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Abstract
Hospital organizational culture has not been extensively investigated, although researchers in numerous recent studies have examined hospital practice environments and their effects on practices, outcomes, and costs. The purpose of this study was to explore the concept of hospital organizational culture and, in particular, nurse specialty subcultures and their impact on nurse and patient outcomes. Drawing on Martin's framework and the differentiation perspective (nested subcultures within organizations), I developed and tested a model depicting causal relationships and mechanisms between nurse specialty subcultures and job satisfaction, quality of care, and selected adverse patient events. A series of structural equation models (SEM) were assessed using LISREL on secondary data obtained through the Alberta Registered Nurse Survey questionnaire from 1,937 nurses employed in four specialties (medical, surgical, ICU, and emergency) in acute care hospitals in Alberta, Canada.
Based upon the findings, nurse specialty subcultures exist within hospitals and differentially influence nurse and patient outcomes. Specifically, the selected informal practices (autonomy, control over practice, and nurse-physician relationships) were more important factors for job satisfaction and quality of care than were the formal ones (satisfactory salary, continuing education, quality assurance program, and preceptorship). Job satisfaction was causally influenced by nurse emotional exhaustion, control over practice, and nurse-physician relationships. Satisfactory salary was not a significant factor for job satisfaction, which is consistent with the argument that cultures of excellence are more important to nurses than good wages. Quality of care was affected by control over practice and was better in ICU than in medical units. Also, quality of care negatively affected adverse patient events. Nurses in ICU and emergency experienced fewer adverse events than did their counterparts in medical specialty.
Overall, I would recommend that nurses and hospital administration enhance their understanding of the meaning of subcultures in various clinical situations, linking these meanings to interventions and outcomes. Finally, more research is needed regarding nested subcultures to better understand both subcultures and entire hospital culture, and to shed light on the problem of diversity and conflict in hospitals. It is important to investigate professional specialty subcultures in healthcare organizations because they are dominated by specialized professionals.
