Organizational Culture and Impact on New Graduate Nurses Performance - Literature review Example

RUNNING HEAD: LITERATURE REVIEW: ORGANIZATIONAL CULTURE AND IMPACT ON NEW GRADUATE NURSES’ PERFORMANCE Literature Review: Organizational Culture and Impact on New Graduate Nurses’ Performance Name: Course: Institution: Date: Literature Review: Organizational Culture and Impact on New Graduate Nurses’ Performance Abstract This literature review examines the impact of organizational culture on new graduate nurses performance as they transition from learning to professional practice. The review will analyse research journals published since 2002 which address various aspects of organizational culture and how they impact on the performance of new graduate nurses in the healthcare settings. The review highlights several themes such as socialisation of new graduate nurses, stress due to roles and expectations of professional practice and workplace bullying and horizontal violence and their impact on new graduate nurses’ emotional or psychological health and productivity. In conclusion, the review identifies the lack of research that addresses organizational culture as a whole and develops a standardized measure to gauge new graduate nurses’ performance in the various aspects of their work as they transition from learning to practice. Introduction The organizational culture of an organization is a term used to refer to a set of values, beliefs, behavioural patterns and the assumptions behind them shared by the members of that organization (An et al 2011). Schein (quoted in Bellot 2011) defines organizational culture as the pattern of basic assumptions, invented, developed or discovered which govern how a group copes with problems of external adaptation and internal integration. This is a pattern of behaviour which has worked well enough for the group and is therefore considered valid and to be taught to new members of the group as the correct way to perceive, think and feel about these problems (Bellot 2011). Using this definition, Bellot (2011) examines the concept of organizational culture in healthcare and links Schein’s definition of organizational culture to the introduction of graduate nurses, implying that as they transition to professional nursing practice, they come into contact with the organizational culture of their new work environment in the form of visible artefacts such as dress codes, values in the form of strategies, philosophies and underlying assumptions such as the taken-for granted beliefs and perceptions. Method This paper will conduct a literature review on organizational culture and how it impacts the various aspects of performance of new graduate nurses. The criteria for the articles selected for review is the relevance to the various aspects of organizational culture as conceptualised by Bellot (2011) such as values, strategies and philosophies in the workplace (hospital or healthcare settings). The articles selected for this review focus on themes such as socialisation of new graduate nurses, stress due to expectations of professional nursing, interpersonal conflict in the workplace and how it is perceived or resolved by co-workers and the organization as a whole and support and empowerment (or lack of it) in the workplace as the new graduate nurses transition into practice. The articles selected were searched using an academic journal search engine that was used to identify articles published after 2002 from various nursing journals. Therefore, only journal articles published after 2002 have been reviewed. Following the review, the implications of the findings for nursing practice will be outlined. Results Socialisation of New Graduate Nurses Various studies which have examined the impact of organizational culture on the transition from being a student nurse to a graduate registered nurse and how it affects various aspects of graduate nurses’ performance. Fox, Henderson and Malko-Nyhan (2005) examine the effect of a hospital’s organizational culture on the integration of new nursing staff and identify some of the supportive elements in a hospital’s organizational culture that facilitate effective integration. The longitudinal study used focus group discussions with new nursing staff at a tertiary referral facility in Brisbane. The study explored the socialization process of new nurses in terms of absorbing the language, culture, rules and norms of the workplace. The study concluded that graduate nurses found integration into the work environment from the student environment much easier when they were allocated one-on-one preceptors that provided support and guidance during their first weeks of actual nursing practice. Therefore, an organizational culture which supports and encourages guidance and learning for new graduate nurses is correlated with a smoother transition process. These findings are supported in similar studies by Morrow (2008), Dyess and Sherman (2009) and Pellico et al (2009). However, most of these studies are limited in their generalisability since studies by Fox et al (2005) and Newhouse et al (2007) examine new graduate nurses’ experiences in acute care nurses while others such as Valdez (2008) examine the emergency care health settings. This may contribute to variations in their findings. Feng and Tsai (2011) also corroborate the findings by Fox et al (2005) and Lea and Cruickshank (2007). Their study explores the socialisation experiences of new graduate baccalaureate nurses as they transition to practising nurses. The study identifies the most difficult aspect of graduate nurses’ work as the organizational socialisation process which includes adjusting and fitting into the hospital’s bureaucratic system and familiarising themselves with the ward rules and culture. The nurses interviewed complained of a harsh socialisation process in the form of work overload and the difficulty of balancing between integrating into a professional, task-oriented environment while simultaneously maintaining interpersonal relationships with their colleagues and superiors. Consistent with findings by Li et al (2007) and Wangensteen et al (2008), organizational cultures which do not provide support for new nurses’ integration are therefore correlated with higher stress levels among new graduate nurses. While Feng and Tsai (2011)’s study is informative and insightful, its major limitation is that it is based on a qualitative and descriptive approach which limits the reliability and replicability of the findings using the same method to other studies. Roles and Expectations As nurses transition from learning to practice, they also face increased pressure due to role ambiguity as established in a study by Chang and Hancock (2003) and the increased demands and responsibilities of professional practice for which new graduate nurses may not have been well trained as indicated by Goh and Watt (2003). However, Goh and Watt (2003)’s study is limited to private hospitals which may make the findings not replicable in public hospitals. Lea and Cruickshank (2007) examine nurses’ experience in a more challenging environment- the rural area. Lea and Cruickshank (2007) also relate the stress levels among graduate nurses during their transition period to the expectations they encounter in the workplace. Their study of the experiences of new graduate nurses in rural healthcare facilities in New South Wales reveals that an organizational culture where new recruits are expected to quickly adjust to the professional environment and assume the workload of experienced nurses contributes to higher stress levels and consequently determined the retention of these new graduate nurses by the healthcare facilities. The study recommends that new graduates must be nurtured to enable their professional development. Healthcare facilities which have an organizational culture where graduate nurses are expected to immediately adjust to the professional environment are not supportive since there are instances where the expectations may be beyond graduate nurses’ skills and experience. However, due to a small sample size and uniqueness of the facilities studied (rural areas) the application of the study’s findings to the general population is limited. Organizational Culture and Emotional/Psychological Health of New Graduate Nurses Organizational cultures in hospitals or health facilities which do not address these stressors for graduate nurses contribute to low retention rates as many graduate nurses are prone to leaving the profession altogether after barely one year of practice. A study by Clarke and Springer (2012) of nursing resident’s first-hand accounts on transition to nursing practice has largely the same findings as those of Fox et al (2005) and Feng and Tsai (2011) citing an unreasonable workload, job stress and lack of organizational support during the critical transition period as responsible for most cases of leaving the profession. Conversely, nurses interviewed by Clarke and Springer (2012) in their study who reported feeling valued in the workplace and not being isolated by senior nurses revealed that they were more likely to remain in the nursing profession for more than ten years. While the study by Clarke and Springer is limited in its applicability to the general population due to the small sample size (37) and shares this limitations with earlier cited studies, these findings reinforce those made by Christmas (2008) who found a similar correlation between the levels of organizational support and commitment and retention of new graduate nurses by healthcare facilities. Within the nursing practice itself, the variations in the type of nursing care imply different organizational structures for healthcare facilities which in turn have different effects on graduate nurses’ emotional and psychological health and performance as they transition from being a student to practice. Moore (2005) notes that while that the transition from being a student to a qualified nurse is generally stressful as has already been demonstrated, there are several situations which are more demanding and are correlated with higher stress levels. Moore (2005) explores the transition from being a student to practice in the military. The transition is more challenging as compared to civilian nurse since military nurses have to cope with both civilian and military demands of being a corporal. The implication of Moore (2005)’s account is that organizational culture of the military can both exacerbate and mitigate stress among new graduate nurses. Working in a highly disciplined environment provides both stability and predictability but on the other hand, new nurses are always aware of the possibility of being deployed overseas to serve with the military. The experience can be even more stressful when they are exposed to combat casualties without sufficient support and experience. This implies that they will have to adapt to challenging circumstances such as warfare rapidly. Therefore, new graduate nurses in the military require more support and clinical experience from their peers as compared to civilian nurses. However, Moore’s experiences are a personal account rather than a study of a sample which limits the applicability and generalisability of the conclusion and findings due to personal bias. Other studies have also examined new graduate nurses’ experiences in more challenging and stressful circumstances such as in intensive care units (ICU) (O’Kane 2011) and in cardiovascular intensive care units (CSICU) (Kollman et al 2007). The qualitative study by O’Kane (2011) on newly qualified ICU nurses seems to contradict the conventional assumption that new graduate nurses in wards face less stress as compared to those in intensive care by suggesting that the nature of intensive care fosters an organizational culture of providing more support and guidance. Kollman et al (2007) note that CSICU nurses are prone to trauma due to the nature of their practice such as patient deaths during surgery but that conversely, CSICU units are more supportive of new graduate nurses than general or emergency wards in the form of providing counselling and support due to the perceived seriousness of CSICU roles. Bullying and Horizontal Violence Another important aspect of organizational culture that relates to new graduate nurses’ performance as they transition from learning to practice is bullying and horizontal violence in the workplace. Several studies have examined how bullying is treated in the organizational culture of some healthcare facilities and concluded that higher incidences of bullying reported by graduate nurses contribute to lower productivity among new graduate nurses and low retention rates in those facilities. Berry et al (2012) examine the effect of workplace bullying as part of organizational culture on novice nurses’ performance using a cross sectional survey of two hundred and forty eight new graduate nurses from Ohio, Indiana and Kentucky as respondents. In the study, workplace bullying is defined as sustained and repeated negative acts perpetrated by employees (nurses) against other employees that is perceived as intentional. New graduate nurses are particularly vulnerable to workplace bullying as they try and cope with the demands of transition from learning to practice. According to the study by Berry et al (2012), social norms are used to model novice nurses (or new graduate nurses) into the organizational cultures of their healthcare facilities. In the study, they argue that workplace bullying is actually role modelled into the organizational culture by senior nurses and eventually becomes a social norm to which new graduate nurses are exposed to in the workplace. In many cases, workplace bullying is perpetuated and expected as a social norm to the extent that the perpetrators are not aware that they are actually bullying fellow nurses. Workplace bullying takes both verbal and physical form including being shouted at, verbal abuse, intimidation, being pushed around or threatened and in extreme cases racial slurs and beatings. The study found that both white and non-white novice nurses that had reported being bullied had significantly lower productivity scores due to factors such burnout, emotional exhaustion and trauma due to the bullying. Bullying is associated with negative effects on new graduate nurses’ well-being such as fear, pain, anxiety, the loss of self esteem, sleeplessness, demoralisation and feelings of vulnerability (Katrinli et al 2011). In many cases, the effect of workplace bullying would be transmitted to patients as the new graduate nurses’ cognitive abilities and ability to handle their workload is negatively affected by the traumatic effects of bullying. Consequently, the quality of patient care delivered by the new graduate nurses is compromised as well as job satisfaction and morale due to increasing burnout. The findings by Berry et al (2012) resonate with those of an earlier study by Laschinger et al (2010) which examines new graduate nurses’ experiences of bullying and burnout in hospital settings. The study by Laschinger et al (2010) has more reliability and validity due to a larger sample size of four hundred and fifteen nurses in acute care hospitals with less than three years experience across Ontario, Canada. In the study, bullying is defined as being subjected to social isolation or exclusion, devaluation of their work effort, being threatened or targeted by derogatory comments or the occurrence of other negative behaviours intended to frustrate, torment or wear down the victim. The findings of the study by Laschinger et al (2010) confirm the hypothesized connection between an organizational culture that accepts or tolerates bullying as a social norm and increased incidences of burnout and other bullying-related effects such as anxiety, fear, hypertension, frustration, weight loss, fatigue and increased sick days for new graduate nurses. The significance of the study by Laschinger et al (2010) and a similar one by Cho et al (2006) is that they adds to the existing stock of literature by exploring how structural empowerment can be used as a workplace strategy to create a bully-free environment in hospital settings. Structural empowerment is presented as an antithesis to bullying and includes ensuring that graduate nurses have access to information, resources, support and opportunities to learn and grow on the job. Therefore, the implication is that an organizational culture which promotes the empowerment of new graduate nurses contributes to better performance in terms of delivery of patient care and higher nurse retention by hospitals since structural empowerment is correlated with increased job satisfaction, motivation, justice and respect and lower levels of burnout (Cho et al 2006, Kovner et al 2009). However, the reliability of the findings of these studies are not guaranteed since the instruments used in the research design usually required a single individual to complete all measures of bullying which in turn influences measures of empowerment and leave the findings susceptible to common method variance and bias. McKenna et al (2002) study the experiences of new graduate nurses with bullying from a horizontal violence perspective. The study was conducted through an anonymous mail survey sent to nurses in New Zealand who had less than one year of practice. From 551 respondents who returned the questionnaire, the study concluded that horizontal violence was a common experience for most nurses in their first year of practice. In the study, horizontal violence is defined from the perspective of interpersonal conflict in the workplace which predominantly takes the form of psychological harassment as opposed to physical aggression through intimidation, threats, verbal abuse, excessive criticism, innuendo, exclusion, discouragement, withholding information or even denial of access to opportunities. The consequences of horizontal violence according to the study are consistent with the findings of most other studies such as fear, reduced confidence or self-esteem, depression, frustration, mistrust and even physical consequences such as headaches, weight loss and hypertension. The study by McKenna et al (2002) points to several aspects or elements of organizational culture which negatively impact on new graduate nurses’ performance. For example, more than half of the respondents admitted not reporting distressing incidences of bullying or harassment out of a fear of retaliation or cynicism due to the fact that in some cases, the senior or the person to be reported to is actually the one responsible for harassment. The study also found that most healthcare facilities do not attach importance to effective reporting mechanisms and provision of counselling or debriefing of victims of bullying and harassment. This indicates complacency towards bullying in the organizational culture of such facilities. However, the study’s findings cannot be independently corroborated since the method of data collection was self reporting. Another limitation is due to the fact that constructive criticism may have been interpreted negatively in addition to exaggeration. King-Jones (2011) also addresses the issue of bullying in the organizational culture of hospitals and the negative effects on the socialisation of new nurses from a horizontal violence perspective. Using a literature review of other studies, King-Jones (2011) defines horizontal violence as inclusive of all acts of unkindness, discourteous behaviour and a lack of cohesiveness from an employee or a group of employees in the workplace to another. This may take the form of verbal abuse, belittling gestures, gossip, sarcastic comments, fault finding and controlling behaviours. The horizontal violence perspective argues that new graduate nurses are socialized in a cultural narrative where new nurses are expected to be subordinate to their nursing instructors and senior nurses. Similar studies by Beercroft et al (2008) and Kovner et al (2009) conclude that such organizational cultures perpetuates and exposes newly practising nurses to hostile environments and is correlated with high intention to leave the nursing profession by the end of the second year of work. However, Hutchinson, Jackson, Vickers and Wilkes (2006) and Salin (2003) reject the premise that bullying or horizontal violence is a feature of nursing which new graduate nurses have to contend with. Hutchinson et al (2006) reinforce the findings of Salin (2003)’s review by examining the organizational context of bullying and arguing that the bullying that new graduate nurses are exposed to is not a reality or a feature of nursing but is product of the hospital’s or healthcare facility’s organizational culture which is perpetrated by its members and enabled by its structures. Their study focuses on workplace bullying in nursing from a wider organizational context which emphasizes the role of power in organizations. According to Hutchinson et al (2006), it is flawed to consider bullying as a feature of nursing. Instead, bullying is a harmful and abusive activity perpetuated within organizations in their organizational culture. The study uses Michael Foucault’s ‘circuits of power’ theory to explain bullying in nursing. For example, new graduate nurses (referred to as junior nurses in the study) are often the target of bullying by more experienced or senior nurses in the workplace. This is related to the fact that they are more prone to making mistakes as they cope with the pressure of transition from learning to practice. However, within the power relations in the organizational culture, this is not viewed as bullying but rather as an effective strategy of reinforcing rules, relations of meaning or membership into the nursing team. Bullying therefore becomes accepted as an organizational value and is confirmed and reinforced as a strategy of maintaining order in hospitals. Senior nurses who bully new graduate nurses often invoke or bring attention to the rules, relations of meaning and membership of the nursing team and by using the target as an example reinforces bullying as an accepted form of social integration. While the study by Hutchinson et al (2006) is not empirical, it is important in conceptualizing how bullying is perpetuated within the organizational culture of many hospitals and identifying how power relations can be restructured to help in the socialisation of new graduate nurses. Culture and Organizational Culture While most of these studies have been conducted in largely homogenous or Euro-centric cultural settings, organizational culture may vary from culture to culture and significantly impact on the psychological well-being of new graduate nurses. Qiao, Li and Hu (2011) study how new graduate nurse in China cope with organizational related stress and reveal how Chinese culture has a differential impact from European and other cultures on organizational culture. Qiao et al (2011) find that nursing curricula in China is deficient in some aspects such as hospice care and elderly care. As a result, the organizational culture of Chinese healthcare facilities does not prepare new graduate nurses to deal with death and dying (which is considered unlucky in Chinese culture) and rather than rely on support from senior nurses or other healthcare professionals, they resort to their own coping mechanisms and strategies such as denial. This variance due to uniqueness of cultures is also observed by Zhao et al (2005) who examine new graduate nurses’ experiences in Chinese settings. However, while the study by Qiao et al (2011) study is more reliable due to a larger sample size, its reliability and validity is limited since both it and the study by Zhao et al (2005) use Western-developed instruments to investigate behaviour in what is essentially an Eastern culture. Research Gap While most of the studies reviewed have addressed various aspects of organizational culture and their impact on new graduate nurses performance, there is a clear lack of studies which deals exclusively with organizational culture as a composite. While Fox et al (2005) have attempted to connect organizational culture to new nurses’ experiences and Han (2002) has explored the impact of organizational culture on organizational performance, Bellot (2011) notes that few if any studies have clearly conceptualised organizational culture as a whole with its various components, developed a tool of measurement that provides standardised scores and tested the correlation with individual new graduate nurses’ performance either in terms of productivity, stress levels or even intention to stay in or leave the profession. Conclusion: Implications for Nursing Practice The literature review on organizational culture and new graduate nurses’ performance has several implications for nursing practice. The articles reviewed have highlighted two major aspects of organizational culture and their impact on new nurses’ performance as they transition from learning to practice. These are stress due to expectations and demands of professional practice and interpersonal relationships in the form of workplace bullying and horizontal violence. From the articles reviewed, it is evident that nursing as a discipline is very stressful across all clinical settings. For new graduate nurses, the situation may be exacerbated in the transition from learning to practice when they are forced to cope with the responsibilities and demands of professionalism. Factors such as role ambiguity and work overload beyond the ne graduate nurses’ capabilities, skills and training also compound the situation. Hospitals and other healthcare facilities should therefore create an organizational culture that nurtures new graduate nurses as they transition from learning to practice to improve on their confidence which in turn increases their competence. Another critical aspect of the organizational culture is bullying and horizontal violence. The review has identified workplace bullying and horizontal violence as a major reason for poor performance and productivity by new graduate nurses due to negative psychological and physical effects such as burnout, frustration, stress, anxiety, depression, weight loss, hypertension and discouragement. Incidences of bullying and horizontal violence are correlated with intention to leave nursing as a profession and lower productivity, morale and job satisfaction in all of the studies reviewed. Hospitals and healthcare facilities in their organizational culture should stamp out bullying and horizontal violence by adopting very strict penalties on such negative acts, strengthening reporting, counselling and support systems for new graduate nurses and undertaking structural empowerment of new graduate nurses primarily through guaranteeing increased access to resources and opportunities for learning and development and training to cope with the demands of nursing as a profession. References An, J., Yom, Y. & Ruggiero, J.S. (2012).Organizational Culture, Quality of Work Life, and Organizational Effectiveness in Korean University Hospitals. Journal of Transcultural Nursing 22(1):22 –30 Beecroft P.C., Dorey F. & Wenten M. (2008) Turnover intention in new graduate nurses: a multivariate analysis. Journal of Advanced Nursing 62(1): 41–52. Bellot, J. (2011). Defining Organizational Culture, Nursing Forum 46(1): 29-37. Berry, P.A., Gillespie, G.L., Gates, D. & Schafer, J. (2012). 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