Article

Facilitating Innovation at the Nursing Unit Level Through Cultural Assessment, Part 1

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  • A scholarly journal of the American Nurses Association
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Abstract

The early hopes and expectations of organizational culture often fail to materialize because the nature of organizational culture is not understood. This article describes what culture is, explains where culture comes from, and analyzes the variety of subcultures that can exist in healthcare organizations. In so doing it explores why managerial ideas for change are not automatically implemented by organizational members. The importance of assessing a group's culture before implementing change is discussed. Tools for assessing the work group culture of a nursing unit are presented. Part 2 (May 1993) will describe a five-step process to strengthen the forces that drive cultural change and overcome forces that resist innovation.

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... Culture may also be thought of as a potential social control system that is finely tuned (Greenwood et al., 2000). Culture is a pattern of behaviour that is unique to each group, and those group members can have a significant impact on determining the prevailing culture (Coeling and Simms, 1993a). The culture in a specific unit can be a determining factor for the success or failure of implementing change (Everson-Bates, 1992). ...
... The measurement of an organisation's culture or the subcultures has been described using various tools (Seago, 1997;Scott et al., 2003). One specific tool is the Nursing Unit Cultural Assessment Tool (NUCAT) developed by (Coeling and Simms, 1993a) and measures the professional subculture of nursing within an organization. ...
... Following the collation of the results, the researchers provided feedback to the nurses on their cultural patterns, behaviours and together with the staff and nursing unit manager, identified areas and made recommendations for change. Coeling and Simms (1993a) developed the Nursing Unit Cultural Assessment Tool-2 (NUCAT-2). This tool assesses 50 different behaviours that have been found to be valid indicators for measuring nursing culture. ...
The Australian New Zealand Neonatal Network undertook a project to close the evidence practice gap for the management of newborn pain in neonatal units within Australia. The aim was to establish a process for using evidence to support practice change and in doing so close the existing practice evidence gap for newborn pain. An implementation model using a clinical network with state facilitators, local champions and project teams was used in 24 tertiary units and six district hospitals throughout Australia. The process included audit and feedback, benchmarking, educational workshops on critical appraisal and audit of family awareness of pain. Multiple types of data were collected to enable changes in practices for pain management to be evaluated. There was a 21% overall improvement in the number of infants receiving breastfeeding or sucrose for procedural pain, however, breastfeeding rates remain poorly utilised. The use of a pain assessment tool increased from 14% to 22%, with 56% of units introducing the use of an assessment tool into their practice. Families became more aware that their infant can experience pain and strategies to manage the pain (from 19% to 57%) project through distribution of information. The networks for the uptake of evidence program have enabled the topic of procedure pain in neonates to be evaluated. We have shown that through a well planned program of coordination, facilitation and using local champions and project teams a change in practice can occur.
... An examination of the cohesion amongst hospital nurses can be viewed from the perspective of organizational culture (Coeling & Simms 1993). Much has been written on the in¯uence of organizational culture on the work experiences of employees. ...
... Hofsteade (1980) asserts that what a group does and how they work together re¯ects this organizational culture. Thus, what the group members say and do can imply cultures (Coeling & Simms 1993). Therefore, nurses' perceptions of their working relationships with other nurses is one indicator of their work culture. ...
... Interactions, behaviours and artefacts were manifestations of a group's culture. Coeling and Simms (1993) asserted that while a culture may be very broad, it manifests itself in behaviours of the individuals within it; thus a group's culture can be inferred from its behaviours. They suggested that various professionals, and even groups within the professions, will have their own cultures. ...
Article
Cohesion among nurses: a comparison of bedside vs. charge nurses’ perceptions in Australian hospitals Aim. This study examines the extent to which hospital nurses view their working environment in a positive sense, working as a cohesive group. Background. Despite the fact that nursing in Australia is now considered a profession, it has been claimed that nurses are an oppressed group who use horizontal violence, bullying and aggression in their interactions with one and other. Methods. After ethical approval, a random sample of 666 nurses working directly with patients and all 333 critical care nurses employed in three large tertiary Australian hospitals were invited to participate in the study in the late 1990s. A mailed survey examined the perceptions of interaction nurses had with each other. The hypothesis, that level of employment (either Level I bedside nurses or Level II/III clinical leaders) and area of work (either critical care or noncritical care) would influence perceptions of cohesion, as measured by the cohesion amongst nurses scale (CANS) was tested. Results. In total 555 (56%) surveys were returned. Of these, 413 were returned by Level I and 142 by Level II/III nurses. Of this sample, 189 were critical care and 355 noncritical care nurses. There was no difference between Level I and II/III nurses in mean CANS scores. It is interesting to note that the item rated most positively was ‘nurses on the units worked well together’, however, the item rated least positive was ‘staff can be really bitchy towards each other’ for both Level I and II/III nurses. There was no difference in CANS scores between critical care and noncritical care nurses. Conclusions. Nurses working in Australian hospitals perceived themselves to be moderately cohesive but, as would be expected in other work settings, some negative perceptions existed.
... It develops as a means of survival to problems encountered by the group (Schein, 1985). As a result, members cling to the behaviours "in the same way a drowning person will cling to a life preserver when they are afloat in the middle of a raging sea" (Coeling & Sirnrhs, 1993a, p. 47). Finally, culture involves patterns of behaviour that, over time, combine to form a unique pattern distinctive to each organization. ...
... The initial survey tool was completed by 62 staff nurses to validate the cultural variables. The researchers stated the tool was pretested "... for retaining qualitative validity while gaining quantitative reliability and validity ..." (Coeling & Simms, 1993a, p. 52) although the results were not reported. The NUCAT reduces culture to numerical scores thereby omitting important dimensions such as complexity, subtlety and distinctiveness of culture. ...
... The members bring their own values, personalities and behaviours to the organization thus over time incorporating them into the culture. Different work groups develop different survival strategies that ultimately create a unique culture (Coeling & Simms, 1993a; del Bueno & Vincent, 1986; Schein, 1985 ...
... (20) . Algumas publicações analisam os aspectos conceituais ou modelos de cultura nas instituições de saúde (21)(22)(23)(24) . ...
... A cultura, enquanto um poderoso e sutil padrão de comportamento organizacional, pode facilitar ou dificultar a implementação de mudanças (21) . ...
... Assim como nas organizações em geral não existe uma cultura única nas organizações de saúde podendo ser identificadas diferentes subculturas, como, por exemplo, a subcultura do "staff" administrativo, a subcultura dos médicos de um setor, entre outra (21) . ...
Article
This study aims at presenting a literature review on the theme concerning organizational culture and at pointing out the subjacent assumptions to some theoretical and methodological conceptions. It focuses on health care and nursing studies.
... (20) . Algumas publicações analisam os aspectos conceituais ou modelos de cultura nas instituições de saúde (21)(22)(23)(24) . ...
... A cultura, enquanto um poderoso e sutil padrão de comportamento organizacional, pode facilitar ou dificultar a implementação de mudanças (21) . ...
... Assim como nas organizações em geral não existe uma cultura única nas organizações de saúde podendo ser identificadas diferentes subculturas, como, por exemplo, a subcultura do "staff" administrativo, a subcultura dos médicos de um setor, entre outra (21) . ...
Article
Full-text available
O objetivo deste artigo é apresentar uma revisão da literatura sobre a temática cultura organizacional apontando os pressupostos subjacentes às diferentes concepções teórico-metodológicas. Focaliza os estudos na área da saúde a da enfermagem.
... The field of organizational culture has a number of theorists, each of which have focused on subsets of perspectives or variables related to organizations. For example, some have reexamined the premises of organizational culture (Alvesson, 1989;Czarniawska-Joerges, 1992), while others have explored various characteristics or dimensions of culture (Coeling, 1997(Coeling, , 2000Coeling & Simms, 1993a;Kilmann et al., 1986). Schein (1992) and Cooke and his colleagues (Cooke & Lafferty, 1983Cooke & Rousseau, 1988;Cooke & Szumal, 1993 are well known for their studies of many organizations' cultures, and Schein, in particular, is regarded as a leading expert in studying the complexity of organizational relationships. ...
... Both Kilmann et al. (1986) and Coeling and Simms (1993a) describe other characteristics or dimensions important to group formation, such as the need for and type of communication patterns and the power of the groups and its effect on group cohesiveness. Saxton (1983, 1991) describe organizational dimensions of task support, task innovation, social relation, and personal freedom. ...
... In the field of health care and organizational culture, Cooke and Lafferty (1983 and Coeling and Simms (1993a) are frequently cited for their instrument development and its use. In nursing academic settings, instruments which have been used to examine faculty perceptions of organizational culture were those cited by Hokanson Hawks (1993) who used the Survey of Organizational Culture (Tucker et al., 1990), and Johnson (2001) who used the Organizational Culture Assessment (Cameron & Quinn, 1999). ...
... Each of these contributes to the degree of success of a given organization. Previous studies have stressed the need to understand the culture of the individual unit prior to implementing innovations or educational programmes (Schien 1990, Coeling & Simms 1993, Ingersoll et al. 2000 as organizational culture has been found to vary between units within the same organization (Coeling & Simms 1993, Adams & Bond 1997. It is, therefore, evident from the literature that workplace culture is multifaceted and asserts a major influence on individual and group behaviour, patient care, the change process, job satisfaction and ultimately organizational success. ...
... Each of these contributes to the degree of success of a given organization. Previous studies have stressed the need to understand the culture of the individual unit prior to implementing innovations or educational programmes (Schien 1990, Coeling & Simms 1993, Ingersoll et al. 2000 as organizational culture has been found to vary between units within the same organization (Coeling & Simms 1993, Adams & Bond 1997. It is, therefore, evident from the literature that workplace culture is multifaceted and asserts a major influence on individual and group behaviour, patient care, the change process, job satisfaction and ultimately organizational success. ...
Article
This paper presents findings from the first phase of a research study focusing on implementation and evaluation of emancipatory practice development strategies. Understanding the culture of practice is essential to undertaking effective developments in practice. Culture is a dominant feature of discussions about modernizing health care, yet few studies have been undertaken that systematically evaluate the development of effective practice cultures. The study intervention is that of emancipatory practice development with an integrated evaluation approach based on Realistic Evaluation. The aim of Realistic Evaluation is to evaluate relationships between Context (setting), Mechanism (process characteristics) and Outcome (arising from the context-mechanism configuration). This first phase of the study focuses on uncovering the context (in particular the culture) of the Special Care Nursery in order to evaluate the emancipatory practice development processes and outcomes. Data collection methods included survey, participant observation and interview. Cognitive mapping, constant comparative method and coding were used to analyse the data. Findings. Four key categories were identified: Teamwork, Learning in Practice, Inevitability of Change and Family-Centred Care and collectively these formed a central category of Core Values and Beliefs. A number of themes were identified in each category, and reflected tensions that existed between differing values and beliefs within the culture of the unit. Understanding values and beliefs is an important part of understanding a workplace culture. Whilst survey methods are capable of outlining espoused workplace characteristics, observation of staff interactions and perceptions gives an understanding of culture as a living entity manifested through interpersonal relationships. Attempts at changing workplace cultures should start from the clarification of values held among staff in that culture.
... There are both structured and unstructured methodologies for performing a culture assessment, but the basic tenets of all assessments involve listening and observing and can include both quantitative (e.g., number of nurses certifi ed) and qualitative (e.g., nurses' overall perception of management) data. For the unstructured approach, the nurse leader is simply an observer of norms and behaviors that form a specifi c culture (Van Ess Coeling & Simms, 1993). The unstructured approach is time and resource consuming, but may yield a richer and dynamic assessment. ...
... For example, a global view of organizational culture could be generated with the Competing Values Framework, but lack the level of detail required to guide an intervention. Studies designed to analyze the culture of a specific professional group may use more targeted tools, such as the Nursing Unit Cultural Assessment Tool (NUCAT2) (Coeling and Simms 1993). A study focusing on team functioning might use the Practice Culture Questionnaire to analyze the cultural issues underlying the willingness , or unwillingness, of primary care teams to engage with quality improvement initiatives. ...
Article
To review the quantitative instruments available to health service researchers who want to measure culture and cultural change. A literature search was conducted using Medline, Cinahl, Helmis, Psychlit, Dhdata, and the database of the King's Fund in London for articles published up to June 2001, using the phrase "organizational culture." In addition, all citations and the gray literature were reviewed and advice was sought from experts in the field to identify instruments not found on the electronic databases. The search focused on instruments used to quantify culture with a track record, or potential for use, in health care settings. For each instrument we examined the cultural dimensions addressed, the number of items for each questionnaire, the measurement scale adopted, examples of studies that had used the tool, the scientific properties of the instrument, and its strengths and limitations. Thirteen instruments were found that satisfied our inclusion criteria, of which nine have a track record in studies involving health care organizations. The instruments varied considerably in terms of their grounding in theory, format, length, scope, and scientific properties. A range of instruments with differing characteristics are available to researchers interested in organizational culture, all of which have limitations in terms of their scope, ease of use, or scientific properties. The choice of instrument should be determined by how organizational culture is conceptualized by the research team, the purpose of the investigation, intended use of the results, and availability of resources.
... The NUCAT3 was developed by Coeling [77,78]. The primary purpose of this tool is to describe and understand nurses' immediate work group in a unit setting. ...
Article
Full-text available
Organizational context plays a central role in shaping the use of research by healthcare professionals. The largest group of professionals employed in healthcare organizations is nurses, putting them in a position to influence patient and system outcomes significantly. However, investigators have often limited their study on the determinants of research use to individual factors over organizational or contextual factors. The purpose of this study was to examine the determinants of research use among nurses working in acute care hospitals, with an emphasis on identifying contextual determinants of research use. A comparative ethnographic case study design was used to examine seven patient care units (two adult and five pediatric units) in four hospitals in two Canadian provinces (Ontario and Alberta). Data were collected over a six-month period by means of quantitative and qualitative approaches using an array of instruments and extensive fieldwork. The patient care unit was the unit of analysis. Drawing on the quantitative data and using correspondence analysis, relationships between various factors were mapped using the coefficient of variation. Units with the highest mean research utilization scores clustered together on factors such as nurse critical thinking dispositions, unit culture (as measured by work creativity, work efficiency, questioning behavior, co-worker support, and the importance nurses place on access to continuing education), environmental complexity (as measured by changing patient acuity and re-sequencing of work), and nurses' attitudes towards research. Units with moderate research utilization clustered on organizational support, belief suspension, and intent to use research. Higher nursing workloads and lack of people support clustered more closely to units with the lowest research utilization scores. Modifiable characteristics of organizational context at the patient care unit level influences research utilization by nurses. These findings have implications for patient care unit structures and offer beginning direction for the development of interventions to enhance research use by nurses.
... The authors counsel researchers to choose an instrument to measure organisational culture that is closely aligned to the purpose and context of the proposed research. For example, investigators wishing to explore a global view of organisational culture may wish to use the Competing Values Framework designed by Cameron and Freeman (1991); those wishing to explore the culture of a particular organisational sub-group may therefore wish to use an instrument such as the Nursing Unit Cultural Assessment Tool (Coeling and Simms, 1993). There are also measurement issues to consider, such as whether a 'typological' or a 'dimensional' approach to culture is required; an issue which will be dependent on the design of the study, for example if it is wholly quantitative or qualitative or whether a large sample size is required. ...
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Central to the practice of professional nursing are the elements of accountability, autonomy, direct communication, and authority. The value that nursing work groups place on authority affects their level of acceptance of responsibility and accountability for clinical decision making. The authors examined the value that nurse managers and staff nurses on primary nursing and total patient care units place on authority/responsibility relationships. Results indicated that nurse managers and staff nurses on primary nursing units valued accountability, authority, and autonomy more than the nurse managers and staff nurses on total patient care units, a finding consistent with the professional practice model of primary nursing.
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Understanding your organizational culture is necessary if you are to be successful in making and surviving the necessary changes in current environments. Although organizational culture frequently has been studied in the business community, there are fewer studies of organizational or work group culture in hospital settings at the nursing unit level. The existing studies have emphasized the need to understand the individual work group culture before successfully implementing innovation and educational programs, or hiring and orienting new employees on nursing units. This descriptive, correlational study describes the relationships among work group culture, work-place stress, and hostility and nursing unit outcomes, specifically absenteeism and turnover. Implications of the findings include the idea that increasing decision latitude in workers may positively impact absenteeism.
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Purpose: The purpose of this article is to describe how clinical nurse specialists can promote the development of knowledge and skills in nurses as one step toward making evidence-based nursing practice the norm in all patient care settings. Background: The need for the use of evidence in nursing practice has been highlighted for several decades. Moving evidence more quickly into practice requires that nursing use many strategies. Description of Strategy: The strategy of clinical coaching is proposed in this article for the development of skills in nurses specifically to promote evidence-based nursing practice. Clinical coaching is a relationship for the purpose of building skills. This strategy is aimed at increasing foundational staff nurse knowledge and skills. Conclusion: The achievement and maintenance of evidence-based nursing practice take continuous attention from clinical nurse specialists. Clinical coaching is only one part of a comprehensive approach for establishing and sustaining evidence-based nursing practice.
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The modified therapeutic community (MTC) is one treatment modality developed to meet the needs of the homeless dually diagnosed population. While studies have shown the effectiveness of the MTC, little is known regarding staff perspectives of this modality. Using data from in-depth qualitative interviews, this study examines key staff perspectives on treatment services offered at an MTC in New York for homeless, mentally ill substance abusers. Many staff members indicated that the services provided are innovative, state of the art, and comprehensive as compared to other programs that specifically treat only one need. The most beneficial aspects of the MTC modality noted were the number of social workers available and the introduction of art therapy groups. The MTC modality also fostered increases in communication and collaboration between staff to introduce more specialized clinical groups not outlined in MTC guidelines to better meet the needs of clients.
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Purpose This study aims to explore the lived experience of learning for a group of staff nurses in the Middle East, who undertook a post‐registration nursing education programme in the speciality of nephrology nursing (the NNP) between 2001 and 2002. The broad‐based curriculum seeks to develop the staff nurses into active learners, able to utilise a new body of specialist nursing knowledge and skills, which challenges their previous behaviourist learning tradition. This study seeks to identify the students' experience of trying to incorporate new learning strategies into their practice, and the effects they experienced as a result. Design/methodology/approach Case study methodology was used to study this unique group of 20 participants. Data were collected using focus group interviews, combined with field observations and document reviews. Findings Thematic analysis revealed three themes, “Social‐cultural influences on learning” with two sub‐themes, “Past experiences of learning” with two sub‐themes, and “Transforming the learning experience” with three sub‐themes. Research limitations/implications Curriculum development in developing countries should aim to prepare practitioners to meet international standards. However, such development has to take account of, and integrate, students' values, beliefs, and experiences, and acknowledge their particular challenges with respect to learning. The preparation for active learners has to include the “tools” to cope with, and change, the cultural and organisational situation in which they find themselves, including knowledge of an organisation's culture to facilitate effective learning to fit the needs of the workplace. Originality/value The research provides a unique insight into the learning experiences of a particular cultural group.
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In an attempt to create new perspectives on the issues facing the US education and healthcare systems, we describe – in tandem – the root causes of system-wide dysfunction in both. A unifying concept is the lack of systems thinking. We assess: Timeline of causality; The substrate; The culture; Outcome measures; Micro-economic disconnection; Unending demand for resources; Incentives and accountability; and Organizational structure. Recommendations include: (1) do what is needed, not what is initially considered possible; (2) implement radical transformation, not incremental adjustment; (3) the Federal government must stand in loco parentis; (4) create a Champion-with-power; (5) develop a process for dialogue between practitioners and experts in education, healthcare and management, particularly systems thinking; (6) engage, educate and learn from the public early in the process; (7) create national databases; (8) reform the legal tort system in order to allow the blossoming of learning cultures.
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Implementatie van veranderingen is een complexe materie. Dit is regelmatig in de literatuur te lezen en veel verpleegkundigen zullen het ook aan den lijve hebben ondervonden. Dit artikel behandelt de context van een implementatie. Er zijn meerdere instrumenten voorhanden om de context bij een implementatie op een systematische wijze in kaart te brengen, zoals de Context Assessment Index (CAI), Nursing Unit Cultural Assessment Tool (NUCAT), de Alberta Context Tool (ACT), het Organisational Culture Assessment Instrument (OCAI) of het Contingentiemodel van Van Linge. Twee van deze instrumenten worden in dit artikel uitgebreider beschreven: de CAI en de NUCAT.
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Older adults who become acutely confused when hospitalized present challenges to nurses because of their increased care needs and risk for injury. This study evaluated the feasibility of introducing the NEECHAM Confusion Scale as part of usual nursing care as a first step in improving nurses' ability to assess, prevent, and manage acute confusion in hospitalized older adults. By addressing several of the factors that influence adoption and continuation of a new practice, this study found that staff nurses could successfully use the NEECHAM Confusion Scale.
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AimThe aim was to measure the culture and level of work excitement in a Neonatal Intensive Care Unit prior to and after the implementation of a new model of practice.BackgroundIn order for the successful implementation of a model of practice, it is imperative to understand the culture of the organization.MethodsThe study sample consisted of nurses working in a NICU before and after the implementation of an individualised developmentally supportive family-centred care model from 1999 to 2002. The unit culture was assessed using the NUCAT-2 tool and level of work excitement was measured by WEXCIT.ResultsResults from descriptive analysis indicated that behaviours that were important to the nurses before and after the introduction of the Care Model were similar. Measures of work excitement showed that the nurses perceived the unit was understaffed, and there was a positive change to participating in the growth and development of other nurses.ConclusionResults show that the introduction and integration of a new model of practice takes time. By understanding the culture of the work environment and what the nurses find as interesting, exciting and frustrating can help in implementing change.
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Change within health-care systems is constant as it relates to the external and internal demands that require continual adaptation by providers. This chapter provides a summary of the history and research contributions related to the study of culture and change through the lens of the nursing profession. The review focuses upon nursing research publications and the knowledge gained, ranging from the earliest to current studies. There has been a substantial increase in research interest regarding the relationship between nursing culture and ability to change; however, there is a considerable gap that remains in understanding subgroups such as individual nursing units or departments, consistent use of tools to measure culture, and interventions that have made a difference over time. From a practical perspective, this discussion provides insight into the importance of recognizing the importance of assessing culture and integrating cultural feedback into operational improvement plans.
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It is still not clear that organizational culture in hospitals is linked to patient or provider outcomes. However, measurement of organizational culture in nursing units within hospitals and for entire hospitals is common. Two instruments frequently used to measure hospital culture or work group culture within hospitals are the Organizational Culture Inventory (OCI) (Cooke & Lafferty, 1987) and the Nursing Unit Cultural Assessment Tool (NUCAT-2) (Coeling & Simms, 1993a). The purpose of this paper is to review selected empirical studies of organizational and work group culture in hospitals and critique these two measurement instruments. The paper discusses the issues of unit of analysis/aggregation bias and sample size when using these two instruments. It was concluded that OCI has been widely used in many types of organizations and has substantial data supporting the reliability and validity. However, the instrument does not always capture variation in nursing units. The NUCAT-2 has less reliability and validity data but researchers have reported wide variation among units. Individual items can be selected for use from the NUCAT-2 and it is less expensive to use than the OCI.
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Hospital organizational culture is widely held to matter to the delivery of services, their effectiveness, and system performance in general. However, little empirical evidence exists to support that culture affects provider and patient outcomes; even less evidence exists to support how this occurs. To explore causal relationships and mechanisms between nursing specialty subcultures and selected patient outcomes (i.e., quality of care, adverse patient events). Martin's differentiation perspective of culture (nested subcultures within organizations) was used as a theoretical framework to develop and test a model. Hospital nurse subcultures were identified as being reflected in formal practices (i.e., satisfactory salary, continuing education, quality assurance program, preceptorship), informal practices (i.e., autonomy, control over practice, nurse-physician relationships), and content themes (i.e., emotional exhaustion). A series of structural equation models were assessed using LISREL on a large nurse survey database representing four specialties (i.e., medical, surgical, intensive care, emergency) in acute care hospitals in Alberta, Canada. Nursing specialty subcultures differentially influenced patient outcomes. Specifically, quality of care (a) was affected by nurses' control over practice, (b) was better in intensive care than in medical specialty, and (c) was related to lower adverse patient events; nurses in intensive care and emergency specialties reported fewer adverse events than did their counterparts in medical specialties. Understanding the meaning of subcultures in clinical settings would influence nurses and administrators efforts to implement clinical change and affect outcomes. More research is needed on nested subcultures within healthcare organizations for better understanding differentiated subspecialty effects on complexity of care and outcomes in hospitals.
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The positive outcomes of the changed healthcare environment are now being realized. The present decade will influence more change and development in organizations and nursing practice to solidify the advances of such outcomes. The effects of outcomes on the work environment and job satisfaction of nurses now must be analyzed. Assessment of social climate via the Work Environment Scale offers nurse executives a valid and reliable means of analysis.
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An exploratory study of 168 nurses has yielded a new dimension of practice patterns, work excitement, a prerequisite to effective practice and quality care. Four reasonable and attainable factors were found to be significant predictors of work excitement: work arrangements; a learning environment that fosters individual growth and development; variety of experiences; and positive working conditions.
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Organizational culture provides a mechanism for controlling the actions of the members of the organization by informally approving or prohibiting certain behaviors. Additionally, it serves an integrative function by generating commitment to the goals of the organization and by providing a framework for shared understanding of the meaning of events that occur within the organization (Smircich, 1983). Organizational theorists suggest that culture plays a particularly important role in those organizations that operate under conditions of high uncertainty and complexity and that strive to achieve outcomes that are difficult to measure (Bolman & Deal, 1984; Wilkins & Ouchi, 1983). Today's healthcare delivery agencies clearly fit this category of organizations. By taking the culture of these organizations into consideration when making recommendations, the nurse consultant can minimize the potential for resistance to the consultation process and maximize the potential for successful consultative outcomes.
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Nurse executives must lead in proactively managing care delivery in the face of an increasingly severe nursing shortage. Failure to do so invites the imposition of untenable "solutions" by outside parties. Much has been written about the magnitude and causes of the current nursing shortage. This article focuses on alternative practice models as a viable solution. Part 1 examines similarities and differences among existing models and describes the Robert Wood Johnson University Hospital ProACT model. Part 2 will discuss the process of developing and implementing this alternative nursing practice and care delivery model.
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The shortage of nurses provides an opportunity to advance clinical reasoning to include deciding exactly which hands-on care activities must be done by the professional nurse and which aspects of care can be provided by a nurse extender. The relationship of the professional nurse and her "extender partner" is a new solution to an old problem...one that has lasting power because it advances professionalism.
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Organizational culture is a significant element in today's health care environment. Understanding work culture can assist the nursing administrator in hiring personnel, orienting newcomers, facilitating organizational change, and promoting learning. The authors report a study that identified the work group culture of two nursing units and suggest that differences between these cultures affect a variety of nursing administration decisions.