| An ethnographic case study design was used to describe from the nurse's perspective the workplace cultural influences on the quality of critical thinking in medical-surgical nurses working in a non-Magnet community acute care hospital. A conceptual framework was developed from the literature and the researcher's professional experience to identify potential cultural elements that might influence the quality of critical thinking. Organizational and unit based management, workplace systems and processes, and workplace relationships, including unit staff nurses, physician and interdepartmental relationships were explored.;Twenty RNs from two different medical-surgical units in one hospital were observed while working and interviewed to determine the quality of the RNs' critical thinking, the nature of workplace culture, and to identify how the culture influenced the RNs' quality of critical thinking. The observations were conducted using an unstructured interview technique and the interviews were conducted using a semi-structured interview guide.;The RNs quality of critical thinking was most influenced by what management emphasized and reinforced and by the absence of two way dialogue between the staff and management. Given the limited emphasis on clinical excellence, the nurses relied heavily on experienced practitioners to make clinical decisions. They created a culture in which harmonious relationships and peer support was paramount. This culture assured that the best clinical decisions were made in the absence of clinical guidelines and defined standards for practice. Negative physician relationships affected the quality of the RNs' critical thinking by causing the RNs to discontinue their thinking, because they were not heard or they were embarrassed. The RNs believed that the patient's condition and their nursing peers had the most profound influence on the quality of their critical thinking, even though through their actions, it was evident that management had the greatest influence.;Nursing leadership must be certain the needs of the patients served are adequately represented by focusing on clinical excellence and improved patient outcomes. A hospital culture must be nurtured that encourages two way dialogue, questioning of the status quo, tolerance for disagreement, on-going learning and the expressed desire for improved critical thinking. |
