Why Nursing Stays Behind: Unveiling the Hidden Culture in Healthcare

In the intricate web of healthcare, nursing often finds itself struggling for recognition and advancement. This isn't merely a matter of policy or practice but deeply rooted in the organizational culture that governs healthcare institutions. To understand why nursing has lagged, we must delve into the three levels of organizational culture: visible manifestations, shared ways of thinking, and deeper shared assumptions.

1. Visible Manifestations

Visible manifestations, or artefacts, are the tangible and observable elements of a culture. In healthcare, these include:

• Distribution of Services and Roles: The historical divides between secondary and primary care, and between health and social care, often place nursing in a secondary role.
• Physical Layouts: Nurses frequently find themselves in less prominent positions compared to doctors, reinforcing traditional hierarchies.
• Pathways Through Care: Established pathways, such as the outpatient appointment system, often sideline nursing roles.
• Staff Demarcation: Clear lines between staff groups can result in "turf wars" that either challenge or reinforce existing hierarchies.
• Staffing Practices and Reporting Arrangements: These often place nurses in subordinate positions, affecting their autonomy and influence.
• Dress Codes: Different colored scrubs signify different staff roles, visually reinforcing the hierarchy.
• Reward Systems: Pay and pensions are significant, but so are the intangible rewards like autonomy and respect, where nurses often receive less.
• Local Rituals and Ceremonies: These practices uphold the status quo, often marginalizing nursing contributions.

Examples:

• Staffing Practices and Reporting Arrangements: Nurses frequently report to a hierarchy that emphasizes administrative oversight rather than professional development. This can limit their autonomy and professional growth.
• Dress Codes: Different colored scrubs in emergency departments symbolize the distinct roles and status of staff groups, often placing nurses in a secondary position.
• Reward Systems: While doctors might receive higher pay and more significant autonomy, nurses often find their rewards in less tangible forms, such as respect and job satisfaction, which are not always adequately acknowledged.

Visible manifestations also encompass approaches to quality improvement, patient safety, risk management, and responses to staff and patient feedback. Nurses' voices are often less heard in these critical areas.

2. Shared Ways of Thinking

Beneath the visible layer lies the shared ways of thinking that justify and sustain these manifestations. For instance:

• Values and Beliefs: Prevailing views on patient care often prioritize medical interventions over nursing care, reflecting a bias towards clinical over holistic approaches.
• Rationales for Change: Innovations and improvements are frequently driven by evidence that favors medical research, sidelining nursing insights.
• Expectations: Safety, quality, and service improvement metrics often overlook the crucial role nurses play, leading to a lack of recognition and support for nursing-led initiatives.

Examples:

• Patient Autonomy and Dignity: Nurses often embody the values of patient-centered care, emphasizing dignity and holistic care. However, systemic constraints can limit their ability to fully implement these values.
• Safety and Quality: While nurses are on the front lines of patient care, their input on safety and quality improvements is not always given due weight compared to other healthcare professionals.

These shared ways of thinking shape the rationale behind why things are done and why they should change, often perpetuating the marginalization of nursing.

3. Deeper Shared Assumptions

At the core of organizational culture are the deeper shared assumptions — the unconscious beliefs that underpin daily practices:

• Professional Roles: Deep-seated ideas about appropriate professional roles often place nurses in supportive rather than leading positions.
• Patient and Carer Expectations: Assumptions about what patients and carers know and want can diminish the perceived value of nursing care.
• Power Dynamics: The relative power of healthcare professionals, both collectively and individually, often skews in favor of physicians, leaving nurses with less influence.

Examples:

• Professional Roles: The historical view of nursing as a supportive role to physicians persists, affecting the professional status and autonomy of nurses. This assumption limits the scope of practice and the recognition of nursing as a distinct, autonomous profession.
• Power Dynamics: The relative power of healthcare professionals often sees nurses having less influence over clinical decisions and organizational policies, reinforcing a hierarchical structure that favors physicians.

These assumptions are rarely examined but have a profound impact on the everyday experiences of nursing professionals, affecting their ability to advocate for themselves and their patients.

Conclusion

To advance the nursing profession, it's essential to address these three levels of organizational culture. Visible manifestations must reflect equitable roles and rewards. Shared ways of thinking should include valuing the contributions of nurses equally. Finally, deeper shared assumptions need to shift towards recognizing nursing as a vital, autonomous profession within healthcare. By addressing these cultural dimensions, we can ensure that nursing not only catches up but leads in the future of healthcare.

References

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By understanding and addressing these cultural dimensions, we can create a more equitable and effective healthcare system where nursing thrives. The journey to elevate nursing within the healthcare hierarchy is not just about policy changes but also about transforming the underlying cultural perceptions and structures.