Organizational culture in the primary healthcare setting of Cyprus

The concept of organizational culture emerges from various disciplines including anthropology, sociology, and management [1]. Recent interest in the culture of healthcare organizations has begun to address the importance of culture for key organizational outcomes [2]. For example, healthcare cultures that emphasize group affiliation, teamwork and coordination have been associated with greater implementation of quality improvement practices [3]. According to Rundall et al. [4], the culture of physician organizations is important in the care of chronic illnesses, as it may relate to the ability of these organizations to support quality improvement efforts and develop information systems to provide better patient care [4]. Other authors have investigated how employee attitudes and behaviors are influenced by the “fit” or congruence between the organization’s culture and the individual’s own values or beliefs about what the organization’s values should be. Different studies have found that greater congruence is associated with more positive employee attitudes [5–9].

Several definitions of organizational culture can be found in the literature. According to O’Reilly and Chatman [10] “culture is a system of shared values defining what is important, and norms defining attitudes and behaviors that guide member’s attitudes and behaviors”. As Schein [11] proposed: “Organizational culture is the pattern of shared basic assumptions - invented, discovered or developed by a given group as it learns to cope with its problems of external adaptation and internal integration - that has worked well enough to be considered valid and therefore to be taught to new members as the correct way to perceive, think and feel in relationship to those problems” [11].

There are a variety of qualitative and quantitative approaches that measure organizational culture depending on the purpose and goals of each investigator [12]. Among the most widely used instruments is the Organizational Culture Inventory [13, 14] which evaluates styles within organizational groups to characterize the overall organizational culture along three dimensions (constructive, passive/defensive, or aggressive/defensive orientations) [13]. It comprises 120 items; each one rated on a 1–5 Likert scale [15] and has internal reliability that ranges from 0.67 to 0.92 [16]. Another two questionnaires are designed to measure the culture and values at the organizational level. The first is the Organizational Beliefs Questionnaire [17]. This tool is a 50 item questionnaire that uses a 5-point Likert scale (strongly agree to strongly disagree) and has ten subscales: work should be fun, being the best, innovation, attention to detail, worth and value of people, quality, communicating to get the job done, growth/profit/other indications of success, hand-on management and the importance of a shared philosophy¹⁷. It has moderate to high internal validity (0.35 to 0.78) [18].

The second tool is the Organizational Culture Profile (OCP), developed by O’Reilly, Chatman and Caldwell [7]. The original version of the OCP consists of 54 value statements with average reliability coefficient of 0.88 [7]. A Q-sort methodology of data collection [19] is used to identify values that characterize a target organization and an individual’s preference for that particular set of values by assessing person- organization fit [7, 20]. Based on a review performed by Ashkanasy et al. [21] concerning 18 culture measures published between 1975 and 1992, OCP was found to be one of only a few instruments to provide details concerning reliability and validity. The OCP has since been revised and shortened by Cable and Judge [22] to measure organizational and personal culture orientations. The instrument was further modified by Sarros et al. [23] along with the development of a five point Likert type scale format [15]. The new shortened version of the OCP consists of a 28-item, seven factor structure comprising the following factors: supportiveness, innovation, competitiveness, performance orientation, stability, emphasis on rewards and social responsibility [23].

The present study was the first to be performed in Cyprus that measured existing and desired organizational culture between primary healthcare professionals. “Performance orientation” and “supportiveness” were the two most desired types of organizational culture among GPs and nurses who practice at the PHC setting. On the other hand, “supportiveness” and “social responsibility” were the main cultures encountered in PHC whereas the least prevailing culture was “emphasis on rewards”. According to the OCP instrument, a performance orientation culture is shaped by the following characteristics: enthusiasm for the job, results orientation, highly organized employees and high performance expectations [23]. Organizations that have performance oriented culture emphasize achievement, results and action as important values and use systems that reward employees [33]. Although this culture dimension was the desired one for primary healthcare professionals the existing culture in PHC was “supportiveness”. This type of culture however, was the second most desired culture as pointed by the participants. Values that shape this culture dimension include team orientation, people orientation, collaboration and sharing information freely [23]. Organizations with cultures that are collaborative and emphasize cooperation among employees, are team oriented and members tend to have positive relationships with their coworkers and their managers [34]. According to the European definition of general practice/ family medicine the principles of the discipline include team collaboration, person –centered approach, community and individual responsibility [35]. These characteristics are included in the culture dimension “supportiveness” which is the one promoted in the PHC setting of Cyprus.

An important finding of the study was the gap identified between desired and prevailing cultures, yielding statistical significance for all cultural dimensions. As the study showed, there is not one strong culture that characterizes healthcare professionals who practice in PHC. According to Nystrom [36] the strength of an organization’s culture refers to the degree of consensus among members about which values prevail and which dominate in importance. In organizations with strong cultures most employees show consensus with the values of the organization [37] and their organizations in turn provide more meaning, commitment and guidance to their employees [36]. As other studies have shown [36, 38] healthcare organizations exhibiting a strong culture achieve desired outcomes such as commitment and satisfaction which in turn often lead to reduced employee turnover and increased job performance. There is convincing evidence that value congruence between individuals and their organizational context is associated with a more positive subjective experience for the person and better performance for the organization [39].

In a similar study performed in five PHC centers in Crete –Greece, the OCI instrument was applied [40]. The results of that study showed that the existing types of culture were aggressive/defensive and passive/defensive. These culture profiles involve expectations for the members of an organization to approach tasks and interaction with other people in powerful ways to promote their status and security [13]. These norms are similar to the values included in the culture dimension “stability” of the OCP tool namely low conflict, security of employment, and stability.

According to the results of three studies performed in the general public hospitals of Cyprus gaps were identified between desired and existing cultures exhibiting statistical significance for every culture dimension [41–43]. In Larnaca hospital [41] desired cultures were “performance orientation” and “stability” with respective means of 1.46 vs 1.47. In Limassol hospital [42] “emphasis on rewards” and “stability” were the most desired cultures (means: 1.42 vs 1.44 respectively), whereas in Paphos hospital [43] “supportiveness” and “stability” were identified as the most desired ones (means: 1.50 vs 1.52). Results emphasize the fact that there is not a unified strong culture among healthcare professionals who work in the public healthcare sector of Cyprus. In all three hospitals “stability” was identified as a desired culture. This type of culture includes characteristics like low conflict, security of employment and calmness. Stable cultures are predictable, rule oriented and bureaucratic and they are usually encountered in public sector institutions. When the environment is stable and certain, these cultures may help the organization to be effective by providing stable and constant levels of output. These cultures however, prevent quick action and may lead to a misfit in a changing and dynamic environment [44]. According to the results of a study performed by Bellou [27] in 20 public Greek hospitals that used the original 54 item OCP instrument [7] the two most prominent characteristics of culture were “aggressiveness” and “supportiveness”, whereas the least prominent ones were “decisiveness” and “team orientation” [27].

Another important finding of our study was that women healthcare professionals working in PHC value more, those characteristics that shape the culture “emphasis on rewards” in comparison to their male counterparts, a finding of statistical significance. There were also statistical significant differences identified between female and male nurses in regard to the importance given to the following cultures: “supportiveness”, “innovation” and “emphasis on rewards” with women valuing these cultures to a greater extent as compared to men (p value < 0.05 for all cultures). A possible explanation could be that men and women undergo a different professional socialization process in which skills and knowledge are acquired. As a result, women have different professional expectations and different values [45]. Studies have shown that women are more people oriented and team oriented whereas men are more task oriented and competitive [46, 47].

A noteworthy finding of the study was the difference identified between nurses with professional experience between 6–15 years and those with tenure up to five years in regard to the importance given for the cultures: “supportiveness”, “competitiveness”, “performance orientation”, “stability” and “emphasis on rewards”. Results yielded statistical significance for the aforementioned cultures (p value < 0.05). One possible explanation could be that newcomers in an organization have different values than those who have been in the organization for longer time. Unmet expectations, the feeling of uncertainty in relation to their work and the lack of congruency between their values and the values of the organization are possible reasons that may contribute to the importance attributed in certain culture categories. As studies have shown, environments that send clear messages to newcomers have the potential to change the most strongly held expectations by newcomers. On the other hand, environments in which newcomers receive ambiguous or conflicting messages from insiders will allow newcomers to maintain their initial expectations [48, 49].

This was the first study performed in Cyprus that provided insight into the organizational culture encountered in the PHC setting. The study provided evidence that the modified OCP [23] is a reliable and valid tool which can be easily applied in healthcare organizations including PHC settings. The new abbreviated form of the questionnaire that uses a Likert scale provides a more user- friendly approach to investigate organizational culture in large samples [23].

Results of the study can serve as an audit tool for managers and policy makers in the expected implementation of a new NHS. The revised OCP [23] can be used during different stages in the process of the implementation of the new NHS so as to monitor organizational cultural change in conjunction with changes in values and leadership styles. It can also provide the information needed for recruitment and selection of new employees [23] in the new NHS.

Healthcare professionals working in PHC will face changes both at organizational and professional level as new employment relationships will be developed jeopardizing their permanent working status. Results of the study can be used to set targets for organizational cultural change in the new working environment [23]. Whatever interventions will take place policy makers should ensure that important values fostered in PHC are well preserved.