Uso de la hoja de cálculo de Microsoft Excel para Resolver la Simulación de los Problemas

In organizations, culture is demonstrated in two ways that can be either mutually reinforcing or con- flict-producing. Organizational culture is typically expressed in a formal manner via written mission, vision, and philosophy statements; job descriptions; and policies and procedures. Beyond formal docu- ments and verbal descriptions given by administra- tors and managers, organizational culture is also represented in the day-to-day experience of staff and patients. To many, it is the lived experience that reflects the true organizational culture. Do the deci- sions that are made within the organization consis-

tently demonstrate that the organization values its patients and keeps their needs at the forefront? Are the employees treated with trust and respect, or are the words used in recruitment ads simply empty promises with little evidence to back them up? When there is a lack of congruity between the expressed organizational culture and the experienced organiza- tional culture, confusion, frustration, and poor morale often result (Casida, 2008; Melnick, Ulaszek, Lin, & Wexler, 2009).

Organizational culture can be effective and pro- mote success and positive outcomes, or it can be inef- fective and result in disharmony, dissatisfaction, and poor outcomes for patients, staff, and the organiza- tion. A number of workplace variables are influenced by organizational culture (Chen, 2008). When seeking employment or advancement, nurses need to assess the organization’s culture and develop a clear under- standing of existing expectations as well as the formal and informal communication patterns. Various tech- niques and tools are available to assist the nurse in performing a cultural assessment of an organization (Casida, 2008). With a solid understanding of orga- nizational culture, nurses will be better able to be effective change agents and help transform the orga- nizations in which they work. The Research Perspec- tive at left presents a study on the relationship between leadership and organizational culture in acute care hospitals.

FACTORS INFLUENCING

ORGANIZATIONAL DEVELOPMENT

To be most effective, organizational structures must reflect the organization’s mission, vision, philosophy, goals, and objectives. Organizational structure defines how work is organized, where decisions are made, and the authority and responsibility of workers. It provides a map for communication and outlines deci- sion-making paths. As organizations change through acquisitions and mergers, it is essential that structure changes to accomplish revised missions.

Probably the best theory to explain today’s nursing organizational development is chaos (complexity, nonlinear, quantum) theory. (See Chapter 7 and the Index.) In essence, chaos theory suggests that lives— and organizations—are really weblike. Pulling on one

RESEARCH PERSPECTIVE

Resource: Casida, J., & Pinto-Zipp, G. (2008). Leadership-organi- zational culture relationship in nursing units of acute care hospi- tals. Nursing Economic$, 26(1), 7-15.

The concepts of leadership and organizational culture are well described in the literature. Using a convenience sample of manag- ers and staff nurses from four hospitals in a large New Jersey healthcare system, this study attempts to explicate the relation- ship between the two concepts in terms of nurse managers in acute care hospitals. Descriptive and explanatory correlational designs were used to describe the leadership styles of the nurse managers as well as the organizational culture on the managers’ units. Data from 37 nurse managers and 278 staff nurses support the notion that transformational and transactional contingent reward leadership styles are likely to create an effective organi- zational culture characterized by a focus on mission, adaptability, involvement, and consistency. A laissez-faire leadership approach was not shown to influence organizational culture in a positive manner. These findings were attributed to the purposeful interac- tions between staff and managers who demonstrated transforma- tional leadership and the lack of purposeful interactions when the manager demonstrated a laissez-faire style.

Implications for Practice

This study supports the belief that well-prepared nurse managers who demonstrate transformational and transactional contingent reward leadership styles have a positive impact on unit culture and staff. Nurse administrators can use the results from this study to guide their efforts to develop robust selection and development programs for future nurse managers. Staff nurses and nurse man- agers can use this study to help identify their own leadership style. In addition, staff nurses can use the information to help them identify work units where they are likely to find a supportive organizational culture.

small segment rearranges the web, a new pattern emerges, and yet the whole remains. This theory, applied to nursing organizations, suggests that differ- ences logically exist between and among various orga- nizations and that the constant environmental forces continue to affect the structure, its functioning, and the services. Brafman and Beckstrom (2008), in their aptly named book, The Starfish and the Spider, identi- fied how organizations differ and yet are successful. Spider organizations are built like a spider, and when the head is destroyed, the spider dies. The starfish, on the other hand, can lose an appendage, and it just grows another one. In fact, a starfish, when cut in half, creates two starfish. Organizations that are controlled in a heavily centralized way can diminish quickly without the strong, central figure. Organizations that are self-generating quickly share leadership as needed and often continue to thrive. The important point for any organization is to find what is known as the “sweet spot,” the point of balance between centraliza- tion and decentralization.

The issues in healthcare delivery, with their con- comitant changes such as reimbursement regulation and the development of networks for delivery of health care, have profound effects on organizational structure designs. Consumerism, the consumer demand that care be customized to meet individual needs, necessitates that decision making be done where the care is delivered. Increased consumer knowledge and greater responsibility for selecting healthcare providers and options have resulted in consumers who demand immediate access to cus- tomized care. Information from Internet sources and direct-to-consumer advertising are significantly alter- ing the expectation and behaviors of healthcare con- sumers. For example, Hospital Compare (www.

hospitalcompare.hhs.gov) is a tool that consumers can

use to access a searchable database of information describing how well hospitals care for patients with certain medical and surgical conditions. Access to this information allows consumers to make informed decisions about where they seek their health care. In response to consumer expectations, facilities concen- trate on consumer satisfaction and delivery of patient- focused care. Changes in both facility design and care delivery systems are likely to continue as efforts are made to reduce cost while still striving to meet or exceed consumer expectations and improve patient outcomes.

Competition for patients is another factor influ- encing structure design. These three factors—con- sumerism, change, and competition—necessitate reengineering healthcare structures. Whereas rede- sign is a technique to analyze tasks to improve effi- ciency (e.g., identifying the most efficient flow of supplies to a nursing unit) and restructuring is a technique to enhance organizational productivity (e.g., identifying the most appropriate type and number of staff members for a particular nursing unit), reengineering involves a total overhaul of an organizational structure. It is a radical reorganization of the totality of an organization’s structure and work processes. In reengineering, fundamentally new orga- nizational expectations and relationships are created. An example of where reengineering is required is technologic change, particularly in information ser- vices, that provides a means of customizing care. Its potential for making all information concerning a patient immediately accessible to direct care givers has the potential for a profound positive impact on healthcare decision making.

The Transforming Care at the Bedside (TCAB) initiative is an example of redesigning the work envi- ronment from the bottom up. The initiative, funded by the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement, was started in 2003 to develop and validate an evidence-based process for transforming care in acute care facilities. Reports from TCAB facilities demonstrate the value of nurse involvement in the process as well as the value to nurses in terms of their participation (Martin et al., 2007; Upenieks et al., 2008).

Regardless of the level of changes made within an organization—redesign, restructuring, or reengineer- ing—staff and patients alike feel the impact. Some of the changes result in improvements, whereas others may not; some of the impacts are expected, whereas others are not. It is critical, therefore, that nurse man- agers as well as staff nurses are vigilant for both antici- pated and unanticipated results of these changes. Nurses need to position themselves to participate in change discussions and evaluations. Ultimately, it is their day-to-day work with their patients that is affected by the decisions made in response to a rapidly changing environment (Martin et al., 2007; Murphy & Roberts, 2008). The Evidence section on p. 155

describes the impact of organizational restructuring on nurses.

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