Identify the key elements of the case and place them in the appropriate four-frame matrix (Structural, Human Resource, Political, Symbolic).  

1. Identify the key elements of the case and place them in the appropriate four-frame matrix (Structural, Human Resource, Political, Symbolic).  Provide a brief rationale for the frame or frames chosen
2. FN Health System in Western NY is a rural health care system that covers an area about the size of the state of Connecticut. There are four hospitals and 25 Outreach Centers in the system that provide primary and specialized care to approximately eight million people in their catchment area. The original hospital was established by a group of physicians and continues to maintain its physician-centered and physician-driven culture. Physicians have a different pay and benefit schedule, a private dining room, chair all hospital-wide committees and sit on the Board of Trustees. The CEO of the hospital is a physician. In 2005, the Chief Nursing Officer (CNO) began a long-term project to establish a nursing Professional Practice Model (PPM) and to work toward the goal of Magnet® designation from the American Nurses Credentialing Center (ANCC). The CNO wished to survey all nursing staff to address their level of interest in shared governance activities, level of professional development and their interest in developing a PPM for nursing throughout the institution. At that time, the nursing staff was 60% RNs and 40% LPNs. Very few of the RN staff were baccalaureate prepared and only two of the five nurse managers had baccalaureate education. The CNO was masters prepared, but her masters was not in nursing. There was a large group of Nurse Practitioner (NP) Advanced Practice Registered Nurses (APRNs) who practiced in the Outreach Clinics, but reported to the Chief of Medicine. Other APRNs included Certified Registered Nurse Anesthetists (CRNA) and Certified Nurse Midwives (CNMW) however these groups of APRNs reported to the physician chiefs in their departments. There were no Clinical Nurse Specialists (CNS) involved at any level of the hospital or in the outpatient clinics. A small department of nursing education provided traditional orientation activities. The CNO worked with a research department at a local university to develop a survey. By 2006, the CNO and nurse researcher were ready to present the survey to the FN System Institutional Review Board (IRB). The IRB was a committee composed of physicians and PhD prepared researchers at the organization. There was no nursing representation on the IRB. Interestingly, there was one community health researcher in the research unit of the system who was a nurse, however she chose not to identify herself as such. Upon review of the survey, the Chair of the IRB immediately noted that the nature of the survey, particularly the questions that related to shared governance and activities that would empower the nursing staff, were controversial. The Chair convened the full IRB to discuss the survey. The CNO was asked to attend the IRB meeting and therein ensued a long discussion on the lack of scientific merit of the survey. The CNO was asked many questions concerning the survey’s general purpose and what indeed the CNO wanted to accomplish. The IRB made extensive suggestions for changes to the survey and a number of members questioned the overall merits of such an initiative since it would disturb what they perceived as good collaborative working relationships that existed within the health care system. The CNO responded that the survey had been developed with a research department at a local college and had been completely vetted and approved by her nursing leadership team. This initiative would be part of a long-term strategic goal of securing ANCC Magnet® designation which would aid them in their recruitment activities and improve the level of nursing practice leading to more timely, effective and high quality interprofessional communication enhancing patient safety and quality outcomes. The survey was approved with revisions and the CNO left believing the issue was settled. The following week, at the CEO Senior Staff Meeting, the CNO was surprised when the CEO announced that all staff surveys were to be placed on hold until further notice. The CEO stated that he was concerned with all of the discussion among the nursing staff about new practice models and shared governance especially as it related to the Advanced Practice Providers (APP) and the collaborative practice models that were already in place. The CEO stated that the leadership in the organization needed to support the structures and reporting systems that were already in place. The Chief of Anesthesiology added that there had been too many changes over the last few years, stating “When my wife was a nurse, things were so much easier. Nurses wore caps and were easily identified. Now there are entirely too many nurses running around in lab coats.” The CNO tried to explain the benefits of a shared governance approach and ANCC Magnet® designation. The CEO responded that they were on a tight schedule, there was a hefty agenda already, and there was no time to discuss this issue. After the meeting, the CNO asked to meet with the CEO to discuss what had transpired. The CEO stated that he knew nothing about the survey or plans to put a PPM in place. He said he was not even too sure what a PPM was and asked the CNO once again if she could do something about the nurses’ charting in the progress notes. The CNO tried to explain her ideas and how the survey and related work were all in preparation for achieving ANCC Magnet® designation. She attempted to explain the benefits this designation would accrue for the organization as a whole. In the following days, the CNO met with her nursing leadership team to discuss what had transpired. It was clear the team felt demoralized and felt their integrity, competence and commitment to the organization had been questioned. The CNO tried to reassure them that this was not the case and that the group should work on new strategies to accomplish their goals