The impact of workplace culture on the provision of person centred care in an acute surgical ward: A critical ethnography

Many Australian health services espouse a method of patient care that ensures that all patients are treated as individuals, with dignity and respect. Referred to as ‘person centred care’, this philosophy is congruent with nurses’ professional philosophy and with the expectations of health care consumers. Person centred care has many stated benefits including satisfaction with care; shorter hospital stays and increased compliance with interventions. However many health care organisations and professionals find it difficult to wholly implement in practice. This is particularly true in acute care settings where increasing acuity, technically complex care and shorter admission times pose significant challenges. This critical ethnography presents the culture of nursing within an acute surgical ward in a regional hospital in Queensland with a specific focus on the impact this culture has on nurses’ ability to provide person centred care. Founded in critical theory and interested in manifestations of power and hegemonic structures, data were gathered using participant observation over a five month period, participant interviews and examination of clinical documents in order to describe the culture of care in this setting. In doing so it presents a broad understanding of what these nurses know, what they do and what they value. The critical perspective examines the social and political forces that shape this culture and nurses’ beliefs about themselves and their nursing practice. This work acknowledges that power differentials and oppression operate at all levels of human interaction and influence whose voice is heard and whose is silenced (Hardcastle et al., 2005). This research was particularly interested in the ways that hierarchies of power in health care generally, and in this workplace specifically, might constrain nurses’ ability to plan and deliver nursing care according to their personal values and professional mandate and patient expectations. The intent was to reveal those oppressive organisational structures that might hinder the delivery of person centred care (Stewart, Holmes, & Usher, 2012). By revealing these dominant ideologies, nurses are free to question many of the assumptions on which nursing practice is based and perhaps generate new ideas for practice (DeForge, van Wyk, & Salmoni, 2011). Findings demonstrate a tension existed between the person centred care nurses espoused and the task focused care they actually delivered. The perceived organisational emphasis on efficiency, cost effectiveness and the demand for measurable targets meant that the emotional and psychosocial aspects of nursing were marginalised and completing tasks became the main focus of nurses’ work. Additionally a traditional hierarchical nurse-doctor relationship meant that bedside nurses were excluded from interdisciplinary clinical decision making and doctors orders were the main way that nurses prioritised their work. This was reinforced through the communication processes and left nurses without timely information to deliver person centred care. Individual nurses had little autonomy over their work leaving them devoid of personal and professional satisfaction; needs that were met through ‘the team’ culture. Nurses cared for and about the team and keeping the team happy became nurses’ raison d’etre. Ironically ‘the team’ functioned to keep nurses efficient in their completion of tasks thereby maintaining the status quo. This research confirms some of what is already known about the impact of workplace culture on nursing care and extends these findings to reveal how nurses are complicit in their subordination. It details how communication structures and competing priorities left nurses uninformed and unable to deliver the care they want leading to significant moral distress. In revealing dominant ideologies, barriers and facilitators to person centred care were revealed that may help move nurses toward empowered practice in the implementation of person centred care.