Organizational culture of a private hospital

ABSTRACT

Objective

To assess the values and practices that characterize the organizational culture of a private hospital in the state of São Paulo in the perspective of nursing professionals.

Methods

Quantitative, descriptive, cross-sectional study. Data collection was conducted between January and March 2013 using the Brazilian Instrument for Assessing Organizational Culture. Twenty-one nurses and sixty-two nursing aides and technicians participated in the study. The responses of the participants were coded into numerical categories, generating an electronic database to be analyzed by means of the software Statistical Package for the Social Sciences.

Results

Scores of cooperative professionalism values (3.24); hierarchical strictness values (2.83); individual professionalism values (2.69); well-being values (2.71); external integration practices (3.73); reward and training practices (2.56); and relationship promotion practices (2.83).

Conclusion

In the perception of workers, despite the existence of hierarchical strictness there is cooperation at work and the institution pursues customer satisfaction and good interpersonal relationships.

Nursing; Health services; Health Management; Organizational culture

RESUMO

Objetivo

Avaliar os valores e as práticas que caracterizam a cultura organizacional de um hospital privado do interior do Estado de São Paulo na perspectiva dos trabalhadores de enfermagem.

Métodos

Estudo quantitativo, descritivo e transversal cuja coleta de dados ocorreu de janeiro a março de 2013, utilizando-se o Instrumento Brasileiro para Avaliação da Cultura Organizacional. Participaram 21 enfermeiros e 62 técnicos e auxiliares de enfermagem. As respostas dos participantes foram codificadas em categorias numéricas, constituindo uma base de dados eletrônica, sendo analisada pelo programa Statistical Package for the Social Sciences.

Resultados

Escores de valores de profissionalismo cooperativo (3,24); valores de rigidez hierárquica (2,83); valores de profissionalismo individual (2,69); valores de bem-estar (2,71); práticas de integração externa (3,73); práticas de recompensa e treinamento (2,56) e práticas de promoção do relacionamento (2,83).

Conclusão

Na percepção dos trabalhadores, existe cooperação no trabalho, a instituição busca a satisfação do cliente e um bom relacionamento interpessoal, apesar de haver rigidez hierárquica.

Enfermagem; Serviços de saúde; Gestão em saúde; Cultura organizacional

RESUMEN

Objetivo

Evaluar los valores y prácticas que caracterizan a la cultura organizacional de un hospital privado en el estado de São Paulo en la perspectiva de la enfermería.

Métodos

Estudio cuantitativo, descriptivo y transversal, donde la recolección de datos se realizó de enero a marzo de 2013, se utilizó el Instrumento Brasileño para Evaluación de la Cultura Organizacional. 21 enfermeras y 62 técnicos y auxiliares de enfermería participaron. Las respuestas se codificaron en categorías numéricas, lo que constituye una base de datos electrónica, analizada por el programa Statistical Package for the Social Sciences.

Resultados

Puntuaciones de los valores cooperativos de profesionalidad (3,24); valores de rigidez jerárquicos (2,83); valores individuales de profesionalidad (2,69); valores de bienestar (2,71); prácticas de integración externa (3,73); prácticas de recompensa y entrenamiento (2,56) y las prácticas de promoción de la relación (2.83).

Conclusión

En la percepción de los trabajadores, existe cooperación en el lugar de trabajo, la institución busca la satisfacción del cliente y la buena relación interpersonal, aunque hay rigidez jerárquica.

Enfermería; Servicios de salud; Gestión en salud; Cultura organizacional

INTRODUCTION

Organizations are similar to micro societies set up by the same particularities that characterize social interactions; they present symbolic and imaginary cultural systems made up of values and rules that guide the behavior of their members(¹-²).

Within an organization these systems of values and rules represent the organizational culture (OC) that is under direct influence of the national culture and represents the result of the reality and cultural dynamics of the society in which the institution is inserted(¹). Therefore, understanding the cultural aspects of a country is critical for the analysis of organizational culture(³).

Hofstede was one of the first authors to discuss the influence of national culture on the culture of organizations. He conducted a quantitative study with employees of IBM subsidiaries in 76 countries (including Brazil) aiming at identifying the characteristics of the national systems of values and the relation between these values and the culture of organizations(¹).

In such study the author identified four dimensions of values of national cultures: power distance, collectivism versus individualism, femininity versus masculinity, and uncertainty avoidance. Brazil was identified as a country that presents a culture represented by high power distance; its members avoid what is new (high uncertainty avoidance), present long-term oriented behavior, and their cultural pattern is more collectivist than individualist. Also, there is a slight predominance of femininity characteristics⁽¹⁾.

In addition to these cultural patterns, the author proposed six dimensions of organizational culture: culture focused on the process versus culture focused on results; culture focused on the worker versus culture focused on work; parochial culture versus professional culture; open system versus closed system; rigid control versus flexible control; normative culture versus pragmatic culture⁽¹⁾.

Studies on organizational culture were intensified in the early 1980s when scholars of the organizations began to recognize the importance of the concept of culture⁽⁴⁾.

The sociological and anthropological bases are the two main disciplinary foundations of organizational culture. The sociological basis considers that organizations have cultures; the anthropological basis considers that the organizations are cultures. Two distinct approaches for culture were developed for each one of these disciplinary foundations: functional approach, in which the culture results from the collective behavior; and semiotic approach, in which the culture consists in individual interpretations and cognitions⁽⁴⁾.

The functional approach assumes that researchers and managers may determine distinctions between organizational cultures, as well as change and measure them. It recognizes organizational culture as a potential element of several organizational results, including efficiency. In turn, the semiotic approach infers that there is nothing but culture in the organizations, and that such culture is understood as a concept to be elucidated regardless of other phenomena⁽⁴⁾.

Studies show that most authors adopt the functional, sociological perspective, that is, that OC can be managed and modified^(1-2,4).

Based on the sociological approach the organizations undergo several types of influences, including international market trends and principles of their members bringing different histories, values, contexts, and subjectivities. As the organizations adapt and deal with challenges and circumstances they tend to develop a prevailing culture; therefore, OC has a heterogeneous nature⁽⁴⁾.

In this context, and through the dynamics and social interaction, groups of individuals discover aspects in common, such as ways of thinking, acting, working, and living; they identify and create links that lead to cooperation in the tasks and result in the creation of rules, values, and specific practices that generate microcultures that are often present in subunits such as departments, hierarchic levels, professional categories, or even different teams. Thus, organizations present prevailing cultures resulting from the integration of their microcultures, and not only a single cultural type⁽⁴⁾.

These microcultures may both favor and hinder organizational performance; there is wider collaboration in a group of individuals that identify and create links. On the other hand, the shock of microcultures in different subunits made up of a particular set of values may generate problems in the coordination or integration of organizational activities. This may lead to conflicts and fragmentation of the organization, affecting organizational performance⁽⁴⁾.

In addition, organizations have different and specific microcultures. Each one of these subcultures has common characteristics that establish the general and prevailing culture of the entire organization. Therefore the analysis of OC may focus on both the dominant culture and their microcultures, identifying the prevailing common traits of the subunits’ culture and grouping them, enabling an approach to the overall culture of the organization⁽⁴⁾.

According to research on organizational psychology, OC determines several dimensions of the institution, from the behavior of workers, managers, and institution to the strategies, goals, work relationships, work organization, and the adopted management model. It is related to a number of variables, such as pleasure and affliction at work, satisfaction and motivation, occupational stress, organizational effectiveness and climate; quality of life at work; and quality of the service^(5-7).

Thus, OC results from the beliefs and values that guide the actions of workers at all levels of the organizational structure, indicating the path in relation to the different options of action⁽⁸⁾. It represents a collective mind programming that determines the identity of the group in the same way the personality determines the identity of the individual. Therefore, OC is an integral, historical, and social phenomenon that reflects the history of the organization⁽¹⁾.

The core of OC is represented by the organizational values that express the perceptions of the individuals and the beliefs that are shared by the workers, their ways of perceiving, thinking, feeling, and acting in given situations, characterizing and differentiating a given group from the others. Organizational values are the foundation of the organization. They are taught from generation to generation, guiding the everyday behavior of workers and reinforcing the behavior of the group⁽²⁾.

In the context of health organizations, culture assumes a particularly complex character as demonstrated by the variety of professional categories involved in the production of health care; each one presents its specific cultural and historical process, differentiated objectives, and its own microcultures^(6-7).

In this context, the aim of the present study was to assess the values and practices that characterize the organizational culture of a private hospital in the state of São Paulo, from the perspective of nursing professionals.

METHOD

A descriptive, cross-sectional study, using a quantitative approach⁽⁹⁾, was developed in a private hospital in the state of São Paulo, which has 121 beds (27 representing beds in intensive care units). Its occupancy rate was 83%, with a mean of 491 hospitalizations. Nearly 600 surgical and 4,520 emergency procedures are conducted per month.

The institution has 213 nursing workers: 29 nurses and 184 nursing aides or technicians. All of them were invited to participate in the study. Twenty-one nurses and sixty-two nursing aides and technicians agreed to participate.

The criterion for inclusion was being a nurse, nursing aide, or nursing technician at the institution. Criteria for exclusion were being away from work during the data collection period; not returning the data collection instrument to the researcher, or not responding to at least 50% of the items of each data collection instrument.

Data were collected between January and March 2013 by means of two instruments in the workplace and during working hours of the participants. The first instrument consisted of questions regarding personal and professional characteristics of the workers (age, gender, education, workplace, and function). The second instrument was the Brazilian Instrument for Assessing Organizational Culture – IBACO⁽¹⁰⁾.

The IBACO was developed and validated by Brazilian researchers⁽¹⁰⁾ based on the model of Hofstede, Hofstede and Minkov⁽¹⁾ in order to assess the values and practices that set up the culture of an organization in the perspective of the workers. It consists of 94 items: 55 aiming at identifying organizational values, Cooperative Professionalism Values (CPV), Hierarchic Strictness Values (HSV), Individual Professionalism Values (IPV), and Well-being and Satisfaction Values (WSV); 39 are related to organizational practices, External Integration Practices (EIP), Reward and Training Practices (RTP), and Relationship Promotion Practices (RPP) randomly arranged. These characterize the culture of an organization.

There is a Likert scale with score from 1 to 5 for each one of them. Thus, in order to respond the IBACO the worker should check if each statement does not apply at all to the institution (1 point); if it partially applies to the institution (2 points); if it reasonably applies to the institution (3 points); if it greatly applies to the institution (4 points); or totally applies to the organization (5 points).

Those who agreed to participate in the study received two copies of an Informed Consent Form and the data collection forms. The participants were instructed to read, sign, and keep a copy of the Informed Consent form, returning the second copy to the researcher. In addition, all of them were informed about the objectives and procedures of the study and all questions about the items of IBACO were answered.

Data processing included codification of the responses of the individuals in numerical categories through Excel spreadsheets, generating an electronic database that was validated by double entry. The database was subsequently transferred to the software Statistical Package for the Social Sciences (SPSS) for statistical analysis. Minimum and maximum values, standard deviation, and mean of variables were calculated.

The research project was approved by the Ethics Committee of the Ribeirão Preto College of Nursing at the University of São Paulo (process CEP EERP/USP 83275/2012). Resolution 466/2012 relating to ethical standards for research involving human subjects⁽¹¹⁾ was respected.

RESULTS

Of the 213 nursing workers of the hospital, 83 participated in this study. Eighteen were assisting nurses (21.7%), two were nursing supervisors (2.4%), one was a nursing coordinator (1.2%), and sixty-two were nursing aides or technicians (74.7%). Fifty-two were women (62.7%), and 31 were men (37.3%); 38 workers were aged between 20 and 30 years (45.5%), 31 were aged between 31 and 40 years (37.3%), 10 were between 41 and 50 years (12%), and 2 were between 51 and 60 years (2.4%), two workers did not inform their age (2.4%). Forty-two had completed elementary education (50.6%) and 41 had an undergraduate degree (49.4%).

In relation to the perception of workers on the values and practices that characterize the organizational culture of the hospital, the values of cooperative professionalism presented a mean score of 3.24; hierarchical strictness values had a mean score of 2.83; individual professionalism values had a mean score of 2.69; well-being values had a mean score of 2.71; practices of external integration presented a mean score of 3.73; reward and training practices presented a mean score of 2.56; and relationship promotion practices had a mean score of 2.3 (Table 1).

Table 1
– Values and practices of IBACO (N=83). Ribeirão Preto, SP, 2013

Values/Practices	Mean	Standard deviation	Min – max value
Cooperative professionalism values (CPV)	3.24	+ 0.78	1.0 – 4.8
Hierarchical strictness values (HSV)	2.83	+ 0.61	1.0 – 4.5
Individual professionalism values (IPV)	2.69	+ 0.67	1.0 – 4.0
Well-being and satisfaction values (WSV)	2.71	+ 0.81	1.0 – 4.3
External integration practices (EIP)	3.73	+ 0.70	1.2 – 4.9
Reward and training practices (RTP)	2.56	+ 0.76	1.1 – 4.5
Relationship promotion practices (RPP)	2.83	+ 0.85	1.0 – 4.4

• Source: Research data, 2013:

DISCUSSION

The culture of public health organizations has not been widely studied in Brazil, and the existing research were mostly developed in the last decade^(12-13). No investigations were found in relation to the culture of private health organizations in the country, reinforcing the importance of this study.

The IBACO⁽¹⁰⁾, instrument used in this investigation, identified the values and practices that characterize the culture of a private hospital from the perception of nursing professionals. Thus, the results of this investigation pointed out EIP, CPV, RPP, and HSV as the values and practices presenting higher scores, followed by WSV, IPV, and RTP.

External integration practices are related to the strategic planning and external adaptation of the institution, focusing on adequacy to market requirements and customer satisfaction; CPV are related to cooperation at work and valorization of professionals that work for the goals of the organization; RPP are related to the actions to promote good relationships between professionals and their satisfaction, generating internal integration; in contrast, HSV are associated with centralization of power, authoritarianism, lack of participation of the workers in decision-making processes and hierarchy⁽¹⁰⁾.

Well-being and satisfaction values are related to valorization of well-being, satisfaction, and motivation of workers, leading to a more humanized work environment; IPV characterize individualism and exclusive valorization of individual skills in the achievement of goals; RTP are organizational practices focused on training and rewarding workers⁽¹⁰⁾.

Therefore, it was verified that the workers perceived a prevalence of cooperation at work (CPV) and recognized that the organization is focused on customer satisfaction and on market demands (EIP). Also, they identified a concern by the institution regarding the maintenance of an appropriate work environment, valuing a good relationship among workers (RPP).

These characteristics represent values of organizations that focus on results and workers. Decision-making processes are shared and there is a concern for the needs of workers through the valorization of well-being and satisfaction of individuals⁽¹⁾.

It is believed that organizations present values related to the valorization of teamwork, cooperation at work, appropriate interpersonal relationships, and well-being of workers; motivation of creativity and promotion of professional freedom for intellectual autonomy. The existence of processes focused on conflict management and sharing of decision-making processes have a more horizontal and flexible organizational structure and are able to provide a higher rate of achievement and satisfaction to workers⁽¹⁴⁾. Also, these factors may promote higher levels of satisfaction and motivation at work, consequently reducing the possibility of work-related illness and promoting the health of workers⁽¹⁵⁾.

High professional satisfaction is critical for improving the quality of health care and patient satisfaction in relation to the provided care, thus contributing to a better clinical progress. Therefore, organizational aspects should be analyzed and used as instruments to improve the quality of health care services^(16-17).

Other organizational factors that contribute to satisfaction at work include appropriate work conditions, appropriate remuneration of the professionals, good interpersonal relationship, possibility of professional growth, autonomy, resolution power, recognition, and valorization of workers⁽¹⁴⁾.

Also as prevailing values in the organization nurses, nursing aides and technicians identified the existence of power centralization and hierarchical strictness (HSV), characteristics of organizations focused on processes and on work, presenting strict structures, centralized power, strong specialization at the job, formalization of the relationships and communication difficulties. There is a control of the work processes and workers (they suffer pressure from managers while developing their tasks, do not participate in decision-making processes, and feel that the organization is not concerned with their personal problems)⁽¹⁾.

This perception by the workers corroborates the results found in the study by Rocha and collaborators⁽¹³⁾, which also used the IBACO⁽¹⁰⁾ to assess the organizational culture of a public hospital and verified the existence of hierarchical strictness as a prevailing value in the institution.

It was possible to verify that professionals inserted in organizations presenting hierarchical strictness and power centralization, poor communication, difficulties in interpersonal relationships, lack of social support, insufficient recognition and rewards, and devaluation of subjectivities may experience more suffering, lack of motivation, dissatisfaction, and discontentment at work, thus representing psychosocial risks of work-related illness^(5,18).

Furthermore, organizations that present cultures characterized by constant pressure, increased productivity requirements, high workloads, inappropriate interpersonal relationships, lack of social support, inflexible schedules, and long working hours are associated with higher incidence of occupational accidents and adverse events related to patient care⁽¹⁸⁾. Within these organizations, workers may experience insecurity, career uncertainty, fear of unemployment, and conflicts related to work requirements, possibly associated with high levels of professional stress and occurrence of burnout syndrome⁽⁵⁾.

These hierarchical strictness values, power centralization, formalization of work relationships, and fragmentation of actions substantiate classical administration models that still prevail in a number of health institutions in Brazil that follow the bureaucratic and Taylorist conception logic that were historically incorporated by the organization of the health work process in the country⁽¹⁹⁾.

Health service in hospitals is considered a complex phenomenon marked by relationships involving professionals from different fields in the production of care, generating a variety of cultures within the same organization, each one having its specific historical process and different objectives. Also, each individual brings their own individual culture⁽⁷⁾.

The health work process is also characterized by instrumental actions and social relationships that occur through communication, both between professional and user and among professionals, enabling an understanding among those involved in the work process and possibly generating a series of conflicts⁽²⁰⁾.

Contributing to the complexity of this context, health workers are constantly subjected to situations that require dedication, engagement, and perfection at work. Also, they have to deal with conflicts and stressful situations on a daily basis. In addition to care demands, nurses perform administrative functions and have to interact with other professionals of the multidisciplinary team and patients on a daily basis, suffering great psychological and emotional pressures. Thus, their professional performance transcends their professional role and may lead to negative consequences for their mental and physical health⁽¹⁵⁾.

In this perspective, it is critical to change the organizational culture of Brazilian health institutions by increasing the incorporation of valorization of the human dimension at work and the implementation of humanization practices and comprehensive care⁽¹⁶⁾.

CONCLUSIONS

The results of this study show that organizational values and practices of the studied hospital permeate cooperation at work and the search for quality and patient satisfaction, although the workers perceive the existence of control and strictness at work and hierarchy in power relations – characteristics related to traditional management models adopted in the Brazilian health institutions.

Although the institution provides quality services to patients and maintains an appropriate work environment, control and strictness values also exist, hindering the participation of workers in decision-making processes, communication, and interpersonal relationships, possibly leading to discontentment and lack of motivation of workers and even to work-related illness. These factors also hinder the maintenance of health care quality as the valorization of processes, rules, and routines favors the fragmentation of actions and prevents care comprehensiveness.

Aiming at health promotion at work and improvement of care quality, the replacement of traditional models of health work management by more flexible and dynamic methods that value individual needs, humanization of relationships, and the participation of individuals in the construction of care practices is essential.

Therefore, this study demonstrated that it is possible to measure OC by means of an instrument in order to implement and change actions in organizations aiming at quality of services and care provided to patients; it may favor teaching and research in the theme as several studies in Brazil approach the important role of OC for health organizations^(3,7-8). However, few studies used instruments capable of assessing OC in Brazilian hospitals⁽⁶⁾. The low number of participants in the research that answered the IBACO due to its high number of questions was identified as a limitation of the study.

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Publication Dates

• Publication in this collection
  2016

History

• Received
  23 Aug 2014
• Accepted
  27 Jan 2016