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HEALTH SCIENCE JOURNAL® Volume 6, Issue 2 (April – June 2012)

Page | 212 E-ISSN: 1791-809X Health Science Journal © All rights reserved www.hsj.gr

SYSTEMATIC REVIEW_

Health care provider’s Organizational Culture Profile: a literature review

Eleni Siourouni1, Catherine K. Kastanioti2, Dimitris Tziallas3, Dimitris Niakas1

1. Faculty of Social Sciences, Hellenic Open University, Patras, Greece 2. Department of Health Management and Welfare, Higher Technological Educational Institute of

Kalamata, Kalamata, Greece 3. Department of Internal Medicine, University Hospital of Ioannina, Ioannina, Greece

ABSTRACT

Purpose: The objective of this critical review was to establish a synthesis of the literature of organizational

culture and to assess whether a single dominant organizational culture exists in public hospitals.

Data sources: A search was contacted in four electronic data bases (MEDLINE, EMBASE, CINAHL and

SCOPUS) using terms ‘‘Organizational culture’’ AND “Health care sector”.

Study selection: Three inclusion criteria were applied: 1) the report of an original research study, 2) a

study focus on evaluation of organizational culture and 3) a conceptualization of culture.

Data extraction: Data was extracted by two reviewers independently.

Results: Twelve studies met inclusion criteria. Although most studies were cross-sectional in design and

variability was noted with respect to assessment instruments, all suggested a significant association

between a strong organizational culture and employee and patient satisfaction. Operating culture found to

be inconsistency within public and private healthcare settings as well as within health care professionals.

Conclusion: While an association between organizational culture and healthcare performance was found,

some of the relationships were weak.

Keywords: Organizational culture, healthcare sector, employee’s values

CORRESPONDING AUTHOR

Kastanioti K. Catherine

A-TEI Kalamata

Antikalamos Messinias

24100, Kalamata, Greece

Phone: +30 27210 45186

Mobile: +30 693 7070969

Fax: +30 2132010418

E-mail: [email protected]

INTRODUCTION

n increasing body of evidence has

indicated that successful

companies--those with sustained

profitability and above-normal financial

returns--are characterized by certain

well-defined conditions and a highly

A

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Health care provider’s Organizational Culture Profile: a literature review

motivated workforce, with shared values

and assumptions 1-4. Peters and

Waterman5 found that successful

organizations possess certain cultural

traits of “excellence”. All of these

companies have a major distinguishing

feature that they all highlight as a key

ingredient for their success: their readily

identifiable, organizational culture6.

Although, organizational culture and

climate are conceptually related, they are

two distinct concepts. Organizational

culture refers to a wide range of social

phenomena, including an organization's

customary dress, language, behavior,

beliefs, values, symbols of status and

authority, myths, ceremonies and

rituals, and modes of deference and

subversion; all of which help to define an

organization's character and norms7-9.

Daft10 defines culture as "the set of

guiding beliefs, understanding, and ways

of thinking that is shared by members of

an organization and is taught to new

members." On the other hand,

organizational climate reflects the

employees’ perception of the

organizational culture11. Daft10

explained that organizational culture

serves to critical functions: internal

integration and external

adaptation.Regardless of the size,

industry, or age of the organization,

organizational culture affects many

aspects of organizational performance12,

including financial performance,

customer and employee satisfaction, and

innovation13,14. Ouchi15 presented a

similar relationship between

organizational culture and increased

productivity, while Deal and Kennedy16

argued for the importance of a “strong”

culture in contributing towards

successful organizational performance.

Additionally, a supportive organizational

culture is often cited as a key component

of successful quality improvement

initiatives in a wide variety of

organizations, including health care17-18.

A hospital’s culture is reflected by what

is valued, the dominant managerial and

leadership styles, the language and

symbols, the procedures and routines,

and the definitions of success that make

a hospital unique. In the health care

organizations physicians and nurses are

generally familiar with the concept of

culture and its importance in the

provision of individualized patient care.

Therefore, organizational culture has

been considered as a variable

influencing hospital performance that

contribute to quality of care19-23, and a

tool that can be used for better nursing24-

27, medical28-29, patient30-32, and system

outcomes including improved workplace

environments9, 33-35, and patient and staff

safety. Moreover, it has been suggested

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that regardless of individual’s

motivation, capabilities and resources, a

supportive work culture may have

significant impact on the feelings

towards one quality of working life as

well as on health consequences in this

health sector29. Two approaches have

been suggested in order to describe

differences in organizational culture

between organizations; either a typology

or a dimensional approach36. Harrison37

adopting the typology approach,

suggests four main types of

organizational culture: power; role;

task/achievement; and person/support.

Deal and Kennedy16 also have proposed

four generic culture types as determined

exclusively by one aspect of

organizational behaviour – the degree

and speed of feedback on whether

decisions or strategies are successful.

Cameron and Quinn38 characterized

organizational cultures as clannish,

hierarchical, market-oriented, or

adhocratic. On the other hand, adopting

dimensional scales Hofstede1 analysed

cultural differences between nationalities

and suggested that culture has four

dimensions: power distance; uncertainty

avoidance; individualism/collectivism;

and masculinity/femininity39. The

designers adopting a dimensional

approach described culture by its

position on a number of continuous

variables using a Likert-type scale for

respondents to indicate their level of

agreement with predefined statements40-

42. Although, there has been an upsurge

of interest in the quantitative

measurement of health care provider’s

behavioural patterns43-55, the overall

organizational culture profile remains

poorly evaluated, in the health care

environment. To the best of our

knowledge, only two reviews of

organizational culture research in

nursing were published. In 1996 Mark

and his colleagues56 including 12 studies,

reviewed methodological and conceptual

issues in nursing organizational culture

research. More recently, Scott-Findlay

and his colleagues57 updated Mark’s

review and demonstrated an increasing

development in nursing organizational

culture research. Specifically, they

included twenty-nine studies pinpointing

a variation in cultural definitions as well

as a larger pool of cultural instruments

in line with Mark’s review. Moreover,

researchers pointed an inconsistency in

use of organizational culture term using

organizational culture and climate

interchangeably. Therefore, the aim of

this critical review is to provide a further

insight in the organizational culture

research in heath care sector, specifically

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Health care provider’s Organizational Culture Profile: a literature review

in public hospitals as the unit of analysis.

Furthermore, we aimed to establish a

synthesis of the literature measuring co-

existing sub-cultures within hospitals.

Methods

Data sources

A literature search was contacted

between January 1998 and December

2008 by using the following electronic

data bases; MEDLINE, EMBASE,

CINAHL, SCOPUS and Cochrane

Library. These databases combine

coverage of the majority of major

medical, nursing and management

journals. Dissertations and “grey

literature” (e.g. conference proceedings)

were not included in the search. Grey

literature is relatively inaccessible to

researchers and, therefore we suggested

that it has less impact than published

studies. Furthermore, meta-analysis of

data was not feasible as a result of

differences in reporting culture measures

and perspectives. The inclusive terms

“organizational culture” OR

“organizational behaviour” OR

“organizational culture” AND “hospital”

OR “nurses” OR “physicians” OR “work

environment” OR “work culture” were

used in the searches.

Study selection The search generated

5.698 titles and abstracts. The first

author electronically assessed the titles

and abstracts using the following

inclusion criteria: i) prospective research

study published during the past 10 years

(1998–2008); ii) in English; iii) focus on

defining the type of organizational

culture using a clear definition of it. The

objective of this critical review was to

assess whether and by how much a

single dominant organizational culture

exists in public hospitals. Using the

previous inclusion criteria, only twelve

articles remained in the data set.

Data extraction

Data for the studies was extracted by

two reviewers independently using a pro-

forma designed for the purpose. Initially,

two reviewers read brief study details

(title, abstract) of papers identified with

the search strategy. Those not relevant

were excluded at this stage. Then, both

reviewers assessed studies that appeared

to meet the inclusion criteria to

determine acceptance in the review. Any

disagreements were resolved by

discussion. The information collected

from each study43-53, 55 included aim and

setting of study, sample, study design

and findings.

Results

The outcome of the search revealed 12

studies in relation to define the

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dominant organizational culture in

public hospitals. Table 1 describes the

research methods for the eligible studies.

In organizational culture research, the

appropriate definition of the “unit of

analysis” is an important methodological

issue. The dilemma is that organizational

culture can be conceptualized as a

psychological variable with the data

collected at the individual level or it can

be understood as a group or

organizational level variable54. In the

latter case, the individual level data are

aggregated to a higher level. The

authors of studies included in this review

analysed their data at the unit or

organizational level. The samples ranged

from 120 health care professionals

[physicians, nurses and administrative

staff] to almost 2,065 healthcare

providers and the studies were

geographically diverse. The increase in

the number of studies published between

2004 and 2008 is a reflection of the

growing interest in organizational

culture as an important element of

successful organizational initiatives,

including quality of services. All

researchers used cross-sectional designs,

and response rates varied across studies,

and ranged from 36% to 90%.

Furthermore, most of the investigators

employed validated instruments to assess

organizational culture; however its

scientific properties varied across

studies. Each of the studies are

discussed below.

Bellou43 aimed to recognize the operating

culture in 20 out of 107 public hospitals

among a sample of front-line employees

[n=1,000], which included a large

number of doctors, nurses and

administrative staff. Using the

organizational culture profile

instrument42, this researcher found that,

the most prevalent characteristics of

culture are aggressiveness and

supportiveness, whereas this operating

culture does not appear very strong.

After examining for potential subcultures

Bellou43 concluded that significant

differences revealed based on age, job

position and tenure in position whereas

gender, occupation and type of

employment do not affect significantly

employee perceptions of culture.

In a recent study, Bosch et al., 44

reported on data originally collected in

2004 from health care professionals [n=

146] in 40 primary care practices. The

investigators examined the relationship

between specific types of organizational

culture, team climate and quality of care

provided to patients as well as clinical

outcomes. Organizational culture was

assessed using the Competing Values

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Health care provider’s Organizational Culture Profile: a literature review

Framework, while team climate among

members of the practices was evaluated

by the Team Climate Inventory. Clinical

outcomes were HbA1c level, systolic

blood pressure and total cholesterol

levels and clinical performance was

measured by a sum score of ten process

indicators of diabetes care quality. The

researchers showed that primary care

organizations characterized by a strong

group culture and they went on to

indicate that a strong group culture was

negatively associated to the quality

indicators for managing care well,

whereas a more balance culture among

the different types of culture [group,

hierarchical, developmental and rational]

was positively correlated to diabetes care

quality. No associations were found

according to the study between

organizational culture, team climate and

clinical patient outcomes. Another study

by Stordeur and colleagues45 conducted

involved a large sample of nurses

[n=1.175] employed in 12 hospitals.

Using a questionnaire, including

perceptions of job demands, work

schedules and organizational climate,

researchers aimed to identify structural

and managerial characteristics of low-

and high-turnover hospitals. The

investigators found that whereas

selected indicators of hospital structure

were comparable between attractive and

conventional hospitals, profiles of nurse

perceptions towards the organizational

features and climate were significantly

different. The authors concluded that

attractive hospitals with selected

organizational characteristics succeeded

in nurse attraction and retention.

A 2003 paper by Mallak et al., 46 studied

culture, built environment and outcome

variables in a healthcare provider

organization using a composite of

existing scales. The authors supported

that organizations with stronger cultures

tend to achieve higher performance and

potentially improved clinical outcomes

than those with weak cultures.

According to the study, job satisfaction

and patient satisfaction were found to be

significantly and positively correlated

with culture strength. Culture strength

referred to the extent of agreement with

statements concerning the hospital’s

culture. The authors, also found that

strong cultures result from consistent,

visible role modeling and leadership,

consistent feedback on performance –

positive and negative – to ensure people

known what is allowed and what is not,

constant communication about what is

important in the organization, and

sharing stories where the strength of the

organization’s culture played a critical

role in a patient’s, staff’s or visitor’s

experience.

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A previous work by Mackenzie47 focused

on staff employed on four strategic

business units of the Combined

Healthcare NHS trust. A sample of 120

employees was surveyed on 12

dimensions of organizational culture

which were measured using quantitative

and qualitative methods. The researcher

concluded that a high level of teamwork

was enjoyed by all respondents. The

majority of respondents felt they

provided high quality care, which

comprised both listening to consumers

and involving them in planning their

care. According to the results, staff

considered the following organizational

values: providing quality care, innovative

practice, the development of staff, the

achievement of goals and targets,

satisfying consumers and competing

effectively. In a sample of 530 executive

employees recruited from six

organizations in the Queensland public

sector, Parker et al.,48 conducted a mail-

out survey of employees with managerial

responsibilities to determine whether

organizational culture reflected the

emphasis on group, developmental and

rational culture, using a later version of

an instrument by Zammuto and

Krakower which measured culture from

a competing values framework. Contrary

to the expectations, authors found that

four out of six departments were

dominated by a hierarchical or internal

process model of organizational culture

involving a commitment to rules and

attention to technical details. The

findings are suggestive of the proposition

that culture in the public sector remains

aligned with a traditional bureaucratic

model. A possible explanation for this

finding according to the authors is that

public organizations are fundamentally

different from private organizations and

will, therefore, remain oriented towards

a traditional model involving a

hierarchical culture.

Regarding financial performance, a study

conducted by Rondeau et al., 49

suggested that culture can have a

significant role in the prediction of

strategic choices that hospitals make in

response to fiscal distress. The findings

also suggested that healthcare

organizations with different operating

cultures tend to take different

approaches in response to reductions in

their funding. A recent study by Gregory

et al.,50 provided a further insight into

the relationship between organizational

culture and organizational effectiveness

by exploring how and why this

relationship exists. Organizational

culture was measured by surveying

members of the top management team

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Health care provider’s Organizational Culture Profile: a literature review

from 99 hospitals across USA. They

found that culture impacts on employee

attitudes (employee satisfaction and

physician satisfaction) and those

attitudes have an influence on

organizational effectiveness as measured

by patient satisfaction and controllable

expenses. Although both group and

balance culture predicted patient

satisfaction, neither type of culture had a

direct impact on controllable expenses.

Zazzali and colleagues51 measured the

organizational culture within 52

physician group practices involving

1.593 physicians across the USA through

the Competing Values framework. The

findings indicated that more positive

physician satisfaction toward key aspects

of their practice was associated with

stronger group culture and negatively

associated with groups dominated by a

hierarchical culture. Furthermore, the

researchers suggested that culture

represents an important feature of group

practices that influence the attitudes of

physicians towards the organizations in

which they work.

In 2007 Seren et al., 52 reported on the

effect of organizational culture and

healthcare professionals’ attitudes on

change. Unlike with private hospitals

where collaboration culture was most

dominant, power culture dominated in

public hospitals. Savic and Pagon53

investigated in a cross-sectional study in

Slovenia how nurses and physicians

perceive organizational culture. The

authors found out that physicians and

nurses had significantly different scores on

current culture type, however there was no

significantly differences between physicians’

and nurses’ scores on preferred culture type

both of them favoring the culture of internal

focus, stability and control. Moreover,

there were significantly differences between

nurses and physicians in flexible and control

organization, with nurses favoring flexible

organization and physicians favoring

control organization.

Norwiski and her colleagues55 reported

initial results from a 4-year project

examining changes in organizational culture

following adoption of a single electronic

health record system. Contrary to

expectation, their findings from baseline

and 12-month follow-up data suggest that

employees perceived the organizational

culture as becoming more hierarchical and

rational. May be cultural readiness for an

innovation is the key requirement for

hospitals when preparing for IT

infrastructure58.

Discussion

To our knowledge, this is the first critical

review of assessing whether and by how

much a single dominant organizational

culture [the underlying assumptions that

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inform beliefs and guide behaviours in an

organization] exists in public hospitals.

Research has indicated the importance

of identifying organizational culture as

well as characteristics of any co-existing

subcultures as a prerequisite for

organizational change or quality of

services43, 52-53. A primary first step to

organizational culture change is to assess

the organizational culture54 whereas,

hospitals with strong prevailing

organizational culture tend to achieve

higher performance and potentially

improved clinical outcomes than those

with weak cultures46. Culture strength

referred to the extent of agreement with

statements concerning the hospital’s

culture, whereas operating culture

referred to the existing or established

culture.

With respect to the type of

organizational culture five out of twelve

studies unveiled the dominant culture of

the healthcare providers. Bellou43

showed that aggressiveness and

supportiveness were the two most

prominent cultural characteristics in

public hospitals; however the operating

culture did not seem to be very strong.

In another study52 identifying the

organizational culture in private and

public healthcare sector, power culture

was found to be the most common

culture in public hospitals, while the

cooperation culture was the most

evident culture in private hospitals. On

the contrary, Parker et al., 48 found that

a hierarchical or internal process model

of organizational culture involving a

commitment to rules and attention to

technical details dominated public

sector. In primary and group practice

settings the review findings revealed a

strong group culture44,53. In a study in

primary care setting44 a strong group

culture was negatively associated to the

quality of diabetes care provided to

patients, whereas a more 'balanced

culture' was positively associated to

diabetes care quality. No associations

were found between organizational

culture, team climate and clinical patient

outcomes.

Regarding employee satisfaction we did

find evidence for a significant and

positive correlation with culture

strength46, 51-52. According to a recent

study54, examining the organizational

culture among nurses in Korea, the

consensual culture which is a part of

Korean culture had a positive effect on

nurses’ job satisfaction. Consensual

culture includes spending time

maintaining group harmony,

encouraging and mentoring staff.

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Health care provider’s Organizational Culture Profile: a literature review

Patient satisfaction is a vital

effectiveness indicator, as it measures

the quality of the service that hospital

provides to its patients. Maintaining

financial viability and providing quality

care are the two critically important

objectives for health care sector49.

According to a recent study by Gregory

et al., 50 culture has an influence on

organizational effectiveness as measured

by patient satisfaction. Large health

service organizations with matched

structures, caseloads, profiles and

environments may have different results

and varying successes depending upon

their cultural characteristics58.

Furthermore, Mallak et al., 46 showed

that patient satisfaction was found to be

significantly and positively correlated

with culture strength.

To conclude, we found heterogeneity for

the overall research outcome regarding

the existence of a strong culture in

hospitals as well as a lack of uniform

definition as most studies used different

assumptions for organizational culture.

Moreover, in most studies different

qualitative instruments were used to

measure organizational culture

dimensions as well as its scientific

properties strongly varied. Furthermore,

in most studies, organizational culture

was studied in relation to other factors

such as job satisfaction59-60, patient

satisfaction and safety61-62 or

organizational changes63.

Our results indicated that the majority of

public hospitals have weak

organizational cultures even though

strong cultures offer compelling benefits

to hospitals as higher employee

satisfaction and potentially improved

clinical outcomes46. Since a strong

culture is associated with positive

benefits, it is prudent for a public

hospital to build a strong culture. And

how does culture become strong?

Culture strength is resulting from

consistent, visible role modelling and

leadership and is certainly something we

can observe in a hospital as nearly all

employees will respond the same way.

There are strengths and limitations to

this body of research evidence.

Strengths of this research review include

the sample populations studied. Since

culture is, by definition, a collective

phenomenon, most researchers

examined culture at group level, even

where the unit of collection is the

individual. Moreover, a wide range of

valid and reliable quantitative

instruments used in the studies

measured culture.

There are a number of limitations of this

review. While extensive effort was made

to conduct a comprehensive review,

eligible studies may have been missed.

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The majority of studies have surveyed

only front-line or top managers.

Although, this is an important group in

terms of formal leadership roles, to

assess organization’s culture, such an

approach clearly results in only a partial

view of the organizational culture. The

most difficult but the most effective

method in assessing culture would be

best accomplished by surveying all staff

members of an organization. Also, an

adequate sample to allow subgroup

analysis alongside whole organization

analysis is another important sample

issue. Despites these limitations, this

review provides support that there is a

growing body of evidence assessing

organizational culture in healthcare

performance. In an era of increased

pressure toward efficiency and cost

containment, the most important issue is

how will a hospital be able to create a

visible culture to others in order to

ensure organizational survive and

commitment and loyalty among

professionals64-65.

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