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UNIT CULTURE ASSESSMENT
Unit Culture Assessment
Lauren Walker
Georgetown University
The Critical Care Unit (CCU) at Prince William Hospital (PWH) is on the second floor of the main building and is a locked unit off of the Progressive Care Unit (PCU). This unit is only accessible to PWH employees and specific family members and guests of the patient. The CCU is an 11 bed Intensive Care Unit (ICU) and manages patients requiring cardiac monitoring with a wide range of diagnosis requiring critical monitoring due to diagnosis such as an unstable arrhythmia, unstable pneumonia, respiratory failure, pulmonary embolism, gastrointestinal bleed, post-operative cardiac catherization, post cardiac arrest, unstable end stage renal disease requiring CRRT, sepsis, and shock. The census of the CCU is nine to eleven patients each shift.
The unit is shaped like a square with the eleven rooms making a “U” shape. The nursing station is located in the center of the unit with the secretary’s desk being the first spot along the station. Two medium size bulletin boards are located on the side walls of the unit containing educational information for staff members and families. Two central monitors are located on each side of the nursing station and eight computer workstations are located across the nursing station. The defibulator and code cart are located on the front of the station. Located on the back wall of the nursing station are two small rooms used by staff only. The first room on the right is the nutrition room containing a large refrigerator and cabinets housing different nutritional formulas, supplements, and nutritional equipment. The second small room located adjacent to the nutrition room is the phlebotomy room. This room contains the equipment necessary for blood draws and laboratory containers. Next to the eleventh room in the back left corner of the unit is the clean supply room containing all equipment stored on the unit from materials management.
The nursing staff on the CCU is composed of one-fourth Licensed Practical Nurses, a fourth are associate degree registered nurses, and the last half have their bachelor degrees in nursing. Critical Care nursing experience ranges from the nurses with only one year critical care experience to twenty years critical care experience with a majority of the nurses practicing in the critical care setting from 2-6 years. The typical staffing ratio is one nurse to two patients. There are two Respiratory Therapists (RT) assigned to the CCU each shift. As well as nurses and RTs, there are four shift managers hired to manage the CCU. One shift manager covers weekend days Friday to Sunday for twelve hours another weekend nights, the third shift manager covers Monday, Wednesday, Friday days and the other covers Monday, Tuesday and Thursday nights. They are not included in staffing and serve as the charge nurse during the twelve-hour shift. On shifts not covered by the shift manager, a senior nurse is designated as the charge nurse, however is included in staffing. The Critical Care Clinical Nurse Specialist (CCNS) and Clinical Educator share an office and are located in the hallway between the PCU and CCU. The Critical Care Director and Critical Care Clinical Manager both have a private office in the same hallway.
Hospitals today have very unique organizational structures that support individual units. The units flow according to the staff, patient demands and needs of the supporting organization. However, it is the overall culture of the unit that drives patient care, nurse and patient satisfaction, and outcomes. According to Harris (2004), Schein’s Level of Culture theory states that the culture of a group can be defined as a pattern of shared basic assumptions that was earned by a group as it solved its problems of external adaptation and internal integration, that has worked well enough to be considered valid and, therefore, to be taught to new members as the correct way to perceive, think and feel in relation to those problems. It is stable membership, shared orientations and a history of learning that has developed some level of culture and holds a group together (Schein, 1999).
Culture determines how organizations and key stakeholders interact with each other, and it uses a common language, provides group boundaries for inclusion and exclusion, determines the distributing power and status, develops norms, rewards and punishments, and helps to explain the unexplainable (Schein, 1999). Schein (1997) also states that culture defines what individuals within a group pay attention to, provides meaning, and defines how they react emotionally to. Cultural assumptions evolve around all aspects of a group’s relationship to its external environment, and the group’s ultimate mission, goals, means used to achieve goals, measurement of its performance and strategies require consensus from the group (Harris, 2004). Once a set of shared assumptions has come to be taken for granted, it determines much of the group’s behaviors, and norms are taught to newcomers in a socialization process that is itself a reflection of culture. Groups that have had considerable turnover of members and leaders or a history lacking in any kind of challenging events may lack any shared assumptions.
Culture and leadership go together, leaders first create cultures when they create groups and organizations. Once cultures exist they determine the criteria for leadership and thus determine who will or will not be a leader (Schein, 2004). If leaders do not become conscious of the cultures in which they are embedded, those cultures will manage them. One needs to understand the culture to understand the organization. One must also understand the environment and culture before change or observation can be made.
The Levels of Culture Theory by Schein describe three levels in which one can interpret and understand the unique culture of an organization or group. The levels include artifacts, espoused values and basic assumptions. Artifacts are what one sees on the surface when encountering a new group with an unfamiliar culture (Harris, 2004). It includes all that one sees, hears, and feels when one encounters a new group with an unfamiliar culture (Schein, 2004). According to Schein (1997), the artifacts in the organization are the visible products of the group that includes the environment, language, technology, products, artistic creations, style, clothing, manners of address, emotional display, myths and stories told about the organization. It is the organization process in which behavior is made routine. While the culture in an organization may be easy to observe, it is difficult to decipher. Schein (2004) notes that it is dangerous to try and infer the deeper assumptions from artifacts alone, for ones interpretations will inevitably be projections of ones own feelings and reactions. In the second level, cultural meaning through artifacts becomes clearer the longer an observer views the group (Harris, 2004).
A graduate student, through the use of Schein’s Level of Culture Theory, examined a Critical Care Unit (CCU) at a small community hospital in Manassas, VA. According to this theory, the artifacts were first examined. When first analyzing the CCU on the artifact level, one sees nurses sitting at the workstation charting on computers and getting up to answer alarms or work with their patient. Staff members appear calm and in good spirits, and the unit is very clean and well kept. Visible technology on the unit includes smart pumps in patient rooms, flat screen televisions in each room, ventilator in the rooms of intubated patients, a defibulator and multiple central monitors at the nurses station, computers on wheels scattered across the unit, and the staff has a specific color uniform according to their position. Nurses are in royal blue, nurse tech in light blue, RTs in gray, and Physicians are in professional clothing. An observer will hear a consistent but bearable central monitor and ventilator alarms and will hear nurses, nurse technicians and RT talking and interacting. The observer in the CCU feels calm with no sense of urgency. It may be possible to achieve understanding of the CCU more quickly through analysis of espoused values.
The second level of understanding the culture within an organization is the espoused values, or the strategies, goals, and philosophies of the group. At this level, the unit seeks social validation by recognizing thatspecific values which are confirmed by the shared social experience of a group (Schein, 2004).The thought process and attitude of employees have deep impact on the culture of any particular organization. The mindset of the individual associated with any particular organization influences the culture of the workplace (Schein, 2004). These beliefs and values are initially started by the founding leader and then assimilated to the group (Schein, 1997). Schein (2004) also states that certain beliefs and values work in the groups functioning. As these beliefs work they become transformed into non-discussible assumptions supported by articulated sets of beliefs, norms, and operational rules of behavior. These new rules of behaviors therefore enable the group to deal with certain key situations. All group learning thereafter reflects the original values of the group (Schein, 1997).
After examining the espoused values of the CCU one has to first determine the root and rules of behavior. Any change in the CCU, small or large, is a very sensitive concernfor the staff. Since the transition to Novant Health System in the recent years, the staff has been required to change attitudes, behaviors, charting and responsibility. This change has disrupted the learned values, rules and behaviors that have structured the daily working lives of staff and are therefore now more resistant to any new staff member or other unit based change. After working with the nurses for a few weeks, it was determined by the graduate student that the nurses who have been employed the longest are the creators of the rules of behavior. Due to the frequent turnover of nursing staff, nursing leadership positions and physicians, the longest employed nurses have help set the culture and attitude of the unit. The espoused values therefore can be seen on a daily basis when working with the nursing staff.
While all nursing staff have completed a skill competency exam, the older nurses have expectations of how the other nurses should critically think, manage difficult patient loads and if they are unable to keep up with the assignment. The nurses also expect to have a set nurse to patient ratio. Even if the patient has stepped down or is less labor intensive, the culture on the staff is to be somewhat inflexible on picking up another patient or responsibility. The pace of the CCU is also very slow. Nurses work hard to make sure all of the needs of the patient are met, even if it is not a CCU responsibility. On a particularly busy shift, there were patients that needed to be admitted to the CCU with no beds available. There were two patients who had been stepped down to the medical surgical unit, however were still in a CCU bed. When the CNS offered to help transfer the patient out of the CCU, the nurse stated that she wanted to wait longer so she could make sure that her patient could eat and get out of bed. The nurse appeared very frustrated when the patient had to be transferred out before these actions could be carried out and bed could be turned over to a more acute patient. The flow of this nurse was disrupted according to values and learned behaviors.
The final level of Schein’s Level of Culture Theory is basic assumptions. This is the unconscious, taken for granted beliefs, perceptions, thoughts and feelings of the group (Schein, 2004). These values are not always measurable but make a difference to the culture of the group. In the basic assumptions level, the group uses repeated success in implementation and hypothesis becomes reality to develop certain beliefs and values (Harris, 2004). Therefore, behavior based on any other premise is inconceivable. Change is very difficult at this level since behavior change is non-confrontable and non-debatable. To learn something new in this realm, the group must resurrect and reexamine the basis of actions. Learning is therefore difficult since the reexamination of set behavior temporarily destabilizes their world, releasing large amounts of anxiety (Schein, 2004). The group therefore follows certain practices, which are not discussed often but understood, on their own (Red article, 2004).
In the CCU at PWH, basic assumptions are seen in the daily actions of the nurses as they care for their patients. Their set standards for care, such as central line care, urine catheter care, ETT suctioning, medication administration, nasogastric tube feedings, and overall patient management are not necessarily evidence based, but the nurses explain that their practice works on their unit and it has been set for many years. There are high levels of resistance when showed a different way of performing a task to a new nurse from an outside facility or CNS bringing a new idea to the bedside. When understanding the culture of the CCU at Prince William Hospital, it was determined through discussions with the Unit Manager, Educator, Clinical Nurse Specialist and nursing staff that the true founding leaders of the culture is the nursing staff. Prince William Hospital was an independent functioning hospital struggling to meet the demands of their patients, hiring and obtaining competent nursing staff and having system wide competitive outcomes. About four years ago, PWH became apart of the Novant Health System and this partnership had positively impacted growth and outcomes of the hospital. Due to the massive changes in PWH, the CCU has been greatly impacted, and there was a dramatic shift in unit leaders within the CCU.
Three of the four shift managers in the past three years have remained three months to a year, the ICU manager has been there for one year, the ICU educator is hands off and primarily works on a separate unit, and the critical care director has held her position for one year and just returned from a two month maternity leave. The medical supervision has also impacted the leadership on the CCU. A hospitalist and one pulmonologist medically manage the CCU. Both physicians are not appointed to care for CCU patients only, however, have other hospital responsibilities and patients. Physicians do not supervise the CCU patients at all times, but come to the hospital for all cardiac arrests and new ventilator patients. Therefore, the nursing staff has been the most stable group in the CCU and has therefore driven many unit based decisions and shaped the culture on the unit. While positive change in the Novant Health has started to impact the culture on the unit, the lack of consist leadership has enabled the culture to remain.
New CCU members are frequently socialized into the unit. The CCU does not hire new graduate nurses, and therefore hire experienced ICU nurses from an outside hospital or an experience nurse from a non-ICU position in PWH. The new nurse is matched with a preceptor for an orientation period lasting according to their clinical experience. The CCU Manager verbalized that when PWH merged into the Novant Health System, there were many nurses who maintained negative attitudes and were resistant to every change made in the CCU as well as within the system. After one-to-one discussions with management and still unable to change their attitude, the nurses either resigned or were asked to step down by management. The other nurses on the CCU maintained a positive attitude and are flexible with new changes, including welcoming new nurses and training them on the unit. The CCU Manager also verbalized that she works hard to recruit energetic, fun, motivated nurses who critically think. These nurses in return attract similar nurses to help impact the culture of the CCU.
The members of the CCU who actively sustain the cultural norms through observation and discussions with the CCU Manager and Educator are the shift managers and fellow nurses who have been working at PWH CCU for many years. The nurses describe one of the older nurses night shift nurse on the CCU as the “mother nurse”. This nurse has a welcoming and contagious attitude. She works with new nurses by providing encouragement, guidance and resource based training. According to the nurse manager, this nurse makes other nurses feel as if there are no dumb questions and will sit down with the nurse to find the correct policy, reference or answer to a clinical question or barrier. While every nurse on this unit is not as thorough with clinical support, the attitude of the nursing staff drives the culture on the CCU.