Introduction Organisational culture ‘is a complex mixture of different elements that influence the way things are done, as well as the way things are understood, judged and valued’ (Kaufman & McGaughan 2013). As you will gather from the work in previous modules, the new graduate registered nurse does not work in isolation but within an organisational environment. One side effect of this environment relates to the special needs of those stepping out of their comfort zone from enrolled nurse to registered nurse particularly if transitioning in the same organisation (Cubit & Lopez 2011, p. 209). The GN (new graduate) reported that their nurse managers and other ward nurses took advantage of them when they knew that they were previous ENs … the GN reported that they needed support as much as any other new RNs in the GNP. For them, they said that because the ward staff knew that they were previously ENs, they were being left behind to manage by themselves. (Cubit & Lopez 2011, p. 209) Enculturation of the new graduate registered nurse is both a promise and a threat; it promises to ease transition when ability and willingness are galvanised towards professional socialisation. It can be a threat because of the stress of adopting ritualistic practices (Duchscher 2008), enduring powerlessness and having to follow rules that conflict with holistic, evidencebased care practices (Boychuck Duchscher & Cowin 2004; Hamilton 2005; Mooney 2007a). Hamilton (2005) identifies these conflicts as ‘discursive dissonances’ arising out of: … differing constructions of the new graduate within institutional discourses of education and health service. In educational discourse the graduate is positioned as a critical thinking and knowing care giver … health service discourses work to construct new graduates as functional, efficient, organizational operatives providing a nursing service. (Hamilton 2005, p. 76) The implication is that if you want to survive, then you have to accept the health service discourse in order to achieve professional socialisation. NGRNs who display assertiveness, reflection and critical thinking can fulfil the goals of holistic evidence-based care; however, this is not easy in an environment of routine care, task orientation and disenfranchisement (Mooney 2007). There are many influences on nursing practice within organisations such as career structures, nursing unions, professional organisation and registering bodies, that is, the Nursing and Midwifery Board of Australia (Chang & Daly 2012, pp. 68-70). It is also important to understand the culture of complexity when delivering nursing care in terms of the trade-off decisions that must be made in the current acute health care environment: An example of a situation in which trade-off decisions must be made would be when the RN must decide at a given moment between the following: stay with a patient who is alone, distraught, and anxious about a diagnosis; leave this patient to give a pain medication to a patient who called 15 minutes ago; check on the new graduate nurse who seems to be overwhelmed by her assignment; or prepare a room for a patient returning from the operating room. Each of these individual situations has obvious clinical and/or workflow management implications along with many nuances and details that only the RN in the situation can see. For example, the patient who is distraught and anxious is threatening to refuse treatment and/or testing that is important for his plan of care; the patient who called for pain medication is scheduled for physical therapy and, if not medicated appropriately before the transporter comes, will not get full benefit of the session, and the nurse may be faulted in the weekly pain management audit; the new graduate is caring for patients who are stable but have the potential to ‘crash,’ and the RN wonders whether the new graduate will be able to notice subtle signs of deterioration if overwhelmed by her assignment; and the elderly patient whose surgery was risky and who has multiple co-morbidities is returning from the operating room and will need one-on-one monitoring for several hours. (Ebright 2010) You will notice that within such complexity it is the relationships between the nurse, the patient/client and the other persons involved that are critical in determining the management of resources. Each relationship is continually evolving/changing and requires adapting/leadership using the skills of critical thinking, clinical reasoning, mindfulness, emotional intelligence, social intelligence and effective and supportive communication. While the NGRN may not have experience, contemporary knowledge and evidence based practice is the trade-off brought to the emerging organisational culture. In a complex adaptive system this resource is valued. Learning outcomes for this module Upon the successful completion of this module, you should be able to: • define organisational culture and complex adaptive systems • discuss the role of complexity within organisational culture • explain the complexity of the RN role within the health care setting • identify the emerging need for change of culture in the context of complexity • discuss the support needs for new graduate registered nurses • consider strategies for leadership and growth into the future. Required readings /Video viewing Text readings Day, G & Rickard, C 2012, chapter 5 ‘Organizational culture in the hospital setting’, in E Chang & J Daly, Transitions in nursing: preparing for professional practice, 3rd edn, Elsevier, Sydney, pp. 71-77. Day, G 2016, chapter 5 ‘Understanding organizational culture in the hospital setting’, in E Chang & J Daly, Transitions in nursing: preparing for professional practice, 4th edn, Elsevier, Sydney, pp. 58-70. White, J 2012, chapter 2 ‘Becoming a competent, confident, professional registered nurse’, in E Chang & J Daly, Transitions in nursing: preparing for professional practice, 3rd edn, Elsevier, Sydney, pp. 17-27. White, J 2016, chapter 2 ‘Becoming a competent, confident, professional registered nurse’, in E Chang & J Daly, Transitions in nursing: preparing for professional practice, 4th edn, Elsevier, Sydney, pp. 19-29. eReadings Boychuk Duchscher, J 2012, ‘New graduate stages of transition: stage 2— being’, in From surviving to thriving: navigating the first year of professional nursing practice, 2nd edn, Nursing the future, Saskatoon, Canada, pp. 157-160. Mellor, P & Greenhill, J 2014, ‘A patient safety focused registered nurse transition to practice program’, Contemporary Nurse, vol. 47, no. 1-2, pp. 51-60. Cubit, K & Lopez, L 2012, ‘Qualitative study of enrolled nurses transition to registered nurses’, Journal of Advanced Nursing, vol. 68, no. 1, pp. 206-211.   Web readings/activities on organisational culture Ebright, P 2010, ‘The complex work of RNs: implications for healthy work environments,’ The Online Journal of Issues in Nursing, vol. 15, no. 1, viewed 21 August 2015, http://nursingworld.org/MainMenuCategories/ ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol152010/ No1Jan2010/Complex-Work-of-RNs.html. Darbyshire, P 2012, ‘What are nurses for? “Couldn’t care less?”, slide presentation, viewed 21 August 2015, http://philipdarbyshire.com.au/media/ southern-health-slides.pdf. SA Health 2015, Floorplans for the new Royal Adelaide Hospital, viewed 21 August 2015, http://www.sahealth.sa.gov.au/wps/wcm/connect/public +content/sa+health+internet/health+reform/the+new+royal+adelaide+hospital/ floor+plans+for+the+new+royal+adelaide+hospital. Videos HYLC, JV 2014, ‘A hospital like no other – the new Royal Adelaide Hospital’, YouTube video, A hospital like no other – new Royal Adelaide Hospital

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Movieclips 2011, ‘The meaning of life (2/11) movie clip—The miracle of birth (1983) HD’, YouTube video, The Meaning of Life (2/11) Movie CLIP – The Miracle of Birth (1983) HD

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Pre-tutorial activities Activity—Organisational culture Read Case study 5.4 from Chang & Daly (2012, p. 78; 2016, p. 69). After graduation, Jessica worked on a surgical ward in a large city hospital which was committed to evidence based practice. Policies for wound dressings were updated regularly to reflect the latest research. After a few years Jessica returned to her home town and started work at the local hospital. During orientation she was shocked to learn that wound care policies differed for each surgeon. For example, laparotomy wounds were washed in the shower for surgeon A, with antiseptic solution for surgeon B and with saline for surgeon C. The nurses seem to have little idea or interest in what wound research had been done. Jessica tried to discuss her frustrations with her colleagues but could not convince them to work towards a standardized best practice approach. ‘You’ll never get the surgeons to agree. ‘We don’t have much wound infection, so it doesn’t matter which way we do the dressings,’ were common statements. After a while Jessica just gave in and learnt each surgeon’s preference? • Why did Jessica succumb to the ward culture? • Is Jessica attempting to provide leadership? Tutorial / workshop activities Activity 1—Group presentation—assignment 2 Allocated students will research the topic ‘Strategies to manage organisational culture’ and complete a PowerPoint presentation to their peers. The presentation should illustrate how competence in the topic area: • will make them a good leader, i.e. to manage patients, staff and work well as a team member • influences their inter-professional collaborative practice • will give them skills to thrive in the work place • will contribute to the responsibility, accountability, supervision and delegation role of the registered nurse. Activity 2—The complex work of RNs In this topic we have explored a number of ways that new graduate registered nurses can support themselves by connecting in a meaningful way, adapting to situations, growing as professionals and working together. Part 1 You will view the following two videos in class. Gonzaga Mentor Gallery 2007, ‘Pat Ebright—Complex adaptive system theory’, YouTube video, Pat Ebright – Complex Adaptive System Theory

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Gonzaga Mentor Gallery 2007, ‘Pat Ebright—Blunt end vs. sharp end’, YouTube video, Pat Ebright – Blunt End vs. Sharp End

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Part 2 Reflect on the article by Ebright (2010) and the section ‘Supporting the new RN’. In small groups/large group discuss the following. • In what way are the support needs for new graduate registered nurses changing? • Brainstorm the following questions posed in the article: ◦ Why must performance increasingly be measured by the level of clinical reasoning skill regarding patient care situations? ◦ What distribution of care delivery, or alternative assignment of RNs, would assure that every patient was assessed by an experienced RN every shift? Part 3 View the following video and as a group discuss James Bates’ experience. Gonzaga Mentor Gallery 2007, ‘Pat Ebright—Stacking’, YouTube video, Pat Ebright – Stacking

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James Bates—Team leader role James begins to take on the team leader role: • What are the attributes that James describes as being necessary for the role? • How does James begin to develop ‘stacking ability’? • In the video it suggests that being able to reprioritize care will take time for the NGRN to develop. What length of time is suggested? How does it relate to Patricia Benners work? • Does TeamSTEPPS® provide any solutions to maintaining patient safety with regard to the NGRN ? Part 4 The Children’s Hospital of Wisconsin is designated a Magnet hospital by the American Nurses Credentialing Centre. Magnet is the highest honour a hospital can receive for excellence in nursing practice. St. Vincent’s Hospital in Sydney is striving to be the first in Australia. This video shows how excellence in nursing practice is portrayed. Children’s Hospital of Wisconsin 2014, ‘Nurses describe what it means to work in a Magnet hospital’, YouTube video, Nurses describe what it means to work in a Magnet hospital

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After watching the video, in small groups/large group complete the following exercises. • List all of the attributes which are indicative of a complex adaptive leadership style. • In complex systems, development requires failing gracefully because that is how growth occurs by trial and error. Are you prepared to fail gracefully and learn? • Are you prepared to be ‘coachable’, open to role models and to seek out mentors that demonstrate excellence in leadership? That is, to look, listen, watch and learn? • Are you prepared to continuously learn and to be flexible with regard to your career path? (37% of nurses do not work in a hospital setting [Health Workforce Australia 2013, p. 24]). • Are you prepared to seek out the health care environment which works best for you and is the best fit for your personal life, interests and skills? • Do you have a plan if you are not accepted into a formal transition to professional practice program? Skip Table of contents TABLE OF CONTENTS • Introduction • Learning outcomes for this module • Required readings /Video viewing • Pre-tutorial activities • Tutorial / workshop activities • Additional resources / videos • References End Main Regions BACK TO TOP Additional resources / videos Web resources Aiken, L, Clarke, S, Douglas, M, Sloane, D, Lake, E & Cheney, T 2008, ‘Effects of hospital care environment on patient mortality and nurse outcomes’, Journal of Nursing Administration, vol. 38, no. 5, pp. 223-229. Fisk, P & Wilson, T 2001, ‘Complexity, Leadership, and management in healthcare organisations’, British Medical Journal, vol. 323, pp. 746-749, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1121291/ Lett, M 2001, ’A case for chaos theory in nursing’, Australian Journal of Advanced Nursing, vol. 18, no.3, http://www.ajan.com.au/Vol18/Vol18.3-2.pdf Video Gonzaga Mentor Gallery 2010, ‘Daniel Pesut story example’, YouTube video, Daniel Pesut Story example

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References Boychuk Duchscher, JE & Cowin, LS 2004, ‘The experience of marginalization in new nursing graduates’, Nursing Outlook, vol. 52, no. 6, pp. 289-296. Chang, E & Daly, J 2012, Transitions in nursing: preparing for professional practice, 3rd ed, Elsevier, Sydney. Cubit, K & Lopez, L 2012, ‘Qualitative study of enrolled nurses transition to registered nurses’, Journal of Advanced Nursing, vol. 68, no. 1, pp. 206-211. [eReading] Duchscher, JB 2008, ‘A process of becoming: the stages of new nursing graduate professional role transition’, Journal of Continuing Education in Nursing, vol. 39, no. 10, pp. 441-450. [eReading] Ebright, PR 2010, ‘The complex work of RUNs: implications for health work environments, OJIN: The Online Journal of Issues in Nursing, vol. 15, no. 1. Hamilton, H 2005, ‘New graduate identity: discursive mismatch’, Contemporary Nurse, vol. 20, no. 1, pp. 67-77. Health Workforce Australia 2013, ‘Australia’s health workforce Series – nurses in focus’, Health Workforce Australia, Adelaide. Kaufman, G & McCaughan, D 2013, ‘The effect of organisational culture on patient safety’, Nursing Standard, vol. 27, no. 43, pp. 50-56. Mooney, M 2007a, ‘Professional socialization: the key to survival as a newly qualified nurse’, International Journal of Nursing Practice, vol. 13, no. 2, pp. 75-80. [eReading]

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