Additional Learning Exercises and Applications
DISPLAY 12.3 Assessing the Organizational Culture
may differ.
Although assessing unit culture is a management function, building a constructive culture, particularly if a negative culture is in place, requires the interpersonal and communication skills of a leader. The leader must take an active role in creating the kind of organizational culture that will ensure success. The more entrenched the culture and pattern of actions, the more challenging the change process is for the leader. Given such entrenchment of culture, success in building a new culture may require new leadership and/or assistance by the use of outside analysis.
For example, many health-care organizations continue to report challenges in establishing a culture where evidence-based practice (EBP) is the norm. Often, this is because senior management or organization leaders have not taken an active role in emphasizing the importance of this culture change or have not provided adequate resources (fiscal or human) to support the culture change.
Organizations, if large enough, also have many different and competing value systems that create subcultures. These subcultures shape perceptions, attitudes, and beliefs and influence how their members approach and execute their particular roles and responsibilities. A critical challenge then for the nurse-leader is to recognize these subcultures and to do whatever is necessary to create shared norms and priorities.
Managers must be able to assess their unit’s culture and choose management strategies that encourage a shared culture. Such transformation requires both management assessment and leadership direction.
In addition, much of an organization’s culture is not available to staff in a retrievable source and must be related by others. For example, feelings about collective bargaining, nursing education levels, nursing autonomy, and nurse–physician relationships differ from one organization to another. These beliefs and values, however, are rarely written down or appear in a philosophy. Therefore, in addition to creating a constructive culture, a major leadership role is to assist subordinates in understanding the organization’s culture. Display 12.3 identifies questions that leaders and followers should ask when assessing organizational culture.
6. Does the organization help pay for the holiday party or other social functions?
What Is the Organizational Power Structure?
1. Who holds the most power in the organization?
2. Which departments are viewed as powerful? Which are viewed as powerless?
3. Who gets free meals? Who gets special parking places?
4. Who carries beepers? Who wears laboratory coats? Who has overhead pages?
5. Who has the biggest office?
6. Who is never called by his or her first name?
How Safe Is the Organization?
1. Is there a well-lighted parking place for employees arriving or departing when it is dark?
2. Is there an active and involved safety committee?
3. Are security guards needed and visible?
What Is the Communication Environment?
1. Is upward communication usually written or verbal?
2. Is there much informal communication?
3. Is there an active grapevine? Is it reliable?
4. Where is important information exchanged—in the parking lot, the doctors’ surgical dressing room, the nurses’ station, the coffee shop, or during surgery or during the delivery room?
What Are the Organizational Taboos? Who Are the Heroes?
1. Are there special rules and policies that can never be broken?
2. Are certain subjects or ideas forbidden?
3. Are there relationships that cannot be threatened?
LEARNING EXERCISE
12.3
Cultures and Hierarchies
H
aving been with the county health department for 6 months, you are very impressed with the physician who is the county health administrator. She seems to have a genuine concern for patient welfare. She has a tea for new employees each month to discuss the department’s philosophy and her own management style.She says that she has an open-door policy, so employees are always welcome to visit her.
Since you have been assigned to the evening immunization clinic as charge nurse, you have become concerned with a persistent problem. The housekeeping staff often spend part of the evening sleeping on duty or socializing for long periods. You have reported your concerns to your health department supervisor twice. Last evening, you found the housekeeping staff having another get-together. This mainly upsets you because the clinic is chronically in need of cleaning. Sometimes, the public bathrooms get so untidy that they embarrass you and your staff. You frequently remind the housekeepers to empty overflowing wastepaper baskets. You believe that this environment is demeaning to patients. This also upsets you because you and your staff work hard all evening and rarely have a chance to sit down. You believe it is unfair to everyone that the housekeeping staff is not doing its share.
On your way to the parking lot this evening, the health administrator stops to chat and asks you how things are going. Should you tell her about the problem with the housekeeping staff? Is this following an appropriate chain of command? Do you believe that there is a conflict between the housekeeping unit’s culture and the nursing unit’s culture? What should you do? List choices and alternatives. Decide what you should do and explain your rationale.
A S S I G N M E N T:
Note: Attempt to solve this problem before referring to a possible solution posted in the Appendix.
Shared Governance: Organizational Design for the 21st Century?
Shared governance, one of the most innovative and empowering organization structures, was developed in the mid-1980s as an alternative to the traditional bureaucratic organizational structure. A flat type of
organizational structure is often used to describe shared governance but differs somewhat, as shown in Figure 12.4. In shared governance, the organization’s governance is shared among board members, nurses,
physicians, and management. Thus, decision making and communication channels are altered. Group structures, in the form of joint practice committees, are developed to assume the power and accountability for decision making, and professional communication takes on an egalitarian structure.
In health-care organizations, shared governance empowers decision makers, and this empowerment is directed at increasing nurses’ authority and control over nursing practice. Shared governance thus gives nurses more control over their nursing practice by being an accountability-based governance system for professional workers.
The stated aim of shared governance is the empowerment of employees within the decision- making system.
In addition, shared governance can be used to improve communication and joint decision making between nursing and other members of the interprofessional health-care team. Torres et al. (2015) describe how implementation of a shared governance model brought nursing and therapists on a brain injury (BI) team together to discuss and better understand challenges faced by each discipline. The end result was improved staff communication, problem solving, patient outcomes, and staff satisfaction (see Examining the Evidence 12.1).
EXAMINING THE EVIDENCE 12.1
Source: Torres, A., Kunishige, N., Morimoto, D., Hanzawa, T., Ebesu, M., Fernandez, J., . . . Borg, S.
(2015). Shared governance: A way to improve the care in an inpatient rehabilitation facility.
Rehabilitation Nursing, 40(2), 69–73. doi:10.1002/rnj.143
Communication in the BI unit of a free-standing inpatient rehabilitation facility was a constant challenge due to the fragmented communication among
disciplines. The gaps between the expectations and responsibilities of each discipline led many staff to feel unheard, frustrated, and in some cases, angry.
Shared governance was identified as a possible solution based on common professional values and the principles of autonomy, shared decision making, and engaged participation.
The shared governance group included the following members from each discipline: physical therapy, occupational therapy, speech therapy, registered nursing, and a nurse’s aide. One member of management (nursing or therapy) was assigned to attend each meeting to oversee the discussion and follow-up on any management action items. The team agreed to trial a shared governance group for at least 6 months; during the first 6 months, the team met weekly for 30 minutes due to the significant number of issues presented.
On more than one occasion, the group discussed the same topic to identify the root cause of a problem and to develop a shared understanding of an issue.
The level of accountability on the unit improved as the shared governance group evolved and the team was transformed to provide patient-centered care at a deeper level. The shared governance members became ambassadors for change and were accountable to share information and discuss process changes with their discipline; program implementation was a huge success.
Although participatory management lays the foundation for shared governance, they are not the same.
Participatory management implies that others are allowed to participate in decision making over which someone has control. Thus, the act of “allowing” participation identifies the real and final authority for the participant.
There is no single model of shared governance, although all models emphasize the empowerment of staff nurses. Generally, issues related to nursing practice are the responsibility of nurses, not managers, and nursing councils are used to organize governance. These nursing councils, elected at the organization and unit levels, use a congressional format organized like a representative form of government, with a president and cabinet.
Typical governance councils include a nursing practice council, a research council, professional development and/or education council, a nursing performance improvement or quality council, and a
leadership council. Sometimes, organizations will have a retention council as well. The councils participate in decision making and coordination of the department of nursing and provide input through the shared
governance process in all other areas where nursing care is delivered.
The number of health-care organizations using shared governance models is continuing to increase.
However, a major impediment to the implementation of shared governance has been the reluctance of managers to change their roles. The nurse-manager’s role becomes one of consulting, teaching, collaborating, and creating an environment with the structures and resources needed for the practice of nursing and shared decision making between nurses and the organization. This new role is foreign to many managers and difficult to accept. In addition, consensus decision making takes more time than autocratic decision making, and not all nurses want to share decisions and accountability. Although many positive outcomes have been attributed to implementation of shared governance, the expense of introducing and maintaining this model also must be considered because it calls for a conscientious commitment both on the part of the workers and the organization.
Shared governance requires a substantial and long-term commitment on the part of the workers and the organization.
Magnet Designation and Pathway to Excellence
During the early 1980s, the American Academy of Nursing (AAN) began conducting research to identify the characteristics of hospitals that were able to successfully recruit and retain nurses. What they found were high-performing hospitals with well-qualified nurse executives in a decentralized environment, with organizational structures that emphasized open, participatory management.
A desire to formally recognize these high-performing hospitals was accomplished when the American Nurses Association (ANA) established the American Nurses Credentialing Center (ANCC) in 1990. Later the same year, the ANA Board of Directors approved the establishment of the Magnet Hospital Recognition Program for Excellence in Nursing Services. The term Magnet was used to denote organizations that were able to attract and retain professional nurses. “Magnet status is not a prize or an award. Rather, it is a credential of organizational recognition of nursing excellence” (ANCC, 2016c, para. 2).
Earning a Magnet designation is not easy. Currently, only about 7% of all registered hospitals in the United States have achieved ANCC Magnet Recognition status (ANCC, 2016c). To achieve designation as an organization, the organization must create and promote a comprehensive professional practice culture. Then it must apply to ANCC, submit comprehensive documentation that demonstrates its compliance with standards in the ANA Scope and Standards for Nurse Administrators, and undergo a multiday onsite evaluation to verify the information in the documentation submitted and to assess the presence of five model components within the organization (ANCC, 2016d) (Display 12.4).