Learning Objectives
By the end of this section, you will be able to:
- Explain the current culture of health care
- Describe how collaborative culture is integrated in health care
- Identify ways to incorporate a culture of safety
A set of values, beliefs, behaviors, language, symbols, and practices shared in common by a group of people is culture. A person can be part of multiple cultures (known as a subculture) or multiple groups of people with whom they share core ideologies. Cultures can be bound together based on ethnicity, nationalism, regionalism, religion, interests, age, and so on. Consider Lydia, a 20-year-old U.S. college student who lives on campus and is from the Deep South. Lydia is active in women’s rugby and tabletop gaming (like Dungeon and Dragons), identifies as nonbinary and bisexual, and has autism. Lydia identifies with multiple cultures and shares beliefs, behaviors, values, language, and symbols with other Southerners, college students, members of Generation Z, the LGBTQIA+ community, gamers, rugby players, and people with autism.
Health care has its own culture, and different organizations develop different types of healthcare cultures. Healthcare professionals practice within various healthcare cultures and subcultures which they internalize. The first of these is a professional culture based on the healthcare practitioner’s discipline (think physician versus nursing versus physical therapy). This type of healthcare culture acquisition begins in school. For example, someone in a nursing program and reading this textbook is beginning to take on the culture of nursing.
There are several aspects of healthcare culture including general healthcare culture, how organizations express culture at a system level, and some planned and targeted strategies to purposefully develop organizational culture, such as a culture of safety and a culture of collaboration. As you read, visualize yourself as the nurse you want to be and consider how culture might impact your nursing practice.
Culture of Health Care
Different healthcare professions each have their own culture as do individual healthcare agencies. The beliefs, attitudes, and shared symbols expressed by the agency create a unique internal culture that shapes the behavior of the entire staff from the healthcare professionals to the ancillary staff (staff employed by the agency who are not directly responsible for caring for patients, such as housekeepers and administrators). An agency expresses its culture through its mission and vision statements, policies, procedures, and rules (Bayot et al., 2022). The resulting culture provides structure for how various healthcare professionals work together at that agency to care for patients and maintain the environment (Bayot et al., 2022). There is an old saying in nursing: if you have worked at one hospital, you only understand how to work at one hospital because they are all different.
Link to Learning
The Veterans Health Administration (VHA) is very clear about their core cultural values. The I CARE core values of Integrity, Commitment, Advocacy, Respect, and Excellence offer a clear picture of their organizational culture.
Organizational Culture
The shared beliefs, thoughts, symbols, and attitudes of an organization shape its organizational culture. Healthcare organizations can be further understood as multiple subcultures united by a set of core beliefs and values (Mannion & Davies, 2018). Consider the I CARE core value of Advocacy shared in Link to Learning. The subculture of VHA intensive care unit nurses may result in their being very actively engaged in advocating for patients who are critically ill and need treatment changes quickly. By contrast, nurses on the acute medicine unit may be more relaxed in their advocacy and follow a chain of command that moves through their charge nurse because they are not performing immediate life and death treatments. Both sets of nurses advocate for their patients but do it in different ways based on the culture of the specific units on which they work.
While organizational cultures can be positive and support high-quality patient care and environments at all levels, they can also become negative (Mannion & Davies, 2018). When agencies do not follow their own mission and vision statements or create environments in which staff cannot perform to the unrealistic expectations of those cultural parameters, staff may become disillusioned. As a result, interdisciplinary (involving more than one discipline, such as medicine and nursing) communication and cooperation may decline, and overall patient care may suffer as a result.
Patient-Centered Culture
Organizations can make systemic changes that foster positive healthcare cultures, but they must be intentional in these changes to achieve their preferred outcomes for the organization and patients alike. One example of an organizational cultural change is the shift to patient-centered care (PCC) (Figure 3.14). Until the early 2000s, most healthcare culture was very provider driven and disease focused; providers diagnosed problems and told the patient what to do, and the patient was expected to do it or else the fault was the patient’s (Bokhour et al., 2018). The patient’s own cultural beliefs, abilities, resources, and desires were generally not considered. While this older model remains common, particularly in secondary and tertiary settings, PCC is an alternate model that many agencies follow (Bokhour et al., 2018).
Patient-centered care focuses on relationships and partnerships between providers and patients. Rather than focusing exclusively on a specific disease or condition, in PCC culture, providers engage the patient in a conversation about their health, listen to patient concerns, explain treatment options, make recommendations, and educate the patient so that they can understand the potential outcomes. Then the healthcare provider allows the patient to make decisions that they are most comfortable with based on the patient’s beliefs and values, available resources, and abilities (Bokhour et al., 2018; Kamrul et al., 2014). Developing a PCC culture presents a change from traditional medical culture and requires careful attention and planning from the administrative level down to the frontline staff in agencies. However, PCC culture has been proven to positively affect patients’ experiences, outcomes, trust, and overall healthcare management (Bokhour et al., 2018).
Culturally Competent Care
A core part of PCC is culturally competent care, ensuring that providers and organizations work with patients in a way that is responsive to cultural differences and adapts to fit a patient’s needs (Kamrul et al., 2014). There are eight main principles of culturally competent care:
- critically examining one’s own culture and the values and beliefs they hold;
- recognizing prejudice or racism in agencies and oneself;
- engaging in activities that expand one’s thinking about other cultures;
- learning about the various cultures served by the facility;
- connecting with patients and families to learn more about their culture and culture needs;
- exploring the ways patients and their families understand their conditions and treatment;
- developing relationships with patients and their families based on trust and characterized with openness and willingness to accept their differences; and
- fostering spaces that reflect the diversity of the local community (Kamrul et al., 2014).
Providing access to medically certified interpreters (often via telephone) to ensure that patients who are not native English speakers receive the information they need is an example of a form of cultural competence. Another example of culturally competent care would be allowing a family to bring religious or cultural items or icons to place around a patient’s hospital bed if they do not interfere with necessary medical equipment.
Collaborative Culture
Once upon a time, “doctor” was synonymous with “god,” nurses did not support one another, and healthcare agency departments vied for resources and did not communicate with each other. There were silos (barriers to communication and efficiency) within the medical system and between organizations based on discipline, hierarchy, or ineffective communication (Kelly et al., 2019) (Figure 3.15). Each group focused on their need to do their jobs most effectively without considering other disciplines, the health of the whole patient, or the overall functioning of the agency (JONS, 2017). This can also be described as task-oriented versus patient-centered or holistic health care. Disciplines were divided into silos, such as medicine (doctors), nursing, radiology, dietary services, physical and occupational therapy, and even housekeeping. All struggled to communicate and collaborate with each other. Leadership was also divided into silos with distance and struggle among disciplines. Patients were separated from those who cared for them. The costs—for patients (satisfaction and outcomes), practitioners (morale and resources), and agencies—were steep (Sperling, 2020).
The solution to the problems that healthcare silos generate is the development of a collaborative culture, which has become a core measure in evaluating health care (Wei et al., 2019). Arising out of the PCC movement, collaborative culture in health care focuses on bringing disciplines together to work as a team in identifying common goals, resolving issues, and improving patient-centered care (Goldsberry, 2018). Collaborative culture involves partnering with and communicating with patients to ensure they receive the most effective care when and how they need it. Collaborative culture moves beyond simple teamwork to ensure that different disciplines recognize and acknowledge the skills, abilities, and innovation that other disciplines bring. In that way, everyone’s contributions can be maximized to supply efficient, high-quality care (Goldsberry, 2018). The use of technology, such as e-health records and computers, also allows greater communication and collaboration between agencies or practices (Goldsberry, 2018).
Continuity of Care
An important component of a collaborative culture is continuity of care. The principal goal of continuity of care is health care provided in a thoughtful fashion without breakdowns in communication throughout the healthcare experience and regardless of the number of involved practitioners (Bakerjian, 2022). With continuity, patients have the same providers over time and develop relationships with them. When patients are transferring between providers or locations, clear hand-off reporting is performed to ensure the providers taking over the care understand the patient’s health, needs, and desires. Continuity of care also encourages patient safety (Rhode Island, Department of Health, 2019).
For nurses, continuity of care is often seen in hospital settings. For example, assigning a nurse to the same group of patients for each shift provides continuity of care. Nurses who have regular interaction with a patient are more likely to develop the relationships needed in a collaborative culture setting. They get to know their patients, can more rapidly identify changes, and are more comfortable providing patient advocacy.
Link to Learning
Continuity of care is expansive and intrinsically connected to both PCC and primary care. This short video on continuity of care describes it and how it links to many topics covered in this chapter.
Care Coordination
Another component of collaborative culture that highlights the sharing of information between disciplines to provide orchestrated care to patients is care coordination. Care coordination ensures that testing is not repeated between agencies, medications are not duplicated, and treatments are not utilized by one provider that will make a different condition worse (Agency for Healthcare Research and Quality [AHRQ], 2018). A care transition (movement among physicians, hospitals, care providers) offers a common place where many patients experience failure in their care. Care transitions are common situations in which care coordination becomes important (AHRQ, 2018).
Life-Stage Context
Care Coordination for Older Adults
People age 65 years or older often require higher levels of care coordination than those under 65 years. For example, older adults are 2.5 times as likely to be hospitalized as those between 45 and 64 years old. They are also more likely to experience several chronic illnesses, each requiring its own health provider, to take multiple medications (38 percent of those over age 65 years take more than five medications daily), and to move between care settings, such as physician’s office, hospital, and skilled nursing facilities.
The gold standard of care coordination for patients over age 65 years with complex medical, psychological, and/or social needs is a geriatric interdisciplinary team (a group of practitioners who work collaboratively to coordinate care across disciplines and locations). The team may be at a single location (such as a multidisciplinary practice) or communicate electronically between separate locations. The geriatric team ensures safe transfer between practitioners and locations, guarantees the most qualified provider manages each issue, safeguards the patient against duplicated services, and ensures the patient receives comprehensive care. When this type of interdisciplinary team is unavailable, the same group of patients can be managed by strong primary medical homes, in which their primary practitioner is skilled in geriatric primary care and able to coordinate their services across secondary and tertiary settings.
Patients and caregivers should be involved in group meetings, as appropriate, and asked about their preferences in terms of end-of-life care and pain management, nutritional plans, and treatments. Caregivers should be encouraged to speak openly about their abilities to provide care and their need for resources to do so. Treatment plans should align with those preferences and abilities and demonstrate respect for the patient’s culture and ideals (Bakerjian, 2022).
Culture of Safety
Healthcare settings are inherently dangerous for patients. There are many places and circumstances within healthcare systems that can jeopardize the safety of patients and/or staff members (AHRQ, 2019a). Providers can give incorrect diagnoses based on the information they have or symptoms they do not see (such as strokes or heart attacks, particularly for women). Nurses can administer incorrect medications because the medications look alike/sound alike (such as Celebrex versus Celexa) or can give an incorrect dose (such as 1 mg instead of 1 mcg). Communication breakdowns between patients and providers or among providers can result in patients receiving incorrect care.
Historically, making errors resulted in punishment for those who made them and led to a culture of secrecy around reporting errors and taking responsibility for patient safety (AHRQ, 2019a). In the early 2000s, the Institute of Medicine put forth a plan to improve safety in health care through the acknowledgment that errors are going to happen and the recognition that safety can be improved by developing plans to prevent errors and to learn from them when they are made (AHRQ, 2019a). From this new approach to error prevention, the culture of safety was born.
The culture of safety is a planned cultural change that must begin at an organizational level (AHRQ, 2019a). It includes the following:
- shared values and goals between leadership and frontline staff;
- no fear of reprisals for errors (to promote honest reporting);
- in-depth exploration into the reasons for errors in order to develop strategies to prevent them in the future; and
- promoting safety through educating and training.
Nurses play a critical role in a culture of safety and are on the front line of most patient care interactions, even when they are not the primary prescribers of treatment. Nurses should always engage in open communication to promote safe patient care. The culture of safety is one of the backbones of the quality and safety education for nurses on which nursing curricula and licensing examinations are built.
Going hand in hand with the culture of safety is the idea of just culture, an organizational principle that fosters open and honest reporting of error and balanced accountability and encourages systemic examination to prevent errors in the future. Use of just culture concepts was endorsed by the American Nurses Association (ANA) in 2010 (Congress on Nursing Practice and Economics, 2010). In a just culture, there are three ways to explain medical errors or potential medical errors (Paradiso & Sweeney, 2019):
- Human mistakes: These are legitimate errors—unintentional errors while trying to act in the best interest of the patient. Comfort and coach the individual who made the error and seek additional education if necessary.
- Risky behaviors: These are often related to work-arounds to intentionally circumventing rules, but with the intention of providing good care for patients. Provide coaching and systemic investigation into why work-arounds or risky behaviors are perceived by staff as more appropriate than acting per policy. Examine whether the system is also at fault and if the policies should be modified to provide better care.
- Reckless behavior: These are actions or behaviors that do not intend to provide or care about providing appropriate care for patients. These types of behaviors may be grounds for serious disciplinary action.
Link to Learning
This video on just culture offers an excellent snapshot of the just culture philosophy.
Quality Improvement
Quality improvement is an important component of a culture of safety. The likelihood that health services will improve patients’ health outcomes in a way that is consistent with current knowledge is healthcare quality (Centers for Medicare and Medicaid Services [CMS], 2021b). A framework designed to continually improve patient care and outcomes is quality improvement (QI).
Quality improvement is made through a variety of mechanisms, and agencies are continually engaging in quality improvement activities. One common quality improvement tactic is the Plan-Do-Study-Act (PDSA) strategy (Figure 3.16) (AHRQ, 2020).
Accountability for Safe, Reliable, Effective Care
In a healthcare environment that encourages a culture of safety and continuous quality improvement, there has been a move toward reliable, consistent care. There are many industries (particularly manufacturing) that function under hazardous conditions (such as aviation or power plants) and still produce products or services in a consistent fashion while keeping higher safety standards than health care. While industrial practices cannot be transferred entirely to health care, the emphasis on process refinement, consistency, and reliability have become components of today’s healthcare culture. Effective and safe provision of care is high-reliability health care (AHRQ, 2019b). High-reliability organizations (HROs) provide complex health care for long periods of time without serious incidents or poor patient outcomes related to errors (AHRQ, 2019b). HROs are characterized by a strong culture of safety, continuous quality improvement, and hospital leadership that is willing to provide support and resources for safety and quality (Table 3.9) (AHRQ, 2019b).
| Characteristic | Rationale |
|---|---|
| Heightened focus on failure or near failure | Forces staff to become vigilant, to prevent failures before they occur, and to learn about systemic issues when failures or near failures occur |
| Refusal to simplify the steps | Health care is complex and dynamic; developing shortcuts in procedures can breed errors |
| Recognize the larger picture | Recognize how one’s work in an area impacts the larger system, for example, taking a patient for imaging without notifying the imaging center or recognizing the imaging center has its own schedule to maintain |
| Recognize the knowledge of the front line | Understand that the people closest to patients or a given situation have knowledge and insights that are valuable to the larger agency, and those individuals should be involved in quality and safety conversations and improvement |
| Teach resilience | Recognize that failures are always possible and practice managing and responding to them |
Pay for Performance
A payment model that ties either bonuses or additional costs to providers based on their performance over several metrics including best practices and patient satisfaction is pay for performance (P4P) (NEJM Catalyst, 2018). It contrasts with standard payment, which is fee for service (FFS), payment for each service provided. The goal of P4P is quality over quantity with the hope that practitioners will use best practices to improve health outcomes while reducing overall healthcare costs. While there is some evidence that P4P is working in some places, it is still a fairly new concept, and its real potential has not yet been recognized. There is some evidence that the gains have been minimal, and it may negatively impact poor and marginalized patients because providers have less incentive to treat them. However, P4P is expected to remain important in health care and over time with appropriate adjustments to the structures will improve healthcare quality and outcomes for all patients (NEJM Catalyst, 2018).
Value-Based Purchasing
The CMS has introduced value-based purchasing programs specifically for hospitals and skilled nursing facilities (SNFs) (CMS, 2022). Value-based purchasing looks very much like pay for performance, and some writers speak of them synonymously (NEJM Catalyst, 2018). In the case of SNFs, CMS holds back 2 percent of their Medicare payments until the end of the year. Then they receive up to 60 percent of those payments back as long as their 30-day readmission rate (number of patients who are discharged from the SNF but readmitted for any reason to an acute medicine facility within 30 days) falls below Medicare’s threshold (CMS, 2023). The program for hospitals is similar to that for SNFs but includes additional measures including mortality and complications, healthcare-associated infections, patient safety, and patient satisfaction (CMS, 2021a).