Climate and Culture
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climate. Likewise, the process elements of climate include supervision, work design, group behavior, and emphasis on quality that is driven by patient centeredness, safety, innovation, and evidence- based practice. Taken together, these components are likely to have an effect on nurse and patient outcomes.
Patient Safety Culture and Climate
Since the publication of the Institute of Medicine report To Err is Human: Building a Safer Health System (Kohn et al., 2000) suggesting that 98,000 persons die in hospitals because of errors, an emphasis on an organization’s patient safety cul- ture and climate has driven both research and change in hospital practices. A safety culture is an outgrowth of the larger organizational cul- ture and emphasizes the deeper assumptions and values of the organization toward safety, whereas the safety climate is the shared percep- tion of employees about the importance of safety within the organization (DeJoy et al., 2004). Like organizational climate, the safety climate has a number of different components including lead- ership, involvement, blameless culture, com- munication, teamwork, commitment to safety, beliefs about errors and their cause, and others (Blegen et al., 2005).
Safety climate refers to keeping both patients and nurses safe. Keeping an “eye out” for patients is at the heart of safety. Nurses, who are on the front line of patient care, are in the best position to monitor patients to prevent adverse events or near misses of adverse events. The ability of nurses to know the patients and recognize early critical warning signs is a skill derived from knowledge, not a simple task application. Astute recognition of deviations from normal and timely intervention signify that nurses know their patients and are capable of res- cuing them from an adverse event. Knowledge of the patient is derived through subjective, objec- tive, and intuitive observations that are honed as nurses develop a level of expertise in working with specific patient populations. Factors that influence nurses’ ability to watch over patients to avoid errors and adverse events include being short staffed or
fatigued from working overtime or lacking educa- tion and experience (Hinshaw, 2008).
Included in the concept of a safety climate is a focus on nurses’ health. Nurses working in hospi- tals have one of the highest rates of work-related injuries, especially back injuries and needlesticks (Mark et al., 2007). As with patient safety, when fewer nurses are working, less help is available to provide care to patients. This results in more work needing to be done in a shorter time. Both of these factors can lead to taking shortcuts that can result in injury.
Regardless of whether the focus of safety is on the patient or the nurse, the likelihood of injury can be lessened where there is a cohesive team.
When there is a shared perception among a group of nurses about the value and importance of safety, they are more likely to work together effectively toward common goals. In believing that the safety climate values learning in preventing, detecting, and mitigating the effect of errors and injuries, the likelihood of improving outcomes increases. As nurses work together as a team, they share infor- mation, can anticipate events, and are more likely to respond positively to unanticipated events.
One major shift in an organization’s safety cli- mate is the move from a punitive environment to one that is characterized as a fair and just culture.
David Marx (2001) suggested that in a just culture, organizational, individual, and interpersonal learn- ing are balanced with personal accountability and discipline. In a fair and just culture, expectations for system and individual learning and account- ability are transparent. Underlying these beliefs, an organizational strategy needs to be identified that can effectively implement just such a fair and just culture. When an organization, such as a hospital, can freely discuss mistakes with the intention of learning from them and when it takes the time and resources needed to understand the mistakes (e.g., root cause analysis), the organizational culture changes from a “who dunnit?” to an environment that is respectful and open to learning (Connor et al., 2007). Within a systems-oriented approach, learning from adverse events and unproductive successes can lead to new wisdoms and new ways
of doing things. When a systems approach under- lies learning and is the concern of everyone, knowledge that is gained from it becomes wide- spread for common use by everyone (Institute of Management Administration, 2000).
Learning Culture and Climate
Access to new information is occurring at a record pace, and organizations need to keep up with new information and ways of practicing. In a learning culture, the norms and assumptions for learning lead to behaviors that support continuous learn- ing (Daft, 2001). A learning climate is character- ized by a shared and positive perception of the value of learning to enhance practice, quality, and outcomes. The emphasis on developing a cul- ture of learning stems from at least three major trends affecting health care. The first is the focus on patient safety in which learning and account- ability are guideposts for error control. Second is the emphasis on evidence-based research and translating findings into practice, and third is the explosion of information technology in health care delivery that increases access and transpar- ency of care.
One area that is motivating and sustaining a learning environment for nurses is linked to a hos- pital’s aspiration to achieve Magnet™ status. In the journey toward Magnet™ designation, research, and evidence-based practice become important in meeting the core criteria. Cultures in which con- tinuous learning is valued are less likely to become outdated and stale. In the past, it was not unusual to hear nurses say in relation to their practice,
“We have always done it that way.” Today, a learn- ing environment fosters nurses to propose new ideas. Moving new research findings into practice has historically taken many years. In a continu- ous learning culture, nurses are challenged to ask,
“How can this be done better?” Nurses interact with many patients on a daily basis. Patients are experts about themselves, and nurses are expert about nursing practice. Blending these areas of expertise best positions nurses to ask the question
“How can practice and the environment in which practice occurs be improved?” Nursing practice
becomes a daily venue for generating questions that are important to practice.
Culture and group norms can have a profound impact on the shared values that are expressed by nursing staff on individual work units in the hos- pital setting (Koerner, 1996). The formation of the team at the unit level holds a collective vision for continuous learning. In turn, the norm for learn- ing intersects with the desire for good practice and forms a cohesive unit that shares a value for learn- ing that generates excitement for moving beyond traditional practice. Cultures and climates in which knowledge is freely shared can have a groundswell effect. Examples of outward and visible signs that support nurses-shared values for inquiry include journal clubs, unit presentations, poster displays, and participation in evidence-based research teams.
LeaDership anD ManageMent iMpLiCatiOns
Culture is characterized by complexity, tangibles, and intangibles and is relatively enduring, making it hard to change. Climate, on the other hand, is easier to change. Regardless, the basic elements that constitute culture and climate must be understood before any change. Change that begins at the unit level may be most influenced by nursing leadership.
Nurses have the ability to create or change a work culture or climate to accomplish a change that may affect productivity, satisfaction, and safe quality patient-centered care.
The role of a nursing leader extends well beyond a formal title into the realm of informal influence to affect culture and the climate. A primary task of the leader is to create a vision so convincing that the entire team is inspired to engage and move forward. Values drive behaviors. The leader com- municates this vision by influencing norms and values and creating a shared perception through role modeling and ensuring role clarity, account- ability, and a work environment that promotes safe patient-centered care.
Nursing unit leadership, particularly that of the nurse manager, is key to creating a positive unit
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Chapter 4 Organizational Climate and Culture 87
climate that promotes effective unit functioning and quality care (Sorrentino et al., 1992). Unit- based nurse managers serve as bridges between the senior nursing leadership and their staff who are frontline providers. By virtue of their position, they are instrumental in shaping and managing the core values of their staff (Anthony et al., 2005).
“Nurse managers have multiple and competing demands that they must balance in defining, pri- oritizing, and implementing their role responsibil- ities to meet the goals of the organization as well as those of the profession” (Anthony et al., 2005, p. 146). Increasingly, studies are showing that the nurse manager is important in retention (Anthony et al, 2005; Boyle et al., 1999; Taunton et al., 1997), professional practice (Manojlovich, 2005), and work environments (Upenieks, 2003). However, this influence is diluted when nurse managers are managing too many units or across too many areas and need to create and support a climate unique to each unit (Kimball & O’Neill, 2002).
Key areas within the leader’s scope of control are recruiting and retaining staff, welcoming new staff, providing orientation, celebrating and recognizing staff accomplishments, facilitating change, and promoting a learning environment. Unit climate
is evident in how policies are enacted, unit norms, dress code and appearance, environment, commu- nication, and teamwork. The nurse manager can articulate the vision, mission, and goals of the orga- nization and work with staff to translate them into unit-level values for performance, thus linking the context of the organization to clinical practice.
Values drive the way resources are distributed.
They contribute to a general attitude and sense about the quality of working life and reflect the organization’s core goals. Clues can be gleaned from organizational documents such as philoso- phy statements and meeting minutes. Caring val- ues of the organization are reflected in the way the organization treats its staff. Organizational values may not mirror professional values. The leader’s role is to bridge such values with the values of indi- vidual team members to construct unit climate.
Values support the mission and the related vision, which support strategies and action plans. The key platform is shared values. Given the complexity and diversity of the nursing workforce, developing and sustaining a set of shared values is no easy task and requires leadership skill.
Leaders are expected to chart a clear course for change and mobilize staff to accomplish
Leadership Behaviors
• envisions a dynamic culture
• inspires a creative climate
• Models constructive interpersonal relationships
• enables followers to be productive
• influences others to work together
• Creates shared values
• develops stories, rituals, and metaphors
• Bridges organizational, unit, and professional goals
• Promotes values that emphasize safety and learning
Management Behaviors
• Manages the structure to affect culture positively
• Models constructive interpersonal relationships
• acts with equity and justice
• Maintains rituals and ceremonies
• influences employees to work together
• Promotes values that emphasize safety and learning
• Builds teams that are proactive and can handle unexpected situations
Overlap Areas
• Models constructive interpersonal relations
• influences the group to work together
• Promotes values that emphasize safety and learning
LeadeRShiP & MaNageMeNT behaviOrs
organizational goals. This means implement- ing change effectively. Effective cultural change requires communication, passion, and sense of the whole. The nurse manager can create such oppor- tunities through using focus groups, holding team meetings, coaching and mentoring, posting min- utes from staff meetings, consulting communi- cation books, and empowering staff by soliciting their input. The value of communication cannot be overstated. Much of the work is common sense, but the importance of doing this work lies in care- fully attending to the basic change process as a way to avoid the need for damage control later.
Peters and Waterman (1982) stressed that the greatest need people have is to find meaning in their work life. The job of managers is to help better create meaning through the use of stories, slogans, symbols, rituals, legends, and myths that convey the values, beliefs, and meanings shared among the staff. These managers have to function as passionate leaders to motivate staff.
The challenges of leadership belong to every nurse, not just those in formal management roles.
Leadership at the staff level may simply take a dif- ferent form—for example, a staff nurse adapting to a challenging patient assignment, taking initiative to change practice through performance improve- ment, or challenging the status quo is participat- ing in unit culture construction. Further, staff nurses are critical to founding and maintaining a Magnet™-designated organization.
Implications
Nurse leaders armed with a valid and reliable assessment of current work cultures can identify strategic target areas for change. A thorough under- standing of organizational culture and unit climate is a powerful diagnostic tool that may be used to identify both troubled units and high-performance areas. An effective organizational culture empow- ers nurses to practice fully within the scope of their knowledge and education. This may be seen in fail- ure-to-rescue rates. Variance in failure-to-rescue rates for adverse events may signal key differences in work cultures within a hospital structure (Aiken et al., 1994).
The culture of a nursing unit practice envi- ronment may exert a significant and indepen- dent effect beyond that of staffing and skill mix by enhancing or impeding interventions once prob- lems are detected. Nurses serve as the surveillance system for early detection of adverse events. The right number of nurses may have less influence on patient outcomes than the organization and struc- ture of the work environment itself for nurses, including the perceived level of autonomy, the amount of control over their practice, and effective collaboration with physicians (Aiken et al., 2001;
Sochalski et al., 1999; Sovie & Jawad, 2001).
Current issues anD trenDs
At the beginning of the chapter, a number of forces were identified that have had significant influ- ence in changing the culture of health care deliv- ery. Several of these forces have particular impact on nursing care, and a brief discussion of them follows.
Patient-Centered and Family-Centered Care The Institute of Medicine’s Crossing the Quality Chasm (2001) has identified that the culture of patient care must transition from care that is driven by providers to care that is patient-centered and family-centered in which patient and fam- ily norms, values, and preferences are respected.
The National Healthcare Quality Report from the Agency for Healthcare Research and Quality (2002) defined two aspects of patient-centered care: the patient experience and patient partnerships. The patient’s experience of care includes communica- tion, care, and understanding of the meaning of his or her illness. This approach changes the per- spective from a patient with a disease to that of an individual with an experience.
Patient partnerships, the second dimension of patient-centered care, are formed when nurses are responsive to patient needs, values, and prefer- ences and then customize the care to the patient.
For example, when doing discharge teaching, infor- mation that is of high importance and value to the patient is addressed first in a patient-centered
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Chapter 4 Organizational Climate and Culture 89
model of care. As patient advocates, nurses can be leaders in transitioning an organizational cul- ture from provider-driven care to care that is truly patient-centered.
Generational Diversity and the Nursing Shortage
The importance of a positive work climate on organizational, patient, and nurse outcomes is firmly established and evidence-based. However, creating a work environment for nurses that meets their personal and professional values is a challenge for most nursing leaders. Nurses from the Baby Boomer generation and Generation X make up more than 80% of the nursing workforce (U.S. Department of Health and Human Services, 2004). Because nurses from each of these gener- ations were raised with a different set of priorities and values, a work environment supportive to each generation is an important retention strategy. For example, Baby Boomer nurses value rewards.
Recognition and pay may be motivators for them.
In contrast, Generation X nurses are concerned with a better balance of work and life (Duchscher &
Cowin, 2004). In its 2002 report “Health Care’s Human Crisis: The American Nursing Shortage,”
the Robert Wood Johnson Foundation provided
a comprehensive overview of the nurse shortage.
A core recommendation was the need to reinvent work environments to address and appeal to needs and values of both new and experienced genera- tions of nurses (Kimball & O’Neill, 2002).
Tailoring the work environment to meet gener- ational and life-stage needs is a recurrent theme in being able to successfully address the shortage and deliver the desired care system. The current and future workforce shortages are compelling realities that have relevance for organizations and leaders who must create cultures that promote a positive work environment for all employees.
Models of Care
A movement is underway to shift from restructur- ing to developing unit-level models of care that will transform health care systems. Multiple inter- nal and external forces require financial account- ability, competitive posture, and change in the structure of care processes. Ensuring the delivery of safe and effective quality care demands flexi- bility and engagement of leaders and staff nurses in changing work processes. The term model of care surfaces frequently; however, the specifics of how to construct such a model seem elusive.
A direct link exists between this concept and culture.
practical tips
Tip #1: Examine the Socialization of New Nurses
examine the practices of how new nurses are socialized to your unit. do the practices reflect the values of your unit?
Of your organization?
Tip #2: Understand Unit Climate and Diverse Workforce
at the next staff meeting, ask your staff to identify three areas that would improve the climate of the unit. Note whether nurses from different generations focus on different aspects of the work environment.
Tip #3: Generate Enthusiasm for Learning
For the next month, listen to what staff members mention during report, in rounds, or in general conversation about ways to improve practice. Write down this information, and keep a running list. at a subsequent staff meeting, let staff know how often they had ideas to improve practice and the content of their suggestions. Form a task force of interested staff to choose one of those suggested improvements and begin a search for the evidence.
Development of a new model must be preceded by assessment of the unit culture, an understand- ing of the patient population, what members of the staff need to care for them, and what roles are required to form the unit team. There is no one right model, nor does one size fit all settings.
The work entails a deliberative process to facilitate change that will improve outcomes. Culture devel- opment must be an essential component of any new model development.
summary
•
Understanding organizational culture is important for successful functioning.•
Culture gives meaning to behavior and influ- ences decision making.•
Culture is shared values and beliefs.•
Culture is determined by organizational factors that are both visible and invisible.•
Climate is the perception of what it feels like to work on a specific unit.•
Climate has elements that can be identified and measured.•
Cultures and climate can and should be built and sustained by nurse leaders with staff.•
Culture and climate elements can influence patient outcomes and retention.•
A positive patient safety climate is one in which there is a balance of learning and accountability.•
Learning climates value curiosity that leads to new ideas, thinking, and practices.Case Study
In response to an anticipated workforce shortage, the patient service leadership team of one organi- zation elected to collaborate with human resources to develop a strategy for future success. It quickly
became clear that planning for the shortage trans- lated to crafting a plan for the future and was far greater than recruitment and retention. The work evolved into a broad initiative with a vision, guid- ing principles, core strategies, expected outcomes, and development of a leadership infrastruc- ture. This work, called Striving for Excellence, was intended to change the culture. The work plan included extensive communication of the vision, identification of key stakeholders, assessment of the current and desired future state, gap analysis, and implementation plan. The vision was trans- lated into actionable concrete steps that engaged nurse managers and staff at the unit level in the change process.
A nurse manager identified patient safety as a high-risk issue for the population of children on an inpatient psychiatric unit. A review of the lit- erature substantiated that traumatic sequelae resulted from the use of restraints. Furthermore, regulatory agencies mandated a reduction in the use of restraints.
Challenges facing this manager were cultural resistance, knowledge deficits, and a changing patient population. The Striving for Excellence vision served as a unifying concept, and change theory provided the framework for mobiliz- ing staff commitment. Psychodynamic concepts helped ensure that the change was integrated into clinical practice. Use of restraints was viewed as a treatment failure, and staff experienced a shift in thinking; that is, interventions moved from stop- ping aberrant behavior through use of restraints to reflection about what the behavior meant.
Outcomes demonstrated a 60% reduction in the use of restraints; this resulted in a sustained change in practice for that nursing unit and has been recognized as a best-practice model. The nurse manager astutely summarized the real work as culture change.