HS850 Unit 8 Perioperative Culture Appraisal Example

Teamwork in the Eye of the Beholder: A Unit 8 Organizational Culture Appraisal of Two Perioperative Departments

[Student Name]

Purdue University Global

HS850: Advanced Health Leadership

Unit 8 Organizational Culture Appraisal

[Instructor Name]

[Date]

The health system, its departments and all local figures are composite and shown as placeholders; the instrument, framework and studies cited are real.

Why Appraise Culture This Way

Describing a culture takes an afternoon; measuring one takes method. Surveys capture what people say they believe; observation captures what they do; documents capture what the organization rewards. Schein (2010) separates what can be seen, such as routines, layouts and rituals, from what people say they value, and both from the unspoken assumptions that steer behavior when no one is watching. He calls these artifacts, espoused values and basic underlying assumptions. A sound appraisal uses evidence from each level and pays attention to where the levels disagree, since the disagreement is where underlying assumptions show.

Level Two, Espoused Values: The Survey

Both departments completed the Safety Attitudes Questionnaire last spring, with response rates of [74] and [69] percent. The questionnaire measures six domains, including teamwork climate and safety climate, and has shown good reliability and the ability to distinguish among clinical areas in large samples across three countries (Sexton et al., 2006).

The striking result is asymmetry. In both departments, [84] percent of surgeons rated the quality of collaboration with nurses as high or very high, while [46] percent of nurses rated collaboration with surgeons that way. Anesthesia clinicians fell between. The same pattern appeared in a survey of operating room personnel across 60 hospitals, in which surgeons rated teamwork with other surgeons high or very high 85 percent of the time while nurses rated their collaboration with surgeons as high or very high only 48 percent of the time; the authors concluded that physicians tend to see teamwork as good while nurses experience it as mediocre (Makary et al., 2006).

The survey tells us people in the same room hold different beliefs about how well they work together. It does not tell us which belief describes the room.

Level One, Artifacts: What an Observer Could Count

To test the survey, two trained observers attended [40] cases in each department over four weeks, using a structured checklist for three practices.

Preoperative briefings. In Department A, a briefing with surgeon, anesthesia clinician and circulating nurse all present occurred in [88] percent of observed cases. In Department B, [52] percent, and in most of the rest the surgeon arrived after the briefing had been held without the surgeon present.

Time-outs. Both departments completed a time-out in every observed case, consistent with the checklist that has become standard since a multinational study linked its use to lower complication and death rates (Haynes et al., 2009). But observers also recorded whether every team member spoke during the time-out. In Department A, the circulating nurse and anesthesia clinician spoke in [79] percent of time-outs; in Department B, [31] percent, with the surgeon reading the items alone.

Event reports. Over the past year, Department A filed [3.1] safety event reports per hundred cases, about a quarter from nurses about physician-related concerns. Department B filed [1.4], with almost none from nurses about physicians.

In Department B, the time-out happens every time and says nothing; the form is complete, and the conversation it was meant to start never occurs.

Comparing the Levels

The survey showed the same asymmetry in both departments. Observation did not. Department A's practices suggest that the asymmetry there is a difference in perception within a team that does in fact work together: briefings are shared, everyone speaks and nurses report concerns about physicians. Department B's practices suggest something more serious. Briefings happen without surgeons, time-outs are a recital and nurses do not report concerns about physicians.

Level Three, Underlying Assumptions

Schein's deepest level must be inferred from patterns. In Department B, the pattern suggests an assumption that the surgeon is the authority in the room and that others' contributions are optional. Surgeons there may rate teamwork highly because, from their position, nothing goes wrong that they hear about. Nurses rate it lower because they experience the silence. The low reporting rate is consistent with that reading: reports about physicians would challenge the assumption, and staff may judge that doing so is not safe.

In Department A, the pattern suggests a different assumption: that everyone in the room is responsible for safety. The perception gap there may reflect a profession-wide difference in how surgeons and nurses judge collaboration rather than a local problem.

What the Two Departments Share and Do Not

The two departments share a hospital system, a surgical safety checklist, an event reporting system and many of the same nurses, who float between them. They differ in leadership history. Department A's medical director, in place for six years, introduced joint briefings and attends them herself. Department B has had three directors in four years, and the last left after a dispute over block time. Floating nurses provide a natural comparison: the appraisal asked [12] nurses who work in both departments whether they would raise a concern with a surgeon in each. In Department A, [10] said yes; in Department B, [3] did. The same people behave differently in the two settings, which points to the settings rather than to the individuals.

That finding matters because a common response to poor survey scores is to train individuals in communication. If the difference lies in the departments' practices and assumptions, training individuals who return to Department B's operating rooms will change little. The intervention has to reach what the department does, not only what its staff know.

Implications for Leaders

The appraisal argues against a single system-wide response to the survey. In Department A, the right response is modest: share the results with both professions and discuss why perceptions differ. In Department B, the problem is in the practices and the assumption beneath them. The appraisal recommends that the perioperative medical director require surgeon attendance at briefings, that time-outs be led by the circulating nurse with each team member stating one item, and that department leaders review event reporting with nurses in small groups, asking what concerns go unreported and why. Progress should be measured by observation, not by repeating the survey alone.

Limits

Observers' presence may change behavior, which would make both departments look better than usual. Forty cases per department is a small sample. Event reporting rates reflect many factors besides culture, including how easy the reporting system is to use. Finally, the appraisal covers one season; culture in a department with frequent leadership turnover may shift within months.

References

Haynes, A. B., Weiser, T. G., Berry, W. R., Lipsitz, S. R., Breizat, A.-H. S., Dellinger, E. P., Herbosa, T., Joseph, S., Kibatala, P. L., Lapitan, M. C. M., Merry, A. F., Moorthy, K., Reznick, R. K., Taylor, B., & Gawande, A. A. (2009). A surgical safety checklist to reduce morbidity and mortality in a global population. New England Journal of Medicine, 360(5), 491-499. https://doi.org/10.1056/NEJMsa0810119

Makary, M. A., Sexton, J. B., Freischlag, J. A., Holzmueller, C. G., Millman, E. A., Rowen, L., & Pronovost, P. J. (2006). Operating room teamwork among physicians and nurses: Teamwork in the eye of the beholder. Journal of the American College of Surgeons, 202(5), 746-752. https://doi.org/10.1016/j.jamcollsurg.2006.01.017

Schein, E. H. (2010). Organizational culture and leadership (4th ed.). Jossey-Bass.

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, 44. https://doi.org/10.1186/1472-6963-6-44