Organisational culture in its widest sense involves common ways of addressing problems and achieving goals within an organisation. It can influence how staff acquire skills and whether they take a flexible approach to work (Sikavica, 2011). Developing a culture is a complex and never-ending process. A strong, healthy culture is a prerequisite for an effective team. Organisations and their cultures in the modern business world are topics for scientific study (Sikavica, 2011).
Aim of the study
Organisational culture is an abstract concept but is deeply embedded within organisations. The signs of a culture are often hidden, making it difficult to determine and define (Sikavica, 2011).
This research aimed to determine which organisational culture was prevalent in hospitals, and which type would be most desirable in the opinion of the employees. The objective of this research was to analyse the culture of two Croatian university hospitals.
Its specific objectives were to:
Subjects and methods of research
Participants
The research was conducted in two university hospitals in Zagreb, Sveti Duh and Dubrava. The study included 87 nurses, seven of whom were team leaders, three from Dubrava and four from Sveti Duh.
Methods of research
The Organizational Culture Assessment Instrument (OCAI) questionnaire, a tool for determining organisational culture, was used (https://tinyurl.com/y5ezh8xb). This was developed by professors Robert Quinn and Kim Cameron from the University of Michigan's Ross School of Business.
The first part of the questionnaire consisted of four questions, covering: sex; years of service; position within the organisation; and level of qualifications (Table 1).
| Sveti Duh hospital (n=39) | Dubrava hospital (n=48) | P | |
|---|---|---|---|
| Sex (male/female) | 7/30 | 12/21 | 0.10 |
|
Years of employment at current workplace
|
2 |
5 |
0.07 |
|
Level of qualifications
|
25 |
31 |
0.79 |
|
Position
|
33 |
40 |
0.54 |
Note: not all questionnaires were complete
The second part of the original questionnaire was divided into six categories. These were as follows:
Questions were adapted to working conditions in the hospitals, and two categories related to the management of hospitals were added to the OCAI questionnaire.
Within each category, participants were asked to distribute 100 points across four answers. They were instructed to give the highest number of points to the answer that described their personal view. They had to distribute the rest of the points among the remaining answers, depending on their own attitude. First they had to answer the questions in the ‘now’ section, which reflected their opinion of the current status in their workplace; the same questions were then answered in the ‘desired’ section, which reflected their vision of the work environment they would most like.
The results are based on the Competing Values Framework (Cameron and Quinn, 2011) and they correspond to the following types of organisational cultures: clan; adhocracy (flexible and informal rather than bureaucracy); competitive (market); and hierarchical. The clan culture was labelled A, adhocracy B, competitive C and hierarchical D.
The analysis and processing involved adding up the total of A statements in the ‘now’ section, then dividing the result by eight to obtain a mean value. In the same way, B, C and D scores were added up then divided by eight to obtain a mean value. The same procedure was also applied to the ‘desired’ column.
Statistical data processing
All results were presented and explained descriptively and tabulated, with distribution frequency graphs created in MS Office 2007. The differences in values between groups were tested by χ2 with the level of significance at 95% (P<0.05).
Ethical consideration
The research was approved by the ethics committees of both hospitals.
Results
The research included 39 nurses from University Hospital Sveti Duh and 48 nurses from University Hospital Dubrava. Not all questionnaires were analysed because data were incomplete.
There were no statistically significant differences between the two hospitals regarding sex (P=0.10), having a higher degree of qualification (P=0.79), years of employment in the current workplace (P=0.07) and the number of team leaders in each hospital (P=0.54).
Overall, respondents from both hospitals reported the clan culture was prevalent. The prevalence of clan culture received the highest score, with a mean of 30.67. The hierarchical culture, with a mean score of 24.21, came in second place. This was followed by a competitive culture, with a mean score of 21.94. The adhocracy culture was the least reported, with a mean score of 20.88.
Regarding the most desirable organisational culture, participants most often opted for the clan culture, with a mean score of 45.13. The second most preferred type was the hierarchical culture with an average score of 21.79. The third most desirable culture was the adhocracy culture with an average score of 18.72. The least desirable was the competitive culture with an average score of 12.79.
There were no differences between participants who had studied as far as secondary school and those with baccalaureate and master's degrees regarding identifying the current organisational culture (P=0.92) and the desirable culture (P=0.97).
However, there were differences depending on years employed at current workplace. Participants who had been in place for longer opted more frequently for clan culture. Scores rose with the years spent at current workplace, but there were no statistically significant differences between them (P=0.14).
There was no significant difference between women and men regarding the current (P=0.66) and the desirable organisational culture (P=0.83).
There was no statistical difference between the opinions of team leaders and other employees regarding the current (P=0.85) and for the desirable culture (P=0.24).
There was no statistically significant difference between employees at both hospitals regarding current and desired culture within any of the categories.
The main characteristic employees wanted was individual respect both now and in the future.
Department and hospital management were rated as facilitators with a mentoring style. The type of organisational glue was loyalty, and participants wanted this to continue in future.
However, there were differences between the two hospitals. In Sveti Duh, the clan culture was prevalent, while in Dubrava the hierarchical type prevailed, but not to a statistically significant extent (χ2=4.11, P=0.24). The desirable culture for employees at both hospitals was the clan culture, but this was preferred more in Sveti Duh (χ2=8.22, P=0.04).
A comparison of current, individual dimensions of organisational culture showed a statistically significant difference between the hospitals in the following dimensions: dominant characteristic ( χ2=7.25, P<0.05); strategic emphasis (χ2=10.20, P=0.01); and criteria for success (χ2=10.00, P=0.01).
A comparison of individual dimensions of a desirable organisational culture showed a statistically significant difference between the institutions in the following dimensions: ‘hospital organisational leadership’ (χ2=9.29, P=0.02); ‘hospital management of employees' (χ2=15.86. P=0.001); and ‘strategic emphasis’ (χ2=9.71, P=0.02).
Discussion
Research on the culture of organisations began in the early 1930s. It became popular as a concept in the Western world following Japanese industry's penetration into the world market in the early 1980s. By analysing Japanese industry, managers in the West noticed the basic characteristics of the Japanese organisational culture, such as loyalty, open communication, team approach and managerial abilities had a positive influence on market competitiveness.
Organisational culture symbolises established ways of solving organisational problems. Even thought it is intangible in nature, it plays a significant role and affects employees and organisational processes (Ng'ang'a and Wesonga, 2012). It reflects the structure of organisations, and embeds the values, beliefs and assumptions held by organisational members (Deal and Kennedy, 1988; Robbins and Coulter, 2005).
Culture can manifest at both visible and invisible levels. The visible level consists of clear forms that can be perceived, such as rituals, customs and problem-solving methods. Invisible levels are values such as strategy, goals and leadership philosophy. Its internal focus reflects management's concern for the wellbeing and efficiency of employees and its external focus is about the wellbeing of the organisation itself.
Measures of culture are related to any organisation's ability to respond to demands, to remain competitive and to sustain high levels of performance.
Over the last few decades, interest in organisational culture has increased in many industries, including healthcare organisations. Healthcare policy in the West is concerned with assessing and improving quality, and there is increasing interest in the relationship between organisational cultures and healthcare service outcomes. Some studies have suggested that culture might be an important factor in the effectiveness of the healthcare industry (Shortell et al, 2000; Ferlie and Shortell, 2001). The literature provides evidence that the shift from a bureaucratic towards a caring culture results in increased patient satisfaction, as well as better staff retention (Hartnell et al, 2011).
Every organisation has its own culture, regardless of type or size. What matters is whether that culture type is suitable for it.
This study, conducted in two university hospitals in Zagreb, found all participants at both hospitals considered a clan culture was most prevalent. The hierarchical culture was in second place, followed by a competitive/market culture, with the adhocracy culture the least represented.
Employees consider a clan culture to be the most desirable. The hierarchical culture is the second most desirable, while the market culture and the adhocracy culture are the least desirable, with results being almost identical at both hospitals.
The relationship between the existence and desirability of each culture is clear. The greatest number of participants expressed their desire for maintaining the clan culture in the future. The second most desirable culture for the future is hierarchical, followed by adhocracy, and market culture as the least desirable one.
There was no difference between staff at the two hospitals on what both predominant and desired cultures were when levels of education, sex or position in the workplace were compared.
There was a difference in the responses of employees of different lengths of work experience. Participants who had worked for their employer for longer opted more frequently for clan culture and scores rose with the years at the workplace. However, this difference was not statistically significant (P=0.14).
Analysis of the eight cultural dimensions conducted on all participants did not show differences between the dimensions when current and desired culture were compared. There was no difference between the hospitals in evaluations of the current status of the culture compared to dominant characteristics, department leadership style, department management of staff, hospital leadership style, hospital staff management, organisational glue and strategy and success criteria.
Comparison between two hospitals
There was a difference between evaluations of the current culture at the two hospitals. Sveti Duh employees said the clan culture was currently prevalent, while Dubrava employees believed that the hierarchical culture was predominant. However, this difference was not statistically significant (χ2=4.11, P=0.24).
There was also a difference between the desirable culture in each hospital. Sveti Duh employees found the clan culture to be more desirable, while those at Dubrava preferred a hierarchical one. This difference can be attributed to the longer employment period of the participants in Sveti Duh. However, overall, more participants thought the clan culture was more desirable. Differences in the perception of working environment can influence the approach to the work-related tasks.
When analysing components of the evaluation of current conditions in the two hospitals, there were differences in assessments of dominant characteristics. The Sveti Duh employees said respect for the individual was the dominant characteristic of their institution, while those at Dubrava said the dominant characteristic was the controlled environment.
Another difference between the institutions was in the strategic emphasis and implementation of action and allocation of resources to achieve the long-term objectives of the organisation dimensions. The Sveti Duh employees consider the human development to be dominant strategic emphasis, while Dubrava employees consider this to be the management of equipment and supplies.
In the future, the Sveti Duh employees would like respect for the individual to remain predominant at their workplace, while Dubrava staff opted for the controlled environment. The difference was found in the desired strategic emphasis dimension; Sveti Duh employees would like that to be an emphasis on human resources, while in Dubrava it was on resource acquisition.
Conclusion
Organisational culture symbolises established ways of solving organisational problems from within. It is developed within each organisation as a long-term process, and can be influenced by external factors, such as regulatory frameworks. It is manifested within the organisation as well as outside it.
Healthcare organisations have a great social responsibility; patients always come first. It is crucial to create a culture that will focus on effective patient outcomes, ie, the best care.
This research has shown that, in these two Croatian university hospitals, a clan organisational culture, whose main characteristic is teamwork, is the most common according to their staff, and is also the most desirable.
Teamwork is the ability to work together toward a common vision and goals. This provides solid foundations for effective outcomes and optimal care, because good interpersonal relations are prerequisites for employee satisfaction, which will influence the achievement of goals.
The main purpose of creating a suitable culture within healthcare institutions is achieving high-quality, safe and efficient care, which is only possible if the institution has a profound sense of mission and direction, a mobilised workforce with a passion to get things done in the best way for the patients, and where defined and promoted values are part of everyday life.
The most effective methods to make changes or develop an organisation's unique culture is management commitment and training for employees.
The differences between the two hospitals that were found in this research can be attributed to the difference in participants' employment periods, showing that new staff need to become socialised into their new workplace.
It is necessary to build a values-based culture into day-to-day activities because they are the basis for effective organisational management.