Work values and practices which characterize the organizational culture of a public hospital

Abstracts

O estudo teve como objetivo identificar os valores e práticas que caracterizam a cultura organizacional de um hospital público na perspectiva de enfermeiros. Trata-se de uma pesquisa descritiva estruturada a partir do referencial de Hofstede e desenvolvida num hospital público do interior do Estado de São Paulo. A amostra foi representada por 52 enfermeiros. A coleta de dados ocorreu no período de dezembro de 2010 a fevereiro de 2011, utilizando-se o Instrumento Brasileiro de Avaliação da Cultura Organizacional. Os resultados mostraram que há rigidez hierárquica e centralização de poder (94%); há competição e dificuldade de trabalho em equipe (63%); há pouco bem-estar e motivação dos trabalhadores (94%); e há pouca satisfação no trabalho e promoção das relações interpessoais (60%). Neste sentido, a cultura do hospital está intimamente relacionada ao modelo de organização e gestão do trabalho, os quais fortalecem a fragmentação do cuidado e dificultam o trabalho em equipe e o desenvolvimento de interdisciplinaridade, comprometendo a qualidade da assistência.

Enfermagem; Serviços de saúde; Organização e administração; Cultura organizacional

ORIGINAL ARTICLE

Work values and practices which characterize the organizational culture of a public hospital¹

Valores y prácticas de trabajo que caracterizan a la cultura organizacional de un hospital público

Michele Cristina de Carvalho^I; Fernanda Ludmilla Rossi Rocha^II; Maria Helena Palucci Marziale^III; Carmen Silvia Gabriel^IV; Andrea Bernardes^V

^IUndergraduate student of the Ribeirão Preto School of Nursing (EERP) of the University of São Paulo (USP). Ribeirão Preto, São Paulo, Brazil. E-mail: [e-mail]

IIPh.D. in Nursing Professor of the Department of General and Specialized Nursing at the EERP/USP. São Paulo, São Paulo, Brazil. E-mail: [e-mail]

^IIIPh.D. in Nursing full Professor of the Department of General and Specialized Nursing at the EERP/USP. São Paulo, São Paulo, Brazil. E-mail: [e-mail]

^IVPh.D. in Public Health Nursing Professor of the Department of General and Specialized Nursing at the EERP/USP. São Paulo, São Paulo, Brazil. E-mail: [e-mail]

^VPh.D. in Fundamental Nursing Professor of the Department of General and Specialized Nursing at the EERP/USP. São Paulo, São Paulo, Brazil. E-mail: [e-mail]

Correspondence

ABSTRACT

The study aimed to identify the values and practices which characterize the organizational culture of a public hospital in the view of the nurses. This is descriptive research structured based on Hofstede's framework and undertaken in a public hospital in the interior of the state of São Paulo. The sample was represented by 52 nurses. Data collection occurred in the period between December 2010 and February 2011, using the Brazilian Instrument for the Evaluation of Organizational Culture. The results showed that there is hierarchical rigidity and centralization of power (94%); there is competition and difficulty in working as a team (63%); the workers have little well-being and motivation (94%); there is little satisfaction in the work and promotion of interpersonal relationships (60%). In this regard, the hospital's culture is intimately related to the model of organization and management of the work, which further the fragmentation of the care and make it harder to work as a team and to develop interdisciplinarity, compromising the quality of the care.

Descriptors: Nursing. Health services. Organization and administration. Organizational culture.

RESUMEN

el objetivo de este estudio fue identificar los valores y prácticas que caracterizan a la cultura organizacional de un hospital público en la perspectiva de las enfermeras. Se trata de un estudio descriptivo estructurado a partir de la teoría de Hofstede y desarrollado en un hospital público en el interior del Estado de São Paulo. La muestra estuvo representada por 52 enfermeras. La recolección de datos tuvo lugar entre diciembre de 2010 y febrero de 2011, mediante el Instrumento Brasileño de Evaluación de la Cultura Organizacional. Se evidenció que existe una jerarquía rígida y centralización del poder (94%); existe competición y dificultad del trabajo en equipo (63%); hay poco bienestar y motivación de los trabajadores (94%); hay poca satisfacción en el trabajo y promoción de las relaciones interpersonales (60%). Así, la cultura del hospital esta estrechamente relacionada con el modelo de organización y gestión del trabajo, que fortalecen la fragmentación de la atención y hacen que sea difícil el trabajo en equipo y el desarrollo de interdisciplinaridad, comprometiendo la calidad de la atención.

Descriptores: Enfermería. Servicios de Salud. Organización y administración. Cultura organizacional.

INTRODUCTION

Culture is a historical and social construction which encompasses knowledge, ethics and the norms which rule the behavior of a group; it is characterized by the individuals' experiences, beliefs and values, which may be learnt and shared, being transmitted from generation to generation.¹

Culture can represent more than a set of rules, habits and artifacts; it also signifies an organization full of meanings where individuals from the same group share them, functioning as a collective standard for identification of different groups, with their own specific ways of thinking, feeling and acting.²

Organizations are understood as micro-societies, characterized by the same problems which determine the social links; they represent cultural, symbolic and imaginary systems, made up of a structure of values and norms which condition their members' behavior, guiding their conducts. ^3-5

Organizational culture is a complex phenomenon, it being important to widely observe its aspects, without characterizing it as a static variable. ⁶ To understand the organizational culture, the multiple social situations experienced by the members of an organization within a particular social context must be considered, as well as historical aspects of the creation and development of the institution. In addition to this, it becomes fundamental to understand the other, his or her vision of the world, his or her culture, in a relationship of intersubjectivity.⁷

In this regard, the perceptions of the members of an organization express shared beliefs and represent the organizational values, forming the nucleus of the organizational culture. The organizational values may be considered as aspects which form the organization's base, constituting the institution's various dimensions and having the function of guiding life in the company and guiding the daily behavior of the workers.⁸

Thus, the organizational values may exercise an influence on the work environment and on organizations' functioning, determining common directions to the workers.^9-10 For this reason, we must consider the group processes, the construction of the social consciousness and of the system of representations of groups within the institutions so as to understand an organization's culture.¹¹

In the context of work in health and nursing, culture is characterized as a complex system which encompasses languages and codes, it being important to understand the individual characteristics, the individual's professional training, the institution's practices and the actions inherent to each profession, considering the intersection between individuals and organizations.^12-13

Understanding the inter-relation existing between the organizational culture and the organization of work in health, we were motivated to undertake this study, seeking answers to the following questions: How do nurses in a public hospital understand the organizational culture? What are the values and practices which define the organization's culture in the nurses' perception?

In this way, the present study aimed to identify the values and practices which characterize the organizational culture of a public hospital in the view of the nurses.

METHOD

This is descriptive research, with a quantitative approach of data, carried out in a public hospital in the interior of the state of São Paulo, a general institution, with over 300 beds, which attends Unified Health System patients, and is made up of approximately one thousand nursing workers.

The study population is represented by 213 nurses from the hospital. For the selection of the sample, the method of stratified random sampling based on the following formula¹⁴ was used:

In which:

e

And considering: N₁ corresponds to the total number of nurses; p₁ to the proportion of nurses who have a negative view of the hospital's culture; B to the precision (error between the real values and the p₁estimated values); and in which the sample size is given by n₁ = N₁w₁.

As there is no scientific evidence showing the workers' perception on the culture of Brazilian health services, it was considered that p₁=0.50 so as to maximize the proportion of nurses who believe in the organizational culture's negative influence on aspects related to the management and organization of the work.

Therefore, considering a precision of 5%, N₁=213 and p₁=0.50, we have the total sample size, which, adding a proportion of losses equal to 10%, is given by n₁ =62.

Inclusion criteria: nurses who were working in the data collection period and who consented voluntarily to participate in the study, signing the Terms of Free and Informed Consent

Data collection

The data was collected from December 2010 to February 2011, in the hospital units and during the nurses' workdays, using a data collection instrument made up of two parts.

The first part is composed of a questionnaire on workers' socio-demographic data (age, sex, color, marital status, schooling, workplace). The second part is made up of the Brazilian Instrument for the Evaluation of Organizational Culture (IBACO).¹⁵

The IBACO was elaborated by Brazilian researchers¹⁵ based on the Hofstede theory⁴, with the objective of assessing the values and practices which configure an organization's culture in the view of the workers. It is an instrument made up of 94 items which characterize an organization's culture, of which 55 statements seek to identify the organizational values and 39 statements refer to the organizational practices, organized randomly.

To answer the questionnaire, the worker should make a mark, based on his perception, if each statement applies to the organization "in no way" (1 point), "little" (2 points), "reasonably" (3 points), a lot" (4 points) or "totally" (5 points).

For analysis of the results, the number of workers who marked each one of the alternatives was identified; later, the absolute frequencies and percentages referent to each category of work values and practices were calculated.

The research project was evaluated and approved by the institution's Research Ethics Committee (process n. 3117/2010). It followed the standardizations of Resolution 196/96, referent to ethical norms of research involving human beings.¹⁶

RESULTS

Of the 213 nurses from the institution, 62 were selected to participate in the study, 35 of these workers being placed in the Clinical and Surgical Inpatient Units, 6 in the Intensive Care Unit, 7 in the Operating Room and 11 in the Clinical Outpatient Center.

Of the 62 nurses selected, 52 consented to participate in the study and returned the instruments appropriately filled out. Two nurses refused to participate in the research; three nurses no longer belonged to the institution's workforce; one worker was on sick leave and four nurses had been transferred to other units, thus being excluded from the sample.

It was ascertained that of the 52 participants, 36 were nurses (69.23 %) and 16 were nurse coordinators (30.77%); there was a predominance of women (96.15%) and of workers aged between 31 and 50 years old (71.16%), who were married (59.62%) and white (94.23%); 10 nurses (19.23%) had Master's degrees and one claimed to have the title of Doctorate in Nursing; 7 workers (13.46%) mentioned having another job.

Values and practices which characterize the organizational culture

The IBACO¹⁵ covers four types of value related to organizational culture: 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 Well-Being of Employees (VWE). In addition to this, the IBACO considers three types of organizational practices: Practices of External Integration (PEI), Practices of Rewarding and Training (PRT) and Practices of Promotion of Interpersonal Relationships (PIR).

According to the authors of the IBACO,¹⁵ the VCP refer to the valorization of the workers who demonstrate a spirit of collaboration, initiative, dedication and professionalism, collaborating with the team so as to achieve common objectives and the organization's goals. Such values represent 23 of the instrument's items.

The VRH are represented by 13 items on the IBACO and characterize organizations which have rigid structures, centralized authority and leaders with authoritarian profiles, which make professional growth difficult and impede motivation and satisfaction in the work, as there is no valorization of the workers.

The VIP, made up of eight items, address the valorization of individual skills and competences in the carrying-out of tasks and in the achieving of established goals, denying the importance of the collective work undertaken by teams and emphasizing competition between the members, which often leads to a lack of ethics in the work relationships.

The VWE, on the other hand, characterize organizations concerned with the humanization of the workplaces, valuing the well-being of their collaborators, and satisfaction and motivation at work, which lead to professional growth. These values are made up of 11 items from the IBACO.

In relation to organizational practices, the PEI involve decision-making processes of the organization's directors and managers, directed at strategic planning and attending external clients. These practices are gathered in 17 of the instrument's items.

The PRT characterize the adoption of practices of rewarding and training the workers by the organizations, which leads to the valorization of the individuals and makes greater satisfaction and motivation at work possible. These practices are made up of 14 items.

Finally, the PIR are related to practices of the promotion of interpersonal relationships and greater cohesion among the workers, directed at the carrying-out of teamwork, for the valorization of the individuals and satisfaction at work. The PIR are grouped in eight items of the IBACO.

Based on the data collected through the application of the IBACO, values of cooperative professionalism are significantly applicable in the institution in the perception of 31 nurses (59.62%) and reasonably applicable for 19 nurses (36.54%); there is significant hierarchical rigidity and centralization of power according to 31 nurses (59.62%) and 18 nurses (34.62%) report that the values of hierarchical rigidity apply reasonably in the hospital; regarding values of individual professionalism and competition, 33 nurses (63.46%) believe that they apply reasonably in the hospital, and 19 nurses (36.54%) judge there to be little competition in the hospital; according to 35 nurses (67.31%), the workers' well-being and motivation are values applied reasonably in the institution, and 14 nurses (26.92%) believe that these values apply little in the hospital.

In relation to organizational practices, strategic planning and external integration are significantly applicable in the opinion of 41 nurses (78.85%); the workers' training and rewarding are reasonably applied practices in the opinion of the majority of the nurses (71.15%) and investments related to the promotion of interpersonal relationships and work satisfaction are practices which are reasonably applied in the perception of 31 nurses (59.62%) and significantly applied in the hospital for 20 nurses (38.46%) (Table 1).

DISCUSSION

Based on the study of the psychodynamics of health work, we consider that the organizational structure and the management model adopted by an organization determine the work processes and the workers' behavior. In addition to this, we understand that values, beliefs, habits and practices exist which are implicit in the work environments and which are shared between an organization's members, defining behavioral norms and ways of organizing the work.

This set of values and practices, expressed through rituals, myths, habits and beliefs which are common to the workers, represents an organizational culture which defines the specific characteristics of each institution and is considered the base of an organization.¹⁷

In the light of this, this investigation's results reveal that the values and practices which define the hospital's culture are intimately related to the model of organization and management of work adopted in an institution. Thus, the institution's culture presents elements related to the rigid organizational structure and centralization of power; to the existence of competition among workers, to individualism and to difficulty in carrying out team work; to disinterest in the workers' well-being and the promotion of interpersonal relationships, disregarding the workers' needs.

This data corroborates the results of studies undertaken by Hofstede and his collaborators4 in 76 countries, which substantiate that different dimensions of the culture of the organizations define the institutional practices and values.

In relation to organizational practices, some authors⁴ consider that process-oriented organizational cultures have rigid structures, centralization of power, strong specialization in the work, and formalization of relationships, while institutions with results-oriented cultures value the workers. The authors also observe that, in the organizations with work-oriented cultures, there is strong control over the processes and the workers, who suffer pressure from the managers in carrying out their tasks, do not participate in decision-making processes, and feel that their personal problems do not matter to the organization, while workeroriented organizational cultures value the individuals' well-being and satisfaction and shared decisions. They further discuss that the values of the founders or leaders of the organizations become the practices of the workers.⁴

These aspects are considered common characteristics of Brazilian public institutions: bureaucratism (excessive control of procedures, administration which is hidebound and not focussed on real needs); authoritarianism and centralization (excessive verticalization of the hierarchical structure and centralization of the decision-making process); paternalism (high control of movement of personnel and of the distribution of jobs, in line with the dominant political interests); aversion to entrepreneurship (absence of entrepreneurial behavior to suggest changes); reformism (administrative discontinuity, political interference).^18-19

Integrated into the context of health work and nursing in public hospitals in the interior of the state of São Paulo, we noted that these features depict the reality experienced by the workers, it being possible to recognize rigid hierarchies, the centralization of power, conflicts and disputes over power between the various professional categories, the valorization of norms and routines, emphasis on the organization and carrying-out of tasks, control of the work and the undervaluing of the human element.

This is because the organizational structure of many Brazilian hospitals still follows directives established by classic models of administration, grounded in the logic of legal authority inherited from the bureaucratic conception, and characterized by hierarchized and verticalized structures, the formalization of work relationships, and the fragmentation of responsibilities.^19-20 In these institutions, the hierarchical rigidity compromises the carrying-out of the work and fragments the relationships, giving rise to subversive behaviors among the workers.²¹

It should be borne in mind that, since its beginning, nursing's productive structure has been based on the social division of work, on the emphasis on organization, processes and tasks, on an excessive preoccupation with manuals of procedures, on routines and norms, on the fragmentation of care and on the control of the work process by the nurse, who takes on the role of manager of the nursing team. In addition to this, the nurse's will is often imposed on those of the other workers, characterizing a process of domination, impersonality, hierarchical relationships and emphasis on formal communication.²²

The authority and the social division of the nursing work, often entrenched in rigid hierarchies, cause distancing and conflicts between the workers,²¹ which may explain the lack of cooperation in the work and the difficulty in developing interdisciplinarity and team work in the institution.

The conflict of the relationships in health work is the result of their complexity, as this involves different professional categories, each with its specificity and culture, constructed historically. In this regard, the nurse's work is based in the profession's historical and cultural context, being integrated into this complexity and performing managerial and assistential roles, becoming an element which is responsible for the composition of the service, for the interpersonal relationships, and for the coordination of the work. In addition to this, the exercising of the nurse's management is characterized by mechanisms of control and power, related to the military and religious influence inherent to the history of the profession.²³

Allied to these characteristics, one can also perceive that health care follows principles of the biomedical model, with the valuing of medical knowledge, the specialization of actions, the submission of other professional categories to the doctors, and a fragmented view of the human being, leading to the fragmentation of care, lack of humanization and integrality in the care, and the inexistence of team work and interdisciplinarity. The great consequence of this process is the poor quality of the care given the patients.

This context of health work has created great professional dissatisfaction, demotivating the workers in the development of their potential and skills and impeding their professional growth, which also directly affects the quality of the services.

Low satisfaction at work can be an indicator of how much workers fail to face good experiences in the organization and keep negative feelings at work, compromising their dedication and professional investment and impairing interpersonal relationships. In this way, it is understand that individuals who are satisfied and motivated at work maximize their own development and tend to have increased productivity, collaborating with the organization's objectives.^24-25

In addition to dissatisfaction and demotivation, workers who lack autonomy and liberty in the carrying-out of their tasks, and who are exposed to constant pressure and control in the undertaking of their work have a high probability of being affected by innumerable forms of psychological suffering, which determines their becoming ill from the work.²⁶

CONCLUSIONS

This study's results establish the relationship between the organizational culture and the model of management and the organization of the work adopted by the health institution. It is evidenced that traditional models of administration and principles of the scientific organization of the work, historically incorporated by the institution's managers and workers, support the work practices and determine the organizational values and practices.

Thus, based on the perception of the nurses, the organizational values and practices permeate the hierarchization, control and rigidity at work, the individualism and competition among the individuals, and the undervaluing of the workers. This conception of the work further fragments the care for the patient, making it difficult to work as a team, to undertake actions of interdisciplinarity in the health care, and to achieve quality in the services provided.

In addition to this, these characteristics of the work in the institution provoke dissatisfac - tion and demotivation among the workers to the degree that their needs and competences are not taken into account, impeding professional growth and further compromising the quality of the care.

For these reasons, we judge it necessary to transform the health practices through the adoption of new forms of management and organization of the work; these have been studied and implemented in various institutions in the attempt to substitute traditional models, and call for shared management, team work, the valorization of the needs of individuals (patients and workers), integrality in the care and the humanization of interpersonal relationships, understanding the human element as an agent of health actions.

We consider, however, that this change will only be effective when changes occur in the values shared among the individuals, which shape the organizations' cultures, a process which must be initiated by the managers and coordinators of the work. Only when managers value the workers' participation in decision processes and seek new ways of meeting the professionals' needs in the workplaces will it be possible to implement new management processes. Only when managers truly believe in the current conception of health, based on the humanization of the relationships and the integrality of the care, will it permeate the health actions.

Based on the initiative of the coordinators, these values will be incorporated by the other workers and will represent the new culture of the organization, which will determine the innovations related to the organization of the health work and management. In this context, the leadership can represent a fundamental element, influencing individuals to take on different behaviors at work, transforming health practices and improving the quality of the care.

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1

Projeto Financiado pelo CNPq.

Publication Dates

• Publication in this collection
  01 Oct 2013
• Date of issue
  Sept 2013