurses feel about being reported, and even that improvement left four in ten responses outside the positive range. I would ask what your survey's response to error scores did over the same period, and whether nurses who reported events heard back about what changed. Proverbs warns that the simple believe everything, but the prudent give thought to their steps (English Standard Version Bible, 2001/2016, Proverbs 14:15). A rise in a single number is worth celebrating cautiously, and pairing it with what nurses say about fairness would make your case much stronger. Do you know whether the units with the largest increases in reporting also had the largest gains in perceived fairness? If they did, your argument is much stronger than the overall count suggests.

Reply to Victor

Victor, your post argued that psychological safety is the key to getting nurses to speak up, and that if leaders create it, speaking up will follow. I wonder whether the relationship is that direct. Abousoliman and Elgamal (2026) surveyed 288 clinical nurses in thirteen hospitals in Port Said, Egypt, and examined courageous leadership, just culture, psychological safety and speaking-up behavior. Courageous leadership was related to all three. Just culture was strongly correlated with psychological safety, yet psychological safety itself was not significantly correlated with speaking up, and neither just culture nor psychological safety explained the link between courageous leadership and speaking up. Leadership behavior remained directly associated with nurses' willingness to voice concerns. If that finding holds in other settings, a leader cannot simply create a safe climate and wait; nurses may need to see the leader take risks first. The study was cross-sectional and from one region, so it cannot settle the question, but it complicates the idea that psychological safety alone is enough. Scripture repeatedly links courage with leading others, as when Joshua was told to be strong and courageous because he would lead the people into the land (English Standard Version Bible, 2001/2016, Joshua 1:6). Could the managers you observed point to a time when they spoke up first, in front of their staff, about a safety concern above their own level? I suspect that example would teach more than any climate survey, and it would give your capstone a leadership behavior that can be observed and coached rather than a climate that can only be measured once a year.

Reply to Simone

Simone, you argued that a better work environment, through staffing, resources and shared governance, is the foundation of a just culture, and that leadership training comes second. I would push back on the order. Kim et al. (2026) surveyed 199 nurses in seven South Korean hospitals and found that ethical leadership was the strongest predictor of nurses' perception of just culture, followed by organizational communication, together explaining 51.8% of the variance. The nursing work environment correlated with just culture but lost significance once leadership and communication were in the model. The authors concluded that day-to-day leadership behavior and communication shape perceptions of fairness more than broad structural factors. That does not mean staffing is unimportant; the environment may work through leaders rather than around them. But it suggests that an organization could invest heavily in structure and still have nurses who expect to be blamed, if managers respond to errors inconsistently. Micah's call to do justice and love kindness (English Standard Version Bible, 2001/2016, Micah 6:8) describes a leader's conduct more than a system's design. If you had one year and limited funds, would you start with your managers' responses to errors or with the structural changes in your post? I would be interested in how your preceptor would answer, since your unit has had both kinds of change. My own guess is that a few months of consistent, fair responses from managers would make nurses more willing to trust the structural changes when they arrive, while structural changes introduced by managers whom nurses do not trust may be read as one more thing done to them rather than for them.

Response to Grace's Reply

Grace, thank you for challenging my claim that the new charting on my unit added nothing for patients. You are right that one or two of the narrative notes did capture early changes that a checkmark would have missed, and I should not dismiss all of it as defensive. The distinction I would draw is between documentation the team chooses because it helps the next nurse and documentation written only in case of a lawsuit. An audit of a sample of notes, reviewed with the staff, could sort one from the other and keep what is useful. I will suggest that to my preceptor this week, and I will report back on the thread if the unit tries it.

References

Abousoliman, A. D., & Elgamal, H. G. (2026). Courageous leadership and nurses' speaking-up behavior: The indirect roles of just culture and psychological safety: A cross-sectional study. International Journal of Nursing Studies Advances, 11, Article 100663. https://doi.org/10.1016/j.ijnsa.2026.100663

El-Sayed, A. A. I., Alsenany, S. A., Abdel Razek, N. M. F., Alaskar, L. A. M., & Asal, M. G. R. (2026). The legal mindset in oncology nursing: How legal consciousness and just culture shape defensive practice of oncology nurses. Cancer Nursing. Advance online publication. https://doi.org/10.1097/NCC.0000000000001564

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

Kim, E. H., Yu, S., & Yoon, Y. S. (2026). The impact of nursing work environment, ethical leadership, and organizational communication on general hospital nurses' perception of just culture: A cross-sectional study. Journal of Patient Safety. Advance online publication. https://doi.org/10.1097/PTS.0000000000001572

McGonigal, M., Hebb, A., Williams, L., & Li, J. (2026). Impact of just culture implementation on safety event reporting in critical care units in an academic medical center. Critical Care Nursing Quarterly, 49(4), 426-433. https://doi.org/10.1097/CNQ.0000000000000623

Roussel, L. A., Thomas, P. L., & Harris, J. L. (2020). Management and leadership for nurse administrators (8th ed.). Jones & Bartlett Learning.