Nursing Culture: Overcoming Organizational 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 to identify 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 considered by the study proposed herein and which is discussed further below.

According to Mannion, Davies, and Marshall (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).

Statement of the Problem

Organizational culture in general, and nursing culture in particular, can have a profound effect on performance and patient outcomes, as well as on receptivity 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.

The review of the relevant literature is 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.

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 describes how things are done in a given workplace setting. Notwithstanding this straightforward definition, the concept of "culture" has been treated differently by different authors, and a number of different approaches to measuring and assessing organizational culture have been offered as a result (Recardo & Jolly, 1999).

Review of the Literature

Recardo and Jolly (1999) identify eight key dimensions of organizational culture, summarized below.

Communications involves the number and types of communication systems, what information is communicated and how, the direction of communications (top-down, bottom-up, or three-way), whether communications are filtered or open, whether conflict is avoided or resolved, and whether formal or informal vehicles are used to transmit and receive information.

Training and Development focuses on employee skill acquisition. Key indices include management's commitment to providing developmental opportunities and how well the organization allows new skills or behaviors to be applied on the job, with particular attention to whether management is focused on current or future developmental needs.

Rewards concerns what behaviors are rewarded and the types of rewards used — whether employees are rewarded individually or as a group, who is eligible for bonuses, what the criteria for advancement are, how performance standards are developed, the perceived equity of rewards, and the degree to which performance feedback is provided.

Decision Making addresses how decisions are made and conflicts resolved, whether the organization is highly bureaucratic, and whether decision-making is centralized or decentralized.

Risk Taking concerns whether creativity and innovation are valued and rewarded, whether calculated risk-taking is encouraged, whether there is openness to new ideas, and whether people are penalized for questioning existing practices.

Barriers to Change in Healthcare Organizations

Planning examines whether the organization emphasizes long-term or short-term planning, whether planning is proactive or reactive, how widely strategy and goals are shared with employees, and the degree to which employees are committed to achieving organizational objectives.

Teamwork relates to the amount, type, and effectiveness of cooperation within the organization, including trust between different functions or units and the level of automation used to support work processes. Notably, an atmosphere of teamwork does not necessarily mean formal teams must be used; research scientists, for instance, may collaborate closely without constituting a formal team.

Management Practices measures the fairness and consistency with which policies are administered, management's accessibility 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. 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 shapes receptivity to change initiatives, discussed further below.

Healthcare providers are no different from any other professionals in their resistance to change. Empirical observations and numerous studies have confirmed that some clinicians cling to "old school" practices even when confronted with mounting evidence of their inferiority compared to more modern, evidence-based practices. Change can be painful and require far longer than many managers might expect. 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 in their careers. James and Chapman (2009) found that as nurses progress through their clinical placement rotations, their confidence levels increase and their ability to deliver appropriate nursing services improves. Conversely, when nurses were placed in unfamiliar settings where routines were unclear or 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 only within the lower echelons of an organization; an organization's leadership team may also be reluctant to change for the same or different reasons, and this reluctance manifests itself in different ways (Moore et al., 2002). 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 at all levels of an organization, substantive change requires an across-the-board shift from the existing organizational culture 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 appropriate to the change and take steps to address any perceived losses on the part of stakeholders in order 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 and fail, they will be regarded as ineffectual, and a loss of faith and loyalty to the organization can result (Moore et al., 2002). 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 remain 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).