Causal relationships between nurse specialty subcultures and patient outcomes in acute care hospitals




Mallidou, Anastasia
Cummings, Greta
Estabrooks, Carole
Giovannetti, Phylis

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Background: Hospital organizational culture is widely held to matter to the delivery of services, their effectiveness, and system performance in general. However, little empirical evidence exists to support that culture affects provider and patient outcomes; even less evidence exists to support how this occurs. Objectives: To explore causal relationships and mechanisms between nursing specialty subcultures and selected patient outcomes (i.e., quality of care, adverse patient events). Method: Martin’s differentiation perspective of culture (nested subcultures within organizations) was used as a theoretical framework to develop and test a model. Hospital nurse subcultures were identified as being reflected in formal practices (i.e., satisfactory salary, continuing education, quality assurance program, preceptorship), informal practices (i.e., autonomy, control over practice, nurse–physician relationships), and content themes (i.e., emotional exhaustion). A series of structural equation models were assessed using LISREL on a large nurse survey database representing four specialties (i.e., medical, surgical, intensive care, emergency) in acute care hospitals in Alberta, Canada. Results: Nursing specialty subcultures differentially influenced patient outcomes. Specifically, quality of care (a) was affected by nurses’ control over practice, (b) was better in intensive care than in medical specialty, and (c) was related to lower adverse patient events; nurses in intensive care and emergency specialties reported fewer adverse events than did their counterparts in medical specialties. Conclusions: Understanding the meaning of subcultures in clinical settings would influence nurses and administrators efforts to implement clinical change and affect outcomes. More research is needed on nested subcultures within healthcare organizations for better understanding differentiated subspecialty effects on complexity of care and outcomes in hospitals.



Hospital organizational culture, Nurse specialty subcultures, Adverse patient outcomes, Patient safety, Structural equation modeling


Mallidou, A. A., Cummings, G. G., Estabrooks, C. A., & Giovannetti, P. B. (2011). Nurse specialty subcultures and patient outcomes in acute care hospitals: A multiple-group structural equation modeling. International Journal of Nursing Studies, 48(1), 81-93. doi: 10.1016/j.ijnurstu.2010.06.002