The Poster Says Speak Up: A Culture Assessment of a Composite Ambulatory Surgery Center Using Schein's Levels and the Competing Values Framework
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Master of Science in Nursing Program, Aspen University
N522: Modern Organizations and Health Care
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Month Day, Year
The Poster Says Speak Up: A Culture Assessment of a Composite Ambulatory Surgery Center Using Schein's Levels and the Competing Values Framework
Every health care organization says it values safety, teamwork, and patients. Culture is what happens when those values compete with time, money, and hierarchy. This paper assesses the culture of a composite ambulatory surgery center using two frameworks: Schein's three levels of culture and the Competing Values Framework. It identifies a gap between espoused and actual values, explains why that gap matters for patient outcomes, and recommends steps a nurse leader could take.
The Organization
Riverside Surgery Center is a composite physician-owned ambulatory surgery center with four operating rooms, performing about 7,000 orthopedic, ophthalmologic, and gastrointestinal procedures a year. It employs 38 nurses, 14 surgical technologists, and support staff, and its surgeons are partial owners. Its reputation for efficiency is strong: first cases start on time 94 percent of the time, and turnover between cases averages 17 minutes. A recent safety culture survey, however, showed that only 41 percent of staff agreed that they could question decisions made by those with more authority, and staff turnover among circulating nurses has risen to 28 percent.
Schein's Three Levels
Schein describes culture at three levels: artifacts, the visible structures and behaviors; espoused beliefs and values, the stated goals and philosophies; and basic underlying assumptions, the unconscious, taken-for-granted beliefs that actually drive behavior (Schein & Schein, 2017).
At Riverside, the artifacts include posters in every room reading "Speak up for safety," a surgical safety checklist completed for every case, a board in the staff lounge displaying turnover times, and a bonus program tied to case volume. Surgeons often arrive after the patient is already positioned, and time-outs are conducted quickly while instruments are being opened.
The espoused values are clear: the mission statement promises "safe, efficient, patient-centered surgery," and leaders describe a culture in which everyone is empowered to stop the line.
The basic assumptions are revealed by what happens when values conflict. When a circulating nurse recently questioned a surgeon about a missing implant consent form, the case was delayed 12 minutes, the surgeon complained to the owner-partners, and the nurse was told to "handle paperwork before the patient is on the table." Staff learned that time matters more than questions and that surgeons' preferences outrank nurses' concerns. The checklist is an artifact of safety; the lesson from the delayed case is the assumption that governs behavior.
The Competing Values Framework
The Competing Values Framework classifies cultures along two dimensions: flexibility versus stability and internal versus external focus, producing four types. The clan culture emphasizes collaboration and people; the adhocracy culture emphasizes innovation; the market culture emphasizes competition, productivity, and results; and the hierarchy culture emphasizes control, rules, and efficiency (Cameron & Quinn, 2011). Most organizations combine types, and assessments compare current and preferred cultures.
Riverside's current culture is dominated by the market and hierarchy quadrants: productivity targets, volume bonuses, standardized procedures, and deference to surgeon-owners. The clan quadrant, emphasizing teamwork, development, and psychological safety, is weak, which is consistent with the survey result on questioning authority and with turnover among nurses. When staff at a similar center complete the framework's assessment instrument, they often describe a preferred culture with more clan characteristics, and the gap between current and preferred culture identifies where change is needed.
Why the Gap Matters
Culture is not merely a matter of staff satisfaction. Across 62 studies synthesized in a systematic review, healthier cultures in organizations and work units kept turning up alongside better results for patients: lower death rates, fewer falls and infections acquired in hospital, and more satisfied patients (Braithwaite et al., 2017). In surgery, the consequences of a culture in which nurses hesitate to question decisions are direct: wrong-site surgery, retained items, and missing consents are the events a checklist is designed to catch, and they are caught only when someone feels free to speak.
Riverside's efficiency is real, and a market orientation has kept it financially healthy. But an organization in which the fastest path is also the one where no one questions anything is accumulating risk that its metrics do not show. The rising turnover among nurses is an early signal that the culture's costs are beginning to appear.
Subcultures and Climate
Culture is not uniform across an organization. At Riverside, the gastrointestinal endoscopy suite, led by a nurse manager who holds brief team huddles before each list, reports noticeably more comfort with speaking up than the orthopedic rooms, where the surgeon-owners work most often. This subculture shows that the center's assumptions are not fixed and that local leadership can shift them. Climate, the shared perception of what is rewarded and supported at a given time, also differs from culture: after the implant-consent incident, the climate in the orthopedic rooms became noticeably more guarded within days, even though the deeper culture had been forming for years. A nurse leader can use the endoscopy suite's practices as a local model and monitor climate through short pulse surveys between annual culture assessments.
Recommendations for a Nurse Leader
Changing basic assumptions requires changing what leaders reward and how they respond when values conflict (Schein & Schein, 2017). A nurse leader at Riverside could start with four steps. First, secure the owner-partners' public commitment that any staff member may stop a case for a safety concern without penalty, and follow through visibly the next time it happens. Second, add safety measures, such as near-miss reports and checklist compliance observed by an independent auditor, to the board that now displays only turnover times. Third, remove the volume bonus or pair it with a team safety component so that speed is not the only thing rewarded. Fourth, repeat the safety culture survey in 12 months to measure change in the proportion of staff who feel able to question authority.
Conclusion
Riverside's artifacts and espoused values describe a culture of safety, but its basic assumptions, revealed when a nurse questioned a surgeon, place speed and hierarchy first. The Competing Values Framework shows a culture dominated by market and hierarchy with a weak clan quadrant. Because culture is associated with patient outcomes, closing that gap is a safety priority, and a nurse leader can begin by changing what the organization rewards and how its leaders respond when someone speaks up.
References
Braithwaite, J., Herkes, J., Ludlow, K., Testa, L., & Lamprell, G. (2017). Association between organisational and workplace cultures, and patient outcomes: Systematic review. BMJ Open, 7(11), Article e017708. https://doi.org/10.1136/bmjopen-2017-017708
Cameron, K. S., & Quinn, R. E. (2011). Diagnosing and changing organizational culture: Based on the competing values framework (3rd ed.). Jossey-Bass.
Schein, E. H., & Schein, P. A. (2017). Organizational culture and leadership (5th ed.). Wiley.
How this N 522 Module 3 example is structured
N522 Module 3 typically covers organizational culture and climate, usually with an assessment applied. Aspen does not publish module deliverables, so check your classroom for the exact prompt. This example applies two named frameworks to one organization, finds the gap between stated and actual culture through a specific incident, ties culture to patient outcomes with evidence and recommends measurable steps.
N522 Module 3 questions, answered
What does N522 Module 3 usually ask for?
The module typically covers organizational culture and climate, often asking you to assess the culture of an organization you know with a named framework. Aspen does not publish module deliverables, so your classroom's instructions govern.
What are Schein's three levels of culture?
Artifacts, the visible structures and behaviors; espoused beliefs and values, what the organization says it values; and basic underlying assumptions, the taken-for-granted beliefs that actually drive behavior, often revealed when values conflict.
What are the four culture types in the Competing Values Framework?
Clan, focused on collaboration and people; adhocracy, focused on innovation; market, focused on competition and results; and hierarchy, focused on control and efficiency. Most organizations combine them in different proportions.
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