Nursing Culture: Overcoming Barriers to Change Introduction

Nursing Culture: Overcoming Barriers to Change Introduction and Theoretical Framework This program of study continues personal research and professional practice in the field of nursing within the area of public and private health systems. In an era characterized by increasing calls for more efficient approaches to healthcare delivery and accountability on the part of healthcare providers, there is a growing need for identifying opportunities to overcome organizational barriers to change that facilitate the implementation and sustainment of evidence-based practices over time.

In order to accomplish this challenging enterprise, the nature of existing organizational barriers must be better understood, an issue that directly relates to the problem to be considered by the study proposed herein and which is discussed further below. Statement of the Problem According to Mannion, Davies and Marshall et al. (2005), the results of much of the research to date have identified a relationship between nursing culture and performance levels that requires further examination.

For example, based on their analysis of several hundred companies, Recardo and Jolly (1999) maintain that "Organizations that closely align their culture to support their business strategy tend to outperform those whose strategy and culture are not aligned. Since culture drives the behaviors of the workforce, it can have a significant impact at a macro level on productivity, customer service, product and service quality, and operational efficiency" (p. 5).

Organizational culture in general and nursing culture in particular can have such a profound effect on performance and patient outcomes, as well as receptivity levels to change. In this regard, Mason and Whitehead emphasize that, "For us, the importance of understanding culture is set in the everyday use of the term as it is applied to nursing culture. Like so many concepts, they also tend to have higher or deeper meanings which, if understood, provide us with the potential for creating change" (2003, p. 135).

Taken together, the foregoing observations indicate that nursing culture, if properly understood, can be used to improve performance and patient outcomes as well as facilitate important changes in the healthcare workplace. Purpose of the Study The purpose of the study proposed herein is three-fold as follows: A. To identify those factors that comprise organizational culture in general and nursing culture in particular. B. To examine ways that nursing culture hinders or facilitates organizational change. C.

To develop a series of recommendations based on the best industry practices that emerge from the study. Review of the Literature The review of the relevant literature will be focused on three primary areas: (a) organizational culture in general, (b) how organizational culture can introduce and sustain barriers to change, and (c) the effect of nursing culture in particular in creating or eliminating such barriers.

Organizational Culture With respect to the term, "corporate" or "organizational culture," the commonly accepted definition is "a set of values and beliefs that are understood and shared by members of an organization. These values and beliefs are specific to that organization and differentiate it from other organizations. An organization's culture helps to shape, and quite frequently to determine, the behaviors of the members and the practices within the organization" (Recardo & Jolly, 1999, p. 5).

In other words, organizational culture consists of the "ropes" that must be learned and how things are done in a given workplace setting. Notwithstanding this straightforward definition, the concept of "culture" has been treated differently by different authors, though, and a number of different approaches to measuring and assessing organizational culture have been offered as a result (Recardo & Jolly, 1999). Table 1 Dimensions of Organizational Culture Dimension Description Communications This dimensions involves the number and types of communication systems and what information is communicated and how.

This includes the direction of communications (top down or bottom up vs. three-way), whether the communications are filtered or open, whether conflict is avoided or resolved, and whether formal (meetings, memos, etc.) or informal vehicles are used to transmit and receive communications. Training and Development Employee success is to a large extent dependent on new skill acquisition. Key indices to assess are management's commitment to providing developmental opportunities and how well the organization allows new skills or behaviors to be applied on the job.

A key index to review is management's focus on education; e.g., is management focused on providing education for employees' current or future developmental needs? Rewards This dimension concerns what behaviors are rewarded and the types of rewards used.

Are employees rewarded individually or as a group, are all members of the organization eligible for bonuses, and what are the criteria for advancement? Other criteria measured include the degree to which employees are involved in developing performance standards, the perceived equity of rewards, and the degree to which the organization provides performance feedback Decision Making This dimension addresses how decisions are made and conflicts resolved.

Are decisions fast or slow? Is the organization highly bureaucratic? Is decision-making centralized or decentralized? Risk Taking This dimension concerns whether creativity and innovation are valued and rewarded, whether calculated risk-taking is encouraged, and whether there is openness to new ideas.

To what degree does management encourage suggestions for improvement? Are people punished for trying new ideas or questioning existing ways of doing things? Planning Does the organization emphasize long-term or short-term planning, and is planning proactive or reactive? To what extent are the strategy, goals, and vision shared with employees? Is the planning process informal or structured? To what degree are employees committed to achieving the business strategy and other organizational objectives? Teamwork This dimension relates to the amount, type, and effectiveness of teamwork within the organization.

It includes, but is not limited to, the amount of cooperation among different departments, the amount of trust between different functions or units, and the level of automation currently used to support work processes. Note that an atmosphere of teamwork does not, in itself, necessarily mean that formal teams should be used in an organization. For instance, research scientists may foster an atmosphere of collaboration and teamwork but may not be a team and may operate quite independently.

Management Practices The final dimension measures the fairness and consistency with which policies are administered, the accessibility of management to employees, the degree to which management provides a safe working environment, and how well management encourages diversity. As noted in the statement of the problem above, a growing body of evidence indicates that organizational culture has a direct effect on employee performance. For instance, according to Mannion et al. (2003), "Culture does affect employee outcomes and performance" (p. 59).

One of the ways in which nursing culture affects employee outcomes and performance is the manner in which it affects receptivity to change initiatives, and these issues are discussed further below. Barriers to Change Healthcare providers are no different than any other professionals in their resistance to change. People hate to change.

Empirical observations and numerous studies have confirmed, for example, that some clinicians desperately cling to "old school" practices even when they are confronted with mounting evidence of their inferiority compared to more modern, evidence-based practices, and change can be painful and require far longer than many managers might believe. After all, when people invest a great deal of time and effort in learning how to do something and become proficient at it, they enter a comfort zone that is difficult to penetrate.

Moreover, this process begins with nurses early on as well. For instance, James and Chapman (2009) found that as nurses progress through their clinical placement rotations, their confidence levels increased and their ability to deliver appropriate nursing services improved. Conversely, when nurses were placed in unfamiliar settings where the routine was not clear or the tasks were unfamiliar, their ability to deliver appropriate nursing services was diminished (James & Chapman, 2009).

It is little wonder, then, that change represents a potential threat to many people, and such resistance can hamper or even prevent meaningful change from taking place (Moore, Baldwin, Camm & Cook, 2002). According to Moore and his associates, "Resistance to change may result from self-interest, misunderstanding, or inherent limited tolerance for change" (2002, p. 53).

Interestingly, resistance to change does not occur just within the lower echelons of an organization, and an organization's leadership team might also be reluctant to change for the same or different reasons and this reluctance manifests itself in different ways (Moore et al., 2002). In this regard, Moore et al. advise that, "Even people in power often work toward maintaining the status quo. The types of resistance include confusion, immediate criticism, malicious compliance, sabotage, easy agreement, deflection, silence, and in-your-face criticism" (2002, p. 53).

Because change may be resisted by all levels of an organization, substantive change requires an across-the-board shift in the organizational culture that is in place to one in which change is embraced. According to Moore and his colleagues, "Organizational culture also affects the readiness and acceptance of change" (2002, p. 54). As an example, Moore et al. cite the use of Six Sigma quality programs as part of a change initiative.

Companies that succeed in implementing and administering this organization-wide management tool have also succeeded in changing their organizational culture prior to its adoption (Moore et al., 2002). As a result, organizations must develop strategies that are appropriate to the change and take steps to address any perceived losses on the part of the stakeholders to ensure higher levels of receptivity to change (Moore et al., 2002). Moreover, there is a great deal at stake in attempting organizational change beyond the immediate initiative.

If corporate leaders consistently seek to effect change in their organizations and fail, they will become regarded as ineffectual and a loss of faith and loyalty to the organization can result (Moore et al., 2002). In this regard, Moore and his associates emphasize that, "If there has been an organizational history of change attempts that have not been entirely or clearly successful, cynicism -- a real loss of faith in the leaders of change -- can arise despite the best intentions of those responsible" (p. 54).

Unfortunately, such reactions remains salient even if the current leadership team is not responsible for previous failed efforts, and the lingering perception of ineffectuality can adversely affect future change initiatives as well (Moore et al., 2002). Effect of Nursing Culture on Organizational Performance and Healthcare Outcomes In spite of its proven importance in promoting higher employee performance levels, though, there has been a relative dearth of timely and relevant studies concerning nursing culture.

In this regard, Mendyka and Bloom (1999) emphasize that, "The concept of culture in nursing is not always clearly defined. Nursing seldom acknowledges any specific culturally based theoretical orientation.. [and frequently stresses] the specifics of individual cultural components rather than their interrelationship" (p. 180). Irrespective of any precise definitional differences, though, it is clear that nursing culture can have a profound effect on clinicians and patients alike. For example, Mendyka and Bloom also note that, "Culture is instrumental in the creation of contextualized meaning for a person's experience of health and illness.

Culture is the source of the meanings attributed to the care situation as experienced by nurse and patient" (1999, p. 180). The importance of understanding this somewhat-nebulous construct is also made clear by Mendyka and Bloom's assertion that, "An awareness of culture and further examination of the concept of embodiment promotes an appreciation for, rather than a minimization of, the meaning of illness or health experiences of others" (1999, p. 180).

Some of the studies conducted to date have either included nursing culture as only an ancillary aspect of the research or have otherwise failed to examine it in its more complete context as it applies to creating and sustaining barriers to change. For example, an analysis of nursing culture by Rizzo, Gilman and Mersmann (1994) evaluated nursing department staff in 13 units preparatory to changing the care delivery model that was in use.

The unit's nursing culture was measured using the Nursing Unit Cultural Assessment instrument and performance was measured with respect to unit skill-mix, cost, worked hours per patient day, quality assurance, documentation of care planning and discharge, and the level of patient satisfaction. The results of this study, though, showed that the initiative was less directed at effecting changes in nursing culture and was more focused on cost savings and achieving a reduction in professional staff nursing levels (Rizzo et al., 1994). More recently, though, a study by Shortell et al.

(2000) examined nursing culture and heart surgery patient outcomes and found mixed results, with the level of supportive nursing culture improving certain outcomes (i.e., reduced length of stay, shorter post-operative intubation periods, and higher mental and physical functioning test scores), but not others (i.e., length of time in the operating suite). Likewise, a follow-up study by Shortell et al. (2001) evaluated the implementation of evidence-based care in U.S. healthcare organizations to determine the effects of healthcare organizational culture on adoption rates.

This follow-up study identified a distinct relationship between economic pressures and incentives, but little or no apparent relationship with nursing culture per se (Shortell et al., 2001). Finally, the results of a study by Zimmerman et al. (1993) found a somewhat tenuous relationship between nursing culture and patient outcomes. The study by Zimmerman and his colleagues (1993) was fairly ambitious in its scope and used a combination of interviews, field observations and archived data. Based on their analysis of this broad-based data, Zimmerman et al.

determined that, in general, strongly patient-centered nursing cultures and nursing leadership were related to reduced lengths of stay in intensive care units, but they were unable to correlate these findings with risk-adjusted survival rates. Consequently, the need for further studies in this area is particularly acute, a gap that this study sought to help fill by using the research questions set forth below as a guide.

Research Questions The proposed study will be guided by the following research questions: a) Does nursing culture affect performance in measurable ways (i.e., medication error rates, patient satisfaction levels)? If so, what have been the results to date and what areas require further investigation? b) How can nursing supervisors and administrators overcome barriers to change created by nursing culture? c) How can nursing culture be used to facilitate the implementation and application of evidence-based care? The Design -- Methods and Procedures The study's research design will be qualitative, consisting of a mixed methodological approach using a review of the relevant and timely peer-reviewed and scholarly literature as well as a series of case studies concerning overcoming barriers to change created by nursing cultures.

With respect to the qualitative design, Banyard and Miller (1998) point out that, "Qualitative research methods are ideally suited to putting a valuation of diversity into practice. The link between qualitative research and diversity can be seen when considering qualitative research as purely a set of tools or methods, and also when examining it as reflective of an alternative research paradigm" (p. 485).

This qualitative mixed methodology is also congruent with the guidance provided by a number of social researchers concerning the need to examine a topic of interest from more than one perspective (Fraenkel & Wallen, 2001). For instance, with respect to the first component of the research methodology, Gratton and Jones (2003) emphasize that a critical review of the relevant literature is an essential task in almost all types of contemporary research.

According to Gratton and Jones, "A literature review is the background to the research, where it is important to demonstrate a clear understanding of the relevant theories and concepts, the results of past research into the area, the types of methodologies and research designs employed in such research, and areas where the literature is deficient" (p. 51).

The use of a literature review to identify existing gaps in the body of knowledge is also cited by Wood and Ellis (2003) who identified the following as important outcomes of a well-conducted review of the literature: a) It helps describe a topic of interest and refine either research questions or directions in which to look; b) It presents a clear description and evaluation of the theories and concepts that have informed research into the topic of interest; c) It clarifies the relationship to previous research and highlights where new research may contribute by identifying research possibilities which have been overlooked so far in the literature; d) It provides insights into the topic of interest that are both methodological and substantive; e) It demonstrates powers of critical analysis by, for instance, exposing taken for granted assumptions underpinning previous research and identifying the possibilities of replacing them with alternative assumptions; f) It justifies any new research through a coherent critique of what has gone before and demonstrates why new research is both timely and important.

With respect to the second component of the mixed methodology, qualitative researchers have a number of research designs available, including historical methodology, ethnography, phenomenology, hermeneutics, grounded theory, action research as well as the case study (Burton & Steane, 2004). With respect to the latter approach, Zikmund (2000) advises that the case study methodology is "an exploratory research technique that intensively investigates one or a few situations similar to the researcher's problem situation" (p. 722).

Likewise, Neuman (2003) reports that, "In case study research, researchers examine, in-depth, many features of a few cases over a duration of time. In a case study, a researcher may intensively investigate one or two cases or compare a limited set of cases, focusing on several factors" (p. 33). In fact, one of the major strengths of the case study approach is that a given topic can be investigated in depth and with greater attention to details that might be of interest to the researcher (Leedy, 1997).

As Feagin, Orum and Sjoberg (1991) point out, "The study of the single case or an array of several cases remains indispensable to the progress of the social sciences" (p. 1).

Generally speaking, case studies are used for three primary purposes: a) Where little or nothing is known about the phenomenon of interest, an intensive study of one or a small number of instances of it can be undertaken in order to produce detailed descriptions of typical cases; b) More usually, especially in research degree studies, case studies are used for explanatory purposes; and, c) Case studies can be particularly useful for producing theory (Thomas, 2004, pp. 128-129). A. Data Collection.

The data needed for the proposed study will be collected in two overlapping phases consisting of: 1. A review of the relevant peer-reviewed and scholarly literature concerning organizational culture in general and nursing culture in particular; and, 2. How this concept has been analyzed to identify its effects on nursing performance, patient outcomes and evidence-based care implementation and application. B. Data Analysis.

The secondary data developed for the literature review will be qualitatively synthesized with the results of the series of case studies following the guidance provided by Neuman (2003) and the results summarized in the study's concluding chapter together with salient findings and recommendations. VII. Limitations and Delimitations A. The primary limitation of the study proposed herein is its strict reliance on secondary data. In this regard, Dennis and Harris (2002) point out that, "Primary data are.

likely to be directly relevant to the research, unlike secondary data, which may be out of date or collected for a totally different purpose. Ideally, an effective research project should incorporate both primary and secondary data" (p. 39). This limitation also affects the proposed study delimitations, which are discussed further below. B.

The proposed study is delimited to the healthcare organizations that will be evaluated in the series of case studies; however, it is reasonable to suggest that similarly situated managers in healthcare organizations in other settings may gain fresh insights concerning their own unique organizational environment. VIII.

Significance of the Study The proposed study is significant for two important reasons: (a) a paucity of timely studies concerning the relationship between nursing culture and its effect on receptivity to change; and (b) increasing calls for evidence-based practices in healthcare organizations around the world.

With respect to the former, although there remains a profound need for additional studies concerning the relationship between nursing culture and how it can either create or eliminate barriers to change, the research to date suggests that it is possible to inculcate a patient-centered nursing culture that will improve nurse performance and patient outcomes in measurable ways.

For instance, a recent study by James and Chapman (2009) that examined nursing culture and how it was developed and sustained over time found that nursing students assigned a great deal of importance to the attitudes of experienced nurses. According to these researchers, "Students identified characteristics such as a consistent approach, a genuine nature, and respect, as qualities of positive role models, with such qualities determining the degree of success experienced on clinical placement" (James & Chapman, 2009, p. 37).

In addition, nursing culture has also been shown to be enhanced when trained nurses took time out to help student nurses, and provided them with the opportunity to have their concerns and questions aired (James & Chapman, 2009). Clinical rotations also provided these nursing students with the opportunity to understand the social context in which healthcare services are delivered and helps nursing students become accepted into the prevailing nursing culture (James & Chapman, 2009).

Although such social acceptance can be achieved at any point in time, professional acceptance into the prevailing nursing culture requires demonstrated competence (James & Chapman, 2009). With respect to the increasing calls for the use of evidence-based practices in healthcare organizations, the American Nurses Association reports that accountability measures are used to evaluate whether evidence-based care processes that are associated with the criteria set forth in Table 2 below resulted in positive patient outcomes; when new measures are introduced, they are measured against these criteria.

Table 2 Criteria for accountability measures Criterion Description Research: Strong scientific evidence demonstrates that performing the evidence-based care process improves health outcomes (either directly or by reducing risk of adverse outcomes). Proximity: Performing the care process is closely connected to the patient outcome; there are relatively few clinical processes that occur after the one that is measured and before the improved outcome occurs. Accuracy: The measure accurately assesses whether or not the care process has actually been provided.

That is, the measure should be capable of indicating whether the process has been delivered with sufficient effectiveness to make improved outcomes likely. No Adverse Effects: Implementing the measure has little or no chance of inducing unintended adverse consequences. Source: JCAHO Annual Report, 2011 The foregoing criteria can therefore be used to assess the efficacy of newly introduced practices, a feature that has become especially important in recent years.

Indeed, during the past 5 decades or so, the healthcare systems in the United States and other developed nations have experienced a series of rapid and significant changes that have been targeted at reducing costs, improving patient outcomes and increasing accountability levels among providers at every level.

Because compliance with Joint Commission on Accreditation of Healthcare Organization (JCAHO) standards is required by many tertiary healthcare providers as well as the range of disciplines that comprise them in other clinical settings, it just makes good business sense to do them as efficiently and expertly as possible in order to achieve the maximum return on investment in organizational resources in terms of improved patient outcomes and reduced costs such as those associated with lengths of stay, nosocomial infection levels and other sentinel events using evidence-based practices.

In this regard, the current JCAHO guidance and representative nursing codes of conduct concerning the use of evidence-based practices is set forth in Table 3 below. Table 3 Current guidance concerning evidence-based care Source Description Department of Health (2000). The NHS Plan: A Plan for Investment, A Plan for Reform. London: The Stationery Office. In order to be credible, healthcare professionals must demonstrate effective integration of evidence, including research findings, into their clinical decision-making.

In the UK, political agendas support the move towards evidence-based practice in their pursuit of improvements in the quality of healthcare. There is an expectation that care should be patient-centered and clinically effective. The introduction of clinical governance, designed to ensure efficient and effective healthcare, requires practitioners to demonstrate that they are using evidence-based practice in supporting service developments. This demands that nurses base their practice on the best available evidence. Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 1.

Top-performing healthcare organizations hospitals have achieved exemplary performance in using evidence-based care processes closely linked to positive patient outcomes. 2. Accountability measures are evidence-based care processes closely linked to positive patient outcomes. These measures are most suitable for use in programs that hold providers accountable for their performance to external oversight entities and to the public. 3.

Most of the measures used through 2010 are categorized as accountability measures; there are six non-accountability measures: smoking cessation advice (heart attack care, heart failure care and pneumonia care); discharge instructions and LVS function assessment (heart failure care); and antibiotic within six hour of arrival (pneumonia care). 4. A 95% score means.