What Is Culture Made of? An Exploratory Study of Ethical Cultures and Provider Perspectives on the Care of Periviable Neonates.

Objective:  Studies examining intercenter variation in neonatal intensive care unit practices at the limits of fetal viability have hypothesized that institutional "culture" can be one of many factors that impact patient care. This study aimed to describe institutional culture at a single, large academic center with regard to the antenatal consultation, resuscitation, and postnatal management of periviable neonates.

Study design:  Members of six clinical groups-attending and fellow maternal-fetal medicine physicians, attending and fellow neonatal-perinatal medicine physicians, neonatal nurses, advanced practiced neonatal nurses, pediatric hospitalist physicians, and neonatal respiratory therapists-were invited to complete qualitative, semi-structured interviews. All audio recordings were transcribed. Dedoose software was used to complete team-based coding and thematic analysis.

Results:  Twenty-two interviews were completed. Thematic analysis revealed three central themes described by participants as contributory to institutional culture: Perception, referring to factors based on individual attitudes and insights, Statements of Information, referring to factors anchored in more objective concepts such as outcomes data and institutional policy, and Dynamic Factors, referring to the relatively fluid factors of institutional culture that interact with both Perception and Statements of Information. Participants were more likely to mention factors in the Perception category (n = 430) compared with factors in the Information category (n = 225), and although the latter were described as critical components of antenatal counseling and perinatal management, the philosophy of our unit appeared to be more heavily rooted in institutional memory and individual belief systems.

Conclusion:  Our data demonstrate a personal undertone to institutional culture at the limits of viability, with an emphasis on individual attitudes and subjective interpretations of fact rather than empirical data. As the landscape of neonatology continues to change, understanding those factors that contribute to culture remains a necessary step toward deconstructing institutional belief systems and optimizing clinical care.

Key points: · Institutional culture is the collective norms and attitudes that help guide organizational behavior.. · Institutional culture may be one of many factors that impact the care of periviable neonates.. · Deconstructing culture helps us better understand our clinical environment and optimize patient care..