Introduction

Since time began, people have organized themselves into groups. The term organization has multiple meanings. It can refer to a business structure designed to support specific business goals and processes, or it can refer to a group of individuals working together to achieve a common purpose. Regardless of how the term is used, learning to determine how an organization accomplishes its work, how to operate productively within an organization, and how to influence organizational processes is essential to a successful professional nursing practice.

Organizational theory (sometimes called organizational studies) is the systematic analysis of how organizations and their component parts act and interact. Organizational theory is based largely on the systematic investigation of the effectiveness of specific organizational designs in achieving their purpose. Organizational theory development is a process of creating knowledge to understand the effect of identified factors, such as (1) organizational culture; (2) organizational technology, which is defined as all the work being carried out; and (3) organizational structure or organizational development. A purpose of such work is to determine how organizational effectiveness might be predicted or controlled through the design of the organizational structure.

Specific organizational theories provide insight into areas such as effective organizational structures, motivation of employees, decision making, and leadership. A common framework in health care for analysis and application of organizational theory is systems theory. A system is an interacting collection of components or parts that together make up an integrated whole. The basic tenet of systems theory is that the individual components of any system interact with each other and with their environment. To be effective, professional nurses need to understand the specific part—role and function—they play within a system and how they interact, influence, and are influenced by other parts of the system.

An organization’s mission, vision, and philosophy form the foundation for its structure and performance as well as the development of the professional practice models it uses. An organization’s mission, or reason for the organization’s existence, influences the design of the structure (e.g., to meet the healthcare needs of a designated population, to provide supportive and stabilizing care to an acute care population, or to prepare patients for a peaceful death). The vision is the articulated goal to which the organization aspires. A vision statement conveys an inspirational view of how the organization wishes to be described at some future time. It suggests how far to strive in all endeavors. Another key factor influencing structure is the organization’s philosophy. A philosophy expresses the values and beliefs that members of the organization hold about the nature of their work, about the people to whom they provide service, and about themselves and others providing the services.

Mission

The mission statement defines the organization’s reason or purpose for being. The mission statement identifies the organization’s customers and the types of services offered, such as education, supportive nursing care, rehabilitation, acute care, and home care. It enacts the vision statement.

The mission statement sets the stage by defining the services to be offered, which, in turn, identify the kinds of technologies and human resources to be employed. The mission statement of healthcare systems typically refers to the larger community the organizations serve as well as the specific patient populations to whom they provide care. An example of a mission statement appears in Box 8-1. Hospitals’ missions are primarily treatment-oriented; the missions of ambulatory care group practices combine treatment, prevention, and diagnosis-oriented services; long-term care facilities’ missions are primarily maintenance and social support–oriented; and the missions of nursing centers are oriented toward promoting optimal health status for a defined group of people. The definition of services to be provided and its implications for technologies and human resources greatly influence the design of the organizational structure, the arrangement of the work group.

Nursing, as a profession providing a service within a healthcare agency, formulates its own mission statement that describes its contributions to achieve the agency’s mission. One of the purposes of the nursing profession is to provide nursing care to patients. The statement should define nursing based on theories that form the basis for the model of nursing to be used in guiding the process of nursing care delivery. Nursing’s mission statement tells why nursing exists within the context of the organization. It is written so that others within the organization can know and understand nursing’s role in achieving the agency’s mission. The mission should be the guiding framework for decision making. It should be known and understood by other healthcare professionals, by patients and their families, and by the community. It indicates the relationships among nurses and patients, agency personnel, the community, and health and illness. This statement provides direction for the evolving statement of philosophy and the organizational structure. It should be reviewed for accuracy and updated routinely by professional nurses providing care. Units that provide specific services such as intensive care, cardiac services, or maternity services also formulate mission statements that detail their specific contributions to the overall mission.

Vision

Vision statements are future-oriented, purposeful statements designed to identify the desired future of an organization. They serve to unify all subsequent statements toward the view of the future and to convey the core message of the mission statement. Typically, vision statements are brief, consisting of only one or two phrases or sentences. An example of a vision statement is provided in Box 8-1.

Philosophy

A philosophy is a written statement that articulates the values and beliefs held about the nature of the work required to accomplish the mission and the nature and rights of both the people being served and those providing the service. It states the nurse managers’ and practitioners’ vision of what they believe nursing management and practice are and sets the stage for developing goals to make that vision a reality. It states the beliefs of nurse managers and staff as to how the mission or purpose will be achieved. For example, the mission statement may incorporate the provision of individualized care as an organizational purpose. The philosophy statement would then support this purpose through an expression of a belief in the responsibility of nursing staff to act as patient advocates and to provide quality care according to the wishes of the patient, family, and significant others.

Philosophies are evolutionary in that they are shaped both by the social environment and by the stage of development of professionals delivering the service. Nursing staff reflect the values of their time. The values acquired through education are reflected in the nursing philosophy. Technology developments can also help shape philosophy. For example, information systems can provide people with data that allow them greater control over their work; workers are consequently able to make more decisions and take more autonomous action. Philosophies require updating to reflect the extension of rights brought about by such changes. Box 8-1 shows an example of a philosophy developed for a neurosurgical unit with the leadership of a nurse manager and clinical instructor.

Organizational Culture

An organization’s mission, vision, and philosophy both shape and reflect organizational culture. Organizational culture is the reflection of the norms or traditions of the organization and is exemplified by behaviors that illustrate values and beliefs. Examples include rituals and customary forms of practice, such as celebrations of promotions, publications, degree attainment, professional performance, weddings, and retirements. Other examples of norms that reflect organizational culture are the characteristics of the people who are recognized as heroes by the organization and the behaviors—either positive or negative—that are accepted or tolerated within the organization.

In organizations, culture is demonstrated in two ways that can be either mutually reinforcing or conflict-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 documents and verbal descriptions given by administrators 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 decisions that are made within the organization consistently 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 organizational culture, confusion, frustration, and poor morale often result (Casida, 2008; Melnick, Ulaszek, Lin, & Wexler, 2009).

Organizational culture can be effective and promote success and positive outcomes, or it can be ineffective and result in disharmony, dissatisfaction, and poor outcomes for patients, staff, and the organization. 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 understanding of existing expectations as well as the formal and informal communication patterns. Various techniques and tools are available to assist the nurse in performing a cultural assessment of an organization (Casida, 2008). With a solid understanding of organizational culture, nurses will be better able to be effective change agents and help transform the organizations in which they work. The Research Perspective 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 decision-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 small segment rearranges the web, a new pattern emerges, and yet the whole remains. This theory, applied to nursing organizations, suggests that differences logically exist between and among various organizations 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, identified 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 centralization and decentralization.

The issues in healthcare delivery, with their concomitant 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 customized care. Information from Internet sources and direct-to-consumer advertising are significantly altering the expectation and behaviors of healthcare consumers. 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 concentrate 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 influencing structure design. These three factors—consumerism, change, and competition—necessitate reengineering healthcare structures. Whereas redesign is a technique to analyze tasks to improve efficiency (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 organizational expectations and relationships are created. An example of where reengineering is required is technologic change, particularly in information services, 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 environment 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 reengineering—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 managers as well as staff nurses are vigilant for both anticipated 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. 153 describes the impact of organizational restructuring on nurses.

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