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...

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…