CHAPTER 9
Values and Behaviors Associated With Exemplary Professional Practice: Enculturation
KEY WORDS
Socialization, resocialization, enculturation, onboarding, talent development, competencies
OBJECTIVES
By the end of this chapter, readers will be able to:
1. Define the terms socialization, resocialization, and enculturation related to professional nurse work
2. Describe the term cultural “fit”
3. Evaluate how hiring practices, onboarding, and talent development contribute to enculturation
4. Differentiate between generic and technical competencies
5. Apply principles of accountability related to a professional practice model (PPM)
6. Analyze evidence for successful PPM enculturation
HEALTH SYSTEM ENCULTURATION
In today’s global workforce, nurses frequently change employment while, at the same time, health systems busily modify their traditions in response to external reimbursement/accreditation forces and internal practice improvement. The transferability of nurses’ clinical skills to new or altered health systems is implied, but the cultural specificity of these skills can often be a barrier to successful professional assimilation (Neiterman & Bourgeault, 2015). In fact, studies of new nurse socialization practices emphasize how nursing’s ethos of caring can be lost to one of competence during the process as beginners transition from student to RN (Mackintosh, 2006; Price, 2009).
Although the majority of nurse socialization literature focuses on those new to the profession, the concept of resocialization is beginning to emerge in terms of appreciating that professional practice is embedded in the wider cultural and political ideologies of health systems. As such, employees often must unlearn, relearn, and acquire relevant system-specific language, norms, and practices. Thus, nursing knowledge and skill is not sufficient for individual career and organizational success. Rather, ongoing individual learning and recurrent modifications to professional nurse work and accommodation to the professional identity of health systems are necessary.
Socializing or resocializing nurses to the underlying values, norms, expectations, and acceptable behaviors (culture) of a health system is typically accomplished through orientation and/or educational programs, which can last anywhere from 2 hours to several weeks (depending on the system and the employee). Yet, to be successful (in terms of job performance and proficiency), nurses not only need to understand the work, but also require an understanding of institutional history, stories, and legends; goals and politics; how decisions are made; the language required to communicate effectively; important symbols and artifacts; values and daily work behaviors necessary to “fit” in, and acquire a sense of belonging (Chao, O’Leary-Kelly, Wolf, Klein, & Gardner, 1994).
The concept of enculturation is used to describe this dynamic process of learning, experiencing, and assimilating system values, expectations, and obligations, and how nursing occurs, including its proper behaviors, language, and interactions.
Enculturation is a socialization process by which employees adjust to, and eventually become part of, the unique culture of their health system (Tutlas, 2011). This unique culture is often made up of unspoken and unwritten rules for working together. In fact, E. Adamson Hoebel (1949), a distinguished anthropologist, noted that enculturation is both a conscious and an unconscious conditioning process whereby a person achieves competence in his or her culture and internalizes it. If successful, enculturation provides a clearer understanding of the complexities of the system and results in competence in the language, values, and rituals of the culture—in essence it ensures a “fit” between the system and the employee. As expected, employees who are good cultural fits work well in a health system, whereas those who fail to fit in the environment either become marginalized and unsuccessful or leave to find a more congruent work environment.
In terms of professional practice models (PPMs), enculturation assumes that nurses acquire the knowledge, skills, and attitudes associated with the model, are responsive to it, and are motivated to behave according to its tenets. In other words, they acquire the competence to practice it, are motivated to continuously improve their practice, reflect on how the PPM informs the larger discipline of nursing, and develop a professional identity that aligns with the model.
Inspiring employees to deliver on the professional practice model is a leadership responsibility that ensures nursing work is performed in accordance with a health system’s unique ethos (i.e., “the way we practice nursing here”).
ALIGNMENT WITH THE PROFESSIONAL PRACTICE MODEL
Because the professional practice model essentially brands the practice of nursing for a health system, it clarifies for any nurse what is “appropriate practice” versus what is “inappropriate practice.” In doing so, it becomes easier to make the right clinical decisions.
Because nursing practice often carries over or influences other health professionals’ practice, the whole health system will eventually have a lens that enables smart and appropriate clinical decisions based on the selected PPM. Building such a culture is not a short-term activity or announcement; rather, it is a genuine and ongoing commitment to the organization’s PPM, resulting in employees who are consistently living the model both inside and outside the system on a daily basis.
Employees must grasp the meaning of the professional practice model and how it translates into observable, actionable behaviors that can positively impact the entire system.
Typically, employees move through three stages: from awareness of the model to advocating for it (based on how well leadership is committed at the highest levels, the particular strategies and evaluation feedback that was implemented [Chapters 5 and 6], and ongoing enthusiasm about how the model is spread; Figure 9.1). In Figure 9.1, new employees begin their integration to the PPM during the onboarding process during which the conceptual foundation is laid. Over time and with specific strategies, they begin to emotionally attach to the model, eventually accepting it and, finally, they begin to identify with the model, using and promoting it daily. This is a long-term process that unravels over many months, sometimes years. New employees must modify their professional identity enough to meet the standards of professional practice at a specific health system, oftentimes balancing the need to present themselves as competent while at the same time ascertaining how they can adjust their behavior in order to fit in. Groups of nurses (departments) who eventually become deeply aligned with the PPM maximize its strength and contribute to a more lively professionally based culture. For example, living a PPM:
Figure 9.1 Progression of professional practice model translation.
• Provides a daily tangible reason for ongoing practice improvement
• Contributes to a level of pride tied to fulfilling the model’s promises
• May facilitate recruitment and retention
• Confirms the focus of nursing practice
• Generates positive energy necessary for engagement
• Shows employees how they fit into the health system’s values and priorities
Alignment with the PPM starts with selecting the right employees.
Hiring Practices and the Professional Practice Model
Hiring nurses based on skill competency alone is not the best approach for enculturating a PPM.
Rather, finding superior talent (talent acquisition) that fits the workplace culture requires finding candidates who have the potential for the same key behaviors that are required to practice the selected professional practice model. The candidate whose values, beliefs, outlook, and behavior are congruent with the professional practice model and those existing within the current system is mostly likely to be a good cultural fit for the organization.
Of course, this means that nursing and human resources departments must be on the same page regarding candidate selection, and the human resources staff must understand the PPM enough that successful hiring (and future enculturation) is accomplished. Searching for candidates who are knowledgeable about nursing as a profession, including its significance, are energetic and interpersonally skilled, committed, passionate, patient centered, and who are comfortable taking risks is essential (Table 9.1).
Prior to or during integration of a PPM, exploring the health system’s talent acquisition program, including the processes of finding, assessing, and eventually hiring nurses who meet the organizations’ requirements for practice, is beneficial. For example, being aware of schools of nursing or other health systems that have similar values and attitudes about nursing is an important strategy. This may require searching others’ websites, seeking out and making connections with educational program directors, and speaking with potential candidates at specific professional conferences. Inquiring of recent hires how the recruiting process might be improved may yield important information. Ensuring that the PPM is prominently positioned on the job description so that potential employees can judge their likely fit when they first examine the requirements for working at a specific health system is valuable. Tailoring the interview for the specific setting and critical role competencies is important, that is, expressing the organization’s mission and nursing values, walking potential employees through a clinical unit and describing the experiences they will encounter should they be hired, observing their interactions with presently employed nurses, and asking the candidates questions about their potential suitability generates valuable information. In some cases, assessment tools are available for evaluating potential employee values and competencies and can be used again after hire to design an appropriate onboarding program. Asking open-ended, behavior-based questions on interview, eliciting responses that might forecast future performance, also called behavioral interviewing (Clifford, 2006; Huffcutt, Van Iddekinge, & Roth, 2011), facilitates successful hires. Some examples include:
Table 9.1 Culturally Congruent Candidate Characteristics
• Can you tell me about a situation that was uncomfortable (risky) for you? What happened? What did you do? How do you feel about it now?
• Tell us what your plans are 10 years from now? What will occupy your time? Can you provide an example?
• What significance do you think nursing makes in the lives of patients? Families? Other health professionals? Why?
• Can you provide an example of a time when you believe you were practicing “professional” nursing? How do you know? What were the patient’s responses?
• Can you tell us about a time when you felt very strongly about a patient or a patient situation. What was the end result? What steps did you take to make this happen?
Finally, despite the fact that letters of reference, background checks, and transcripts are considered essential hiring practices, this author has witnessed several scenarios of employees being hired without such validating information. Consider the following case:
A large system had a vacancy posted for a job that required a master’s degree and some work experience related to the specific position. The hiring practices at the system required a search committee made up of peers. Thus, the search committee conducted a series of interviews with potential candidates, per policy. A particular candidate described his or her prior work experience, stating verbally and in writing that graduate work was done at a specific university. The search committee concluded this person was a good candidate and developed a recommendation for hire. It is not the routine practice of the human resources department at this system to solicit reference letters or transcripts; rather they rely on search committee recommendations. The recommended individual was hired and a year later, after some negative work evaluations, it was discovered that the individual never completed the required graduate degree. Upon questioning, the search committee revealed they never solicited transcripts—rather, they “assumed the human resources department did that.” The individual remains in the position, although he/she is not able to successfully execute its requirements.
How often do hiring practices such as this result in a poor fit between the organization’s needs and the employee’s competencies and values?
Background checks provide general character information that does not reflect the candidate’s job performance, but does give an overall picture of the candidate’s behavior. Reference checks and official transcripts, however, are much more focused, and can garner important information that can facilitate the system’s success in hiring.
Onboarding
Onboarding is “the process of acquiring, accommodating, assimilating, and accelerating new team members” (Bradt & Vonnegut, 2009, p. 3). Stated another way, “onboarding is the process of helping new hires adjust to social and performance aspects of their new jobs quickly and smoothly” (Bauer, 2010, p. 1). Effective onboarding drives employee productivity, accelerates the delivery of results, and improves retention (Bradt & Vonnegut, 2009). It can be a culture-shaping process that gives a competitive advantage to one health system over another, provided it is conducted for success. Unfortunately, only about 20% of organizations achieve this level of onboarding, creating less than desirable results (reduced manager and hourly worker assimilation and retention; Bauer, 2010; Hall, 2013). And, to decrease costs of onboarding, many health systems have shortened the process.
Overwhelming new employees with large amounts of information in a short period of time may be counterproductive, leading to failure of the process. Rather, an extended onboarding process that accommodates employees’ needs not just for compliance, but for better understanding of the health system itself (history, values, mission, politics), how to interact with others in the system, competencies required for the particular role, the language associated with the PPM, and important connections to others is recommended. Some examples of such successful onboarding processes include:
• Question-and-answer time with the chief operating officer or another similar executive-level administrator who demonstrates commitment to the PPM
• An overview of the system’s culture and future goals
• A breakdown of the various roles within the organization, including associated responsibilities
• An outline of potential career paths for employees
• A diagram of the new employee’s workplace connections
• Welcoming attitude beginning on the first day
• Exposure of new employees to various relevant departments
• An effective preceptor, mentor, or transition coach strategy in which new hires are paired with seasoned employees over time
• Extracurricular bonding opportunities such as sports events, dinners, or service projects
Noticeably absent from the preceding list are specific nursing skills; rather, factors that are specific to creating a lasting bond between a new employee and the health system are dominant. “Research has established that new employees who feel connected and accepted by their new colleagues have less initial anxiety upon entering the new organization” (Bauer, 2013, p. 5). To ensure a successful cultural fit, new employees need information and experiences that help them learn how “to be” in the health system. Such learning facilitates assimilation of values, appropriate behaviors, and system interaction norms. A written onboarding plan with associated training, coaching, precepting, frequent feedback, participatory approaches delivered consistently over time, and evaluations of important employee milestones is essential. As previously indicated, this process is most successful when the human resource and nursing departments work together for the good of the employee to consciously shape a work culture that ensures the success of the PPM. Outcomes from successful onboarding include employee self-efficacy, role clarity, social integration, and knowledge of the culture in the short term and then, optimistically, job satisfaction and organizational commitment in the long term (Bauer, 2010).
Talent Development
Talent (or aptitude) is a concept that refers to some exemplary characteristic that certain people possess (Garavan, Carbery, & Rock, 2012). The concept can be defined at three levels: individual, group, and organizational. Individually, it is described as a unique, exceptional, outstanding ability or skills in a certain area or topic. It may also refer to a person who is creative, innovative, and achieves superior results, for example, the athlete or musician who is deemed quite talented. At the group level, the talent of one individual is blended in among several individuals, whereas at the organizational level, collective employee talent is considered essential to achieving the overall aspirations of the system. In this case, organizational “talent” can be viewed as referring to a pool of employees (nurses and those who support them) who possess unique capacities (or have the potential to develop them) that facilitate nursing work as defined by the selected PPM.
Health systems define talent specific to their organizations; thus, it is a dynamic concept that changes over time based on organizational goals. As such, health systems bear the burden of talent development, making it an expensive and time-consuming endeavor. Talent development “focuses on the planning, selection and implementation of developmental strategies for the entire talent pool to ensure that the organization has both the current and future supply of talent to meet strategic objectives” (Jamka, 2011, p. 65). Thus, talent development is a focused, evolving process that requires highly engaged professionals who work in tandem with employees to ensure up-to-date health system capacity.
Talent emerges progressively from the transformation of individual aptitudes (or raw material) to systematically developed skills that are catalyzed by intrapersonal and environmental forces (Gagné, 2000). The process of talent development manifests as systematic learning followed by practicing. The higher the level of talent sought, the more intensive is the process required. In a practice-oriented profession such as nursing, the critical component of practice or experiential application cannot be overstated. Role models become highly influential to new employees in this process as do the relationships developed with other health care professionals. Emerging talent is manifested as “credible individuals who consistently deliver strong results; master new types of expertise quickly, recognize the importance of behavior, relentlessly focus on learning, have an entrepreneurial spirit with the capacity to take risks” (Micheals, Handfield-Jones, & Axelrod, 2001, p. 111). Such individuals exude competence, accountability, and engagement.
Competencies Required for Professional Practice
Competencies are the skills and personal characteristics required for superior performance (Workitect, 2012). They focus on specific behaviors that can be grouped into two domains: generic and technical. Generic competencies are highly contextual (Dierdorff, Rubin, & Morgeson, 2009) and include role, social, and physical dimensions. For example, role competencies focus on the informational and structural features of the professional role, as well as accountability and autonomy (Johns, 2006). The social dimension focuses on interpersonal aspects of the role such as communication, conflict, the degree of interdependence, and density of human interaction. Physical context focuses on issues, such as the working conditions like degree of risk, hazard, noise, and so on, which influence work performance and behavior. Unlike technical competence, generic competencies provide more significant developmental challenges.
Generic competencies tend to be holistic, to overlap, and interweave (Capaldo, Landoli, & Zollo, 2006), and they are intrinsically tied to personal characteristics such as self-confidence, motivation, and interpersonal skills. Talented employees are expected to display generic competencies that meet the demands of a unique and continually changing work environment, which requires flexibility of process (Garazonik, Nethersell, & Spreier, 2006).
One approach to generic competency identification is to use competency maps that help identify key core competencies for a health system that can be used to guide employee development, provide a common language, and assess attainment (Isrealite, 2010). These maps are typically standardized across all units of a health system with established domains used to identify both individual and business unit development needs. For example, domains for generic competencies might include health system mission, goals, strategic plan, and role in community; role and identity of health system leadership; general communication mechanisms; the performance evaluation and advancement processes; appreciating diversity; dress and behavior codes. Mixed reviews on competency maps are apparent in the literature without good empirical evidence of their long-term value.
Technical competencies, on the other hand, include the knowledge, skills, and attitudes required for a specific task, that is, professional nursing. In this case, such competencies are derived from professional standards, state nurse practice acts, and the PPM. Examples of nursing-specific competency domains might include observation and communication (obtain accurate and pertinent information from patients, e.g., comprehensive assessment), motor (perform certain procedures), cognitive (interpret patient information, prioritize patient needs, retrieve and critically appraise research to determine the best available research evidence, develop plans of care), and communication (accurately convey information to health team members).
