Organizational culture of a psychiatric hospital and resilience of nursing workers

Objective: to analyze the organizational culture of a psychiatric hospital and identify the capacity of resilience of nursing workers. Method: quantitative research. For data collection, were used the Brazilian Instrument for Evaluation of Organizational Culture (IBACO – Instrumento Brasileiro para Avaliação da Cultura Organizacional) and the Resilience Scale (RS). Results: participants reported the existence of centralization of power and devaluation of workers, despite recognizing the existence of collaboration at work and practices for improving interpersonal relations. In relation to the capacity of resilience, 50% of workers showed high level, and 42.9% a medium level of resilience. The correlation tests revealed negative values between the IBACO and RS domains, indicating that the lower the appreciation of individuals in the institution, the greater their capacity of resilience. Conclusion: the organizational values refl ect the work organization model in the institution that devalues the workers’ needs and requires greater capacity of resilience. Descriptors: Nursing; Hospital Administration; Worker’s Health; Organizational Culture; Psychological Resilience. RESUMO Objetivo: analisar a cultura organizacional de um hospital psiquiátrico e identifi car a capacidade de resiliência dos trabalhadores de enfermagem. Método: pesquisa quantitativa. Para a coleta dos dados, foram utilizados o Instrumento Brasileiro para Avaliação da Cultura Organizacional (IBACO) e a Escala de Resiliência (ER). Resultados: os participantes relataram a existência de centralização de poder e desvalorização dos trabalhadores, embora reconheçam haver colaboração no trabalho e práticas voltadas para melhorar o relacionamento interpessoal. Em relação à capacidade de resiliência, 50% dos trabalhadores apresentaram alto grau e 42,9% grau médio de resiliência. Os testes de correlação revelaram valores negativos entre domínios do IBACO e da ER, indicando que quanto menor a valorização dos indivíduos na instituição, maior sua capacidade de resiliência. Conclusão: os valores organizacionais refl etem o modelo de organização do trabalho na instituição, o qual desvaloriza as necessidades dos trabalhadores e exige maior capacidade de resiliência. Descritores: Enfermagem; Administração Hospitalar; Saúde do Trabalhador; Cultura Organizacional; Resiliência Psicológica. Organizational culture of a psychiatric hospital and resilience of nursing workers Cultura organizacional de um hospital psiquiátrico e resiliência dos trabalhadores de enfermagem Cultura organizacional de un hospital psiquiátrico y la resiliencia de los trabajadores de enfermería


INTRODUCTION
The hospital is a complex organization, in which the process of work and attention to users depends on the combination of knowledge from different professional categories (1) .The psychiatric institutions, as well as other hospital organizations, represent a field of action of nurses and nursing technicians and assistants.In these places, the nursing work (part of the health work process) consists of care dimensions (actions related to direct patient care), predominantly performed by nursing assistants and technicians under the supervision of nurses; and management dimensions (actions related to the work organization in the unit), an exclusive role of nurses (2) .
In this work process, nursing professionals are exposed to workloads potentially generators of strain processes.Among them, the mental strain is relevant given the psychic loads experienced daily in the care of people with mental disorders, such as stress, need for permanent alertness, sexual harassment, verbal abuse, lack of supervision and support of the leadership, intense work pace and depreciation of the worker.These workloads result in fatigue, tiredness, depression, dissatisfaction and demotivation at work, fear, anxiety, anguish, irritability, anger and crying episodes on workers (3) .
These risks show the need to develop health promotion actions in the work of nursing professionals acting in mental health care units.Health promotion involves understanding the interactions between individuals and their social context for the development of health actions as part of an expanded conception of the health-disease process, considering the social determinants of health and disease, and relating with the quality of life and wellbeing of individuals (4) .
Thus, health is understood as a social production with multiple and complex determination, which requires the participation of all subjects involved in the analysis and planning of actions focused on improving the quality of life of individuals and groups (4) .For this reason, it is necessary to analyze the workspace and interactions among workers to promote health at work in psychiatric institutions, in order to understand which factors can promote or hinder the wellbeing in the workplace.
The study of the organizational culture (OC), understood as a set of values and practices that characterize the core of an organization and how the union of basic assumptions that directly influence the behavior of workers (5)(6) , represents an important tool.
Culture is the basis of the organization.It comprises artifacts, values and basic assumptions, elements manifested by the beliefs shared by individuals and groups, and reflected in organizational habits and in the behavior of workers (6) .
The OC is a collective programming of the mind, and determines the identity of the group in the same way the personality determines an individual's identity.Moreover, the OC is a comprehensive, historical and social phenomenon, and it reflects the history of the organization (5) .
Besides the importance of knowing the culture of institutions, for the health promotion, it is a key to understand the individual and the group capacity to overcome problems arising from many adverse situations faced daily in working spaces.The ability to build adaptive resources to maintain a healthy relationship between workers and their workplace in a constant process of transformation and permeated by stress conditions is called resilience (7) .
The concept of resilience originates from the Physical Sciences and its use in Health Sciences emerged in the 1970s.Only in the 1990s it began to be used in the context of institutions, referring to the existence or construction of adaptive resources of individuals, in order to preserve the healthy relationship between people and their work in a changing environment (7) .
Resilience can be described as the ability of an individual or group to keep well in face of unfavorable situations (8) , such as an internal reconfiguration of the subjects, their own perception, and their attitude toward adversities or trauma, representing a factor of growth or personal development (7) .It represents the construction of creative solutions in face of adversities of working conditions, resulting in responses to the problem in question and the renewal of the skills of individuals fighting for their work group (9)(10) .To this end, resilience involves strength, competence, optimism, flexibility and ability to effectively cope with adversities (11)(12) .
Once men produce and reproduce themselves and their subjectivity through work, it is relevant to study resilience in the employment context, and the factors that may cause the Fernanda Ludmilla Rossi Rocha E-mail: ferocha@eerp.usp.brCORRESPONDING AUTHOR RESUMEN Objetivo: analizar la cultura organizacional de un hospital psiquiátrico y determinar la capacidad de resiliencia del personal de enfermería.Método: investigación cuantitativa.Para la recolección de los datos, se utilizó el instrumento Brasileño de Evaluación de la Cultura Organizacional (IBACO) y la Escala de Resiliencia (ER).Resultados: los participantes informaron de la existencia de centralización del poder y la devaluación de los trabajadores, reconociendo al mismo tiempo que existe colaboración en el trabajo y prácticas para mejorar las relaciones interpersonales.En cuanto a la capacidad de resiliencia, 50% de los trabajadores tenían un alto grado y 42,9% un grado promedio de capacidad de resiliencia.Las pruebas de correlación revelaron valores negativos entre los dominios del IBACO y de la ER, lo que indica que cuanto menor sea la valoración de las personas en la institución, mayor será su capacidad de resiliencia.Conclusión: los valores organizacionales reflejan el modelo de organización del trabajo en la institución, lo que devalúa las necesidades de los trabajadores y requiere una mayor capacidad de resiliencia.Descriptores: Enfermería; Administración Hospitalaria; Salud Laboral; Cultura Organizacional; Resiliencia Psicológica.illness of workers, so individuals are capable to adopt certain behaviors during adverse times (7) .
The relevance of this study is also justified by the lack of studies evaluating the OC of health institutions in Brazil through psychometric scales, allowing its measurement.Furthermore, the knowledge gap on the subject was identified in the lack of studies on the relationship between the OC and the illness of nursing professionals resulting from work.
Therefore, we consider essential to understand the OC and identify the workers' resilience capacity in order to propose health promotion strategies for nursing professionals working in psychiatric institutions, which motivated the development of this study.

OBJECTIVE
To analyze the organizational culture of a psychiatric hospital and to identify the capacity of resilience of nursing workers.

METHOD
This is an exploratory study of quantitative approach performed in a psychiatric hospital at São Paulo State.It has comprehensive care units to assist people with mental disorders in acute or chronic phase of the disease.The hospital also offers treatment to drug addicts focused on their rehabilitation and reintegration into society.
The data collection was between November 2013 and May 2014 during the day (morning and afternoon shifts) because the hospital administration did not authorize the researchers' entrance at night.For the selection of participants it was used the convenience sampling method.It involves the selection of the most conveniently available individuals for participation in the study (13) .
The inclusion criteria were the nursing professionals working at the institution for at least six months, who were not on leave from work during the data collection period and answered at least 50% of the questions of each data collection instrument.
The aforementioned institution has 233 nursing workers, of which 156 worked during the day.Of these, 120 have worked for more than six months in the hospital and were not on leave from work in the data collection period, hence were invited to participate.Because of refusals or failure to return the questionnaires to researchers, the sample comprised 56 nursing workers.
Given the homogeneity of the study population, the sample is considered representative to the extent that its features depict the population characteristics accurately (14) .However, it is impossible to generalize the data as they only depict the reality of the institution.
The workers were approached individually, invited to participate in the study, and informed about the research objectives.Those who agreed to participate signed the Informed Consent Form (ICF) and received the data collection instruments.
Three instruments were used for data collection: Individual and Professional Characterization Instrument; Brazilian Instrument for Evaluation of Organizational Culture -IBACO (Instrumento Brasileiro para Avaliação da Cultura Organizacional) (14) ; Resilience Scale -RS (10) .The total average time to answer the instruments was approximately 30 minutes.
The Individual and Professional Characterization Instrument included questions about the characteristics of workers, such as age, sex, educational level, job role and workplace.
The IBACO was developed by Brazilian researchers (14) based on the theoretical assumptions of Hofstede (5) with the aim to evaluate values and practices that shape the culture of an organization from the perspective of workers.This instrument has 94 items related to four types of organizational values: values of cooperative professionalism (VCP), values of rigidity in the hierarchical structure (VRH), values of competitive and individualist professionalism (VIP), and values associated with the satisfaction and wellbeing of employees (VWE); and related to three types of organizational practices: practices of external integration (PEI), practices of rewarding and training (PRT), and practices of promotion of interpersonal relationship (PIR).
According to the authors of IBACO (14) , VRH characterize organizations with rigid structures, centralized authority and leaders with authoritarian profiles, which makes the professional growth difficult and discourages motivation and job satisfaction because there is no appreciation of workers.VCP refer to valorization of workers who demonstrate a spirit of cooperation, initiative, dedication and professionalism, and contribute to the team for achieving the common objectives and goals of the organization.VIP are composed of eight items, address the appreciation of individual skills and competencies in the development of tasks and the achievement of targets by denying the importance of teamwork and enhancing the competition between members, which often leads to the lack of ethics in labor relations.VWE characterize organizations concerned with the humanization of workplaces by appreciating the wellbeing of their employees, the satisfaction and motivation at work, which favors professional growth.
In relation to organizational practices, PEI involve decisionmaking processes by the organization directors and managers focused on strategic planning and service to external customers, including their satisfaction and the quality of services.PIR relate to the promotion of practices of interpersonal relationships and more cohesion between workers, focused on the development of teamwork for the appreciation of individuals and job satisfaction.Finally, PRT characterize the adoption of reward practices and workers' training by the organizations, which leads to the appreciation of individuals and provides greater satisfaction and motivation at work (14) .
The scale rating is performed by calculating the sum of the points assigned to each of the items comprising the factor and its division by the number of items that compose it.Then, is calculated the average of the scores attributed to the factor by all workers in order to obtain the average score of the organization as a whole.Scores can range from 1 to 5; the greater the result, the greater is the level to which the value or organizational practice measured by the factor is present in the evaluated organization.
The third instrument was the Resilience Scale (RS) translated and validated for Portuguese (10) based on the Resilience Organizational culture of a psychiatric hospital and resilience of nursing workers Rocha FLR, et al.
Scale Instrument developed by Wagnild and Young (9) .It has been widely used in many countries, proving to be one of the most reliable instruments to measure resilience (11)(12)15) . The S is composed of 25 items randomly arranged, with answers in a Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree).Thus, the final scores can range 25-175 points, and the higher the score, the greater the individual resilience (10) .
The Statistical Package for the Social Sciences (SPSS) version 16.0 was used for data analysis.The results were presented using descriptive statistics.In addition, Pearson (r) and Spearman (r s ) correlation tests were performed to verify the relation between each category of IBACO and RS, adopting a significance level of 5% (p≤.05).The choice of both coefficients was by the fact that some averages of categories did not show normal distribution.
The study project was authorized by the Technical Director of the Institution and the Research Ethics Committee.The normalizations of resolution of 466/2012 were followed in relation to ethical standards for research involving human beings (16) .

Sample characterization
Of the 120 invited professionals, six refused to participate and 58 did not return the questionnaires to the researchers, even after several attempts.Thus, 64 subjects were removed (53.3%), and the sample was composed of 56 nursing workers, of whom 45 (80.4%) were women; 22 (39.2%) were aged between 20 and 40 years, and 30 (53.6%) between 41 and 60 years -mean age of 42.5 years; 11 (19.6%) were nurses and 45 (80.4%) were nursing technicians or assistants.Regarding the educational level of participants, 30 (53.6%) nursing technicians or assistants had completed high school and eight (14.3%) had incomplete higher education; of 11 nurses, seven (12.5%) had postgraduate courses.

Organizational culture
Participants mentioned the existence of rigid hierarchy and centralization of power (average VRH = 2.61) and cooperative professionalism at work (average VCP = 2.52) as organizational values relatively applicable to the organization.In the perception of workers, values related to wellbeing and motivation of employees (average VWE = 2.20) and the existence of individual and competitive professionalism (average VIP = 2.13) were less applicable to hospital culture.
In relation to organizational practices, workers considered the following reasonably adopted in the organization: practices of external integration and strategic planning (mean PEI = 2.96) and actions related to the promotion of interpersonal relationships and job satisfaction (mean PIR = 2.52).The practices of rewarding and training employees (average PRT = 2.05) were considered less adopted.Data are presented in Table 1.

Resilience of workers
To facilitate the discussion of data, the result of the RS final scores were analyzed in tertile that were calculated based on the maximum and minimum values assigned to the RS by participants.Values were classified as low, medium and high level of resilience.
Based on the responses of employees, was obtained a minimum value of 86 and a maximum of 163 points in the RS (SD = 13.79).Thus, values between 86 and 110 were considered as low level of resilience; values between 111 and 136 were medium level; and high level of resilience were values between 137 and 163.Fifty percent (50%) of participants showed high level of resilience, and 42.9% presented medium level of resilience, as shown in Table 2.In order to verify the correlation between the domains of the IBACO instrument and the level of resilience of workers, were performed the Pearson (r) and Spearman (r s ) correlation tests, considering the average values assigned by workers to each domain of the IBACO and RS.Tables 3 and 4 show these data.

DISCUSSION
Based on these results, in the perception of nursing workers, there is control at work, rigid hierarchy, centralization of decision-making, and relative appreciation of workers in the institution, as well as collaboration at work and some practices to promote interpersonal relationships.However, the institution does not value the wellbeing at work and the professional development.
These elements comprise the OC of the hospital and show a place where the organization of nursing work is still based on the centralization of power and devaluation of workers, characteristics of work-oriented organizations (5) .
The results of this study corroborate previous studies performed with the objective to evaluate the OC of Brazilian hospitals (17)(18) .Such studies found centralization of power, rigid hierachy, control at work and little appreciation of individuals as organizational values and practices of the hospitals.Based on the literature on the subject, the authors argue that these characteristics portray the history of Brazilian public administration, marked by authoritarianism, bureaucracy, paternalism and political interference.Furthermore, historically, the model of organization and work management predominant in Brazilian public hospitals is based on principles of Classical Administration, that is, vertical and hierarchical organizational structures, centralized power and excessive bureaucracy, which leads to the formalization of relationships and emphasis on work processes, devaluing professional skills and the autonomy of individuals (18) .This prevailing management model of Brazilian hospitals has direct impact on the work organization and health care.Thus, since its origin, the nursing work in the hospital is considered strongly influenced by the Taylorist/Fordist and Bureaucratic models, based on the logic of the technical division of work, and by the Biomedical Model of healthcare, leading to social division of labor, valuation of routines, impersonality of relationships and fragmentation of care (2) .
The appreciation of tasks, work processes, and institutional norms and routines by nurses in detriment to the assistance focused on meeting the psychosocial needs of patients was also a feature of the nursing work observed in a Canadian hospital (19) .In other studies, these same authors argue that nurses have dedicated much of their time to perform tasks related to direct patient care or management of the units, but focused on biological aspects and treatment proposed by the medical team, instead of developing actions from the perspective of comprehensive care, aimed at assessing the psychosocial needs of patients and family members.
Thus, the biomedical healthcare model hinders the implementation of teamwork and interdisciplinary attention, strengthening the fragmentation of care and preventing comprehensive care to patients (19) .Overcoming the Biomedical Model and implementing more flexible and participatory strategies of hospital management represents the current major challenge of Brazilian health services in the search for quality of care (1) .
The work-oriented cultures value the control and specialization of activities and have vertical organizational structures with rigid hierarchy, centralization of power and formalization of relations.In environments like this, workers are under pressure to achieve organizational goals, do not participate in decision-making and feel undervalued and demotivated.Conversely, institutions with worker-oriented cultures value the competences and individual skills, providing conditions for the development of autonomy and freedom at work and, consequently, generate wellbeing and individual satisfaction (5) .
Individuals exposed to constant pressure and control at work that do not have autonomy and freedom to perform their activities and cannot exercise their potentialities can be affected by feelings of dissatisfaction, demotivation and mental suffering, which can determine the mental illness (20) .
The illness caused by work is a widely discussed topic by the Psychodynamics of Work, whose precursor is Christophe Dejours.For him, The work organization exerts a specific action on men, which impacts on the psychic apparatus.Under certain conditions emerges a suffering that can be attributed to the clash between an individual story with projects, hopes and desires, and the work organization that ignores them... (20) .
Organizational culture of a psychiatric hospital and resilience of nursing workers Rocha FLR, et al.
The burnout syndrome is one of the main forms of mental illness at work among nursing professionals, mainly due to the stressful nature of this activity.Emotional exhaustion and the occurrence of burnout are strongly associated with the perception of nursing professionals about their work environment and job satisfaction, which directly affects the quality of care provided (21) .
The main factors that stand out as triggering work stress, leading to increased tension and professional fatigue, and resulting in the occurrence of burnout are the demands for higher productivity associated with the reduced number of workers, work pressure, complexity of tasks, and the presence of tense and precarious employment relationships (22) .
A study on working conditions and the occurrence of minor psychiatric disorders (MPD) in nursing workers found that individuals exposed to high psychological demands and low control at work had twice greater chances of developing MPD (23) .
Thus, corroborating national (24)(25)(26) and international (27) studies, occupational stress is associated with organizational factors (poor working conditions; lack of institutional values related to the appreciation of workers, satisfaction and motivation at work; reduction of personnel; low pay); the health work organization (work overload; night shift; long working hours; ambiguity in task development); and the different problems arising from interpersonal relationships (impaired communication; bad relationship with supervisors and colleagues; interpersonal conflicts).
Regarding the capacity of resilience, the results showed 50% of workers presented a high level and 42.9% a medium level of resilience, suggesting that nurses, and nursing technicians and auxiliaries seek to develop protective factors to face a work environment unappreciative of their subjectivity and individual needs.In other words, in this case, resilience represents an important individual defense mechanism against the risks of suffering and having illnesses related to the work organization in the hospital, which has aspects of rigid hierarchy, control, power centralization and devaluation of individuals.
These results were confirmed by performing the correlation test between the variables of IBACO and RS to verify the relationship between the OC and the workers' capacity of resilience.Although there was no statistical significance between variables in the Pearson and Spearman correlation tests, negative values were found in relation to some variables, such as VWE, PRT and PIR in both tests.
VWE, PRT and PIR are organizational values and practices related to the promotion of wellbeing, vocational training, and interpersonal relationships at work.In other words, they represent values related to the appreciation of employees in the organizational context, and the inversely proportional relationship of these variables with the workers' resilience means that the higher the appreciation of the worker by the institution the lower the individual's level of resilience.Or, conversely, the lower the appreciation of individuals in the institution, the greater their resilience capacity to face adversities in the workplace.
Resilience is a psychological process initiated by the individual in response to the action of stressors faced daily and therefore, the focal point of resiliency and mental health promotion lies in minimizing the impact of risk factors and increasing the protective factors against everyday adversities (12) .
Research on stress and levels of resilience among health professionals showed that nursing technicians are the most vulnerable category.The main risk factors for stress are the long working hours and double shift.Social support was detected as the main protective factor of the individual in stressful situations.Job satisfaction, emotional competence and empathy were evident among resilience indicators (28) .
A study performed in Spain revealed an association between emotional stress and emotional exhaustion of nurses, and found that resilience is an important protective factor against emotional exhaustion (29) .
When organizations choose to minimize occupational risk factors and implement strategies to enhance the mechanisms related to resilience, consequently, there are better work conditions and workers' wellbeing.In turn, the wellbeing at work is directly related to reduced absenteeism and turnover, and increased productivity of workers, bringing benefits to the institution itself (30) .
Therefore, there is a close relationship between organizational values, the organization of work and human behavior in institutions, the interfaces studied by the Psychodynamics of Work and resilience, which focus on the study of occupational risk factors and the mechanisms used by workers to deal with suffering and adversities at work.

Study limitations
A limitation of the study was the low adherence of workers, since 58 participants did not return the questionnaires to researchers and six refused to participate.This high rate may be related to: professionals' lack of interest in participating of scientific research; professional demotivation; and fear of retaliation by the organization after participating in investigations that reveal problems, difficulties and institutional inadequacies.However, the responses of 56 participants allowed the evaluation of the organizational culture and the resilience of workers of the institution, objectives of this study.

CONCLUSION
The results of this study show the nursing workers' perception reflects the values that determine the OC of the hospital, permeated by rigidity, hierarchy, work control and devaluation of individual freedom and autonomy.
These values depict the model of management and work organization adopted by the institution and can cause suffering and illness of workers.Thus, they are required to develop their resilience to face the adversities of the work environment and situations generating stress experienced daily in the care to mental disorder patients.
Thus, individual and organizational factors are important in determining the workers' process of health and illness, requiring a multidimensional understanding for the health promotion at work in health services.

Table 2 -
Number of employees, percentages, means and minimum-maximum values of the level of resilience of workers, hospital in the interior of the state of São Paulo, Brazil, 2014 (N=56)

Table 1 -
Means, median, standard deviation and minimum-maximum values of domain scores of the Brazilian Instrument for the Evaluation of the Organizational Culture, in the perception of nursing professionals, hospital in the interior of the state of São Paulo, Brazil, 2014 (N=56)

Table 3 -
Values obtained after the Spearman correlation test between the mean of domains of the Brazilian Instrument for Evaluation of Organizational Culture and the Resilience Scale, hospital in the interior of the state of São Paulo, Brazil, 2014 (N=56)

Table 4 -
Values obtained after the Pearson correlation test between the means of domains of the Brazilian Instrument for Evaluation of Organizational Culture and the Resilience Scale, hospital of the interior of the state of São Paulo, Brazil, 2014 (N=56) Notes: VCP = Values of Cooperative Professionalism; VRH = Values of Rigidity in the Hierarchical Structure; VIP = Values of Individualist Professionalism; VWE = Values of Wellbeing; PEI = Practices of External Integration; PRT = Practice of Rewarding and Training; PIR = Practices of Promotion of Relationship.