"We Discharge When the Doctors Say So": Assessing the Culture and Safety Climate of Two Medical Units Before Asking Them to Change How the Day Is Organized
[Student Name]
University of Phoenix
DNP/730: Organizational and Systems Leadership
Week 2 Assignment
[Instructor Name]
[Date]
The units and survey results are composites written for a model paper.
Before asking two medical units to reorganize their day around morning discharges, I need to understand their culture. A change that conflicts with deeply held beliefs about roles and priorities will be resisted, however sound its rationale. This paper assesses the culture and climate of 5 East and 5 West.
Why Culture Matters
Braithwaite et al. (2017) systematically reviewed 62 studies of organizational and workplace culture and patient outcomes and found that positive cultures were consistently associated with a wide range of better outcomes, including reduced mortality and improved patient safety. Most studies were cross-sectional, and none were randomized, but the consistency of associations across settings suggests culture is a meaningful influence on care.
Understanding Culture for Improvement
Mannion and Davies (2018) describe culture as the beliefs, values and habits that members of an organization hold in common and rarely say aloud. They caution that organizations contain multiple subcultures, that culture is not easily engineered by leaders and that culture and performance influence each other. They recommend attending to the subcultures relevant to a change and working with them rather than attempting wholesale culture change.
Measuring Climate
Sexton et al. (2006) developed the Safety Attitudes Questionnaire, which measures six factors: teamwork climate, safety climate, perceptions of management, job satisfaction, working conditions and stress recognition, with good reliability and benchmarking data. Attitudes varied greatly within and between organizations, which supports measuring at the unit level. I administered the questionnaire to nurses, aides and case managers on both units, with a 71% response rate.
The survey showed how staff felt; the interviews showed why morning discharges seemed like someone else's job.
Why Use Several Methods
A survey alone would show that 5 West trusts management less, but not why. Observation shows what people actually do, and interviews reveal the beliefs behind behavior. Combining methods gives a fuller picture of culture than any one source, and the findings from each method can be checked against the others.
Survey Results
5 East scored higher than 5 West on teamwork climate, 72 versus 58 on a 100-point scale, and on perceptions of management, 64 versus 49. Both units scored low on working conditions, reflecting staffing concerns. Stress recognition was moderate on both.
Observation
I spent two morning shifts on each unit. On 5 East, the charge nurse held a brief huddle at 7:30 a.m. that included discussion of expected discharges. On 5 West, there was no huddle, and nurses learned of discharges when orders appeared. On both units, nurses deferred discharge timing to physicians, and physicians assumed nurses would prompt them.
Interviews
Interviews with 12 staff revealed shared beliefs. Nurses said, "We discharge when the doctors say so," expressing a belief that discharge timing belongs to physicians. Case managers believed their role began after orders. Aides saw discharge as an afternoon task. On 5 West, several nurses said management "never listens," reflecting the lower perceptions of management scores.
Subcultures
Consistent with Mannion and Davies (2018), I found distinct subcultures: a nursing subculture that values thorough, unhurried discharge teaching; a physician subculture focused on acute patients first; and a case management subculture shaped by insurer requirements. The change must work across these subcultures.
Physician and Case Management Views
I interviewed three hospitalists and two case managers. Hospitalists said they would see likely discharges earlier if nurses told them who was ready, while nurses believed physicians would decide. Each group was waiting for the other. Case managers said insurer authorization for nursing facility placement often arrives after noon, a constraint outside the units' control.
Stories Staff Tell
Staff on 5 West repeatedly told the story of a previous director who launched a discharge initiative, held one meeting and never returned. Stories like this carry culture and explain skepticism better than any survey score. Acknowledging that history openly will be part of rebuilding trust.
Culture Features That Will Help
Both units value patient safety and thorough teaching. The finding that emergency department boarding is associated with mortality appeals to this value. 5 East's stronger teamwork and existing huddle provide a platform for a pilot.
Culture Features That Will Hinder
The belief that discharge timing belongs to physicians limits nurses' initiative. Low perceptions of management on 5 West suggest skepticism toward a leadership-driven change. Concerns about working conditions mean any change seen as adding work will meet resistance.
Artifacts of Culture
Culture also shows in artifacts. On 5 East, a whiteboard lists each patient's expected discharge date. On 5 West, the board shows only room numbers and nurse names. The first unit's board reflects a habit of thinking ahead; the second reflects a focus on the current shift. Small artifacts reveal underlying assumptions.
Implications for the Change
First, pilot on 5 East, where teamwork climate and an existing huddle provide support. Second, frame morning discharge as a patient safety effort that also benefits nurses, for example by spreading workload across the day. Third, involve physicians and case managers from the start, so no subculture feels imposed upon. Fourth, on 5 West, rebuild trust through listening sessions before introducing the change.
Sharing the Results
I will share the survey results with each unit in a staff meeting, presenting their own scores, what they suggest and what I plan to do. Asking staff to interpret the results with me treats them as partners in understanding their culture and models the listening that 5 West reported missing.
Remeasuring
I will repeat the survey after six months to see whether teamwork climate and perceptions of management change on both units.
Climate on Each Shift
Night nurses scored lower on teamwork climate than day nurses on both units. Since discharge preparation could begin the evening before, night staff's engagement matters. I will include night representatives in the working group and hold one listening session at 6 a.m. so night staff can attend.
Culture and the Evidence on Boarding
When I shared the finding that boarding time is associated with mortality in a staff meeting on 5 East, several nurses said they had never connected discharge timing to emergency department patients. Culture shifts when staff see how their work affects patients they never meet.
Limits
Survey climate is a snapshot and does not capture deeper assumptions fully. Staff may answer cautiously when the director is the surveyor; I used an anonymous online survey to reduce this effect and reported results only at the unit level, never by shift or role where groups were small.
Conclusion
A systematic review links positive culture with better outcomes, and a framework for understanding culture warns against simplistic culture change. Survey, observation and interviews show that the two units differ in teamwork and trust, and share a belief that discharge timing belongs to physicians. These findings shape where to pilot, how to frame the change and whom to involve.
References
Braithwaite, J., Herkes, J., Ludlow, K., Testa, L., & Lamprell, G. (2017). Association between organisational and workplace cultures, and patient outcomes: Systematic review. BMJ Open, 7(11), Article e017708. https://doi.org/10.1136/bmjopen-2017-017708
Mannion, R., & Davies, H. (2018). Understanding organisational culture for healthcare quality improvement. BMJ, 363, Article k4907. https://doi.org/10.1136/bmj.k4907
Sexton, J. B., Helmreich, R. L., Neilands, T. B., Rowan, K., Vella, K., Boyden, J., Roberts, P. R., & Thomas, E. J. (2006). The Safety Attitudes Questionnaire: Psychometric properties, benchmarking data, and emerging research. BMC Health Services Research, 6, Article 44. https://doi.org/10.1186/1472-6963-6-44
How this DNP 730 Week 2 example is structured
The DNP/730 Week 2 work usually assesses organizational culture and climate. This paper distinguishes culture from climate, uses a validated instrument alongside qualitative methods, compares two units and translates the findings into implications for the planned change. Students search this week as DNP 730 Week 2, DNP730 Wk 2 or DNP/730 Wk 2; all three are the same assignment.
DNP/730 Week 2 questions, answered
What does DNP/730 Week 2 usually ask for?
Many sections ask students to assess the culture and climate of a unit or organization, using tools or observation, and to consider how culture affects quality and change.
What is the difference between culture and climate?
Culture refers to deeper shared beliefs, values and assumptions about how things are done; climate refers to staff perceptions of policies, practices and priorities at a given time, which are easier to measure.
Does organizational culture affect patient outcomes?
A systematic review of 62 studies found that positive organizational and workplace cultures were consistently associated with better patient outcomes, including lower mortality and fewer adverse events.
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