Learning objectives
How do I:
• understand the key concepts associated with workplace cultures?
• identify the impacts of positive and negative workplace cultures on the
functioning of an organisation, particularly in the area of patient safety
and quality?
• identify different types of workplace cultures?
• understand the impact a health manager or leader can make on the culture
of an organisation or department?
• build positive workplace cultures?
Introduction
Understanding, managing and building culture within a workplace are key responsibilities
of leadership and management. This chapter outlines what workplace culture is, the
impact of poor culture on an organisation and what managers can do to improve workplace
culture.
Peter Drucker (as cited in Fernandez-Araoz, 2014, para. 2) once famously said,
‘Culture eats strategy over breakfast’. This might seem implausible, because there is
an expectation on healthcare managers to plan, set out, implement and then evaluate
strategy. Drucker’s point is that unless there is a positive culture in a workplace, seeing
a strategy move to successful implementation and adoption is very difficult, sometimes
impossible.
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Definitions
Workplace culture (also called organisational or corporate culture) has been well
defined in the literature. Culture has often been described as the particular beliefs or values
of an organisation that distinguish it from other similar
Workplace culture organisations. Local definitions include ‘the way we do things
around here’ and ‘our corporate DNA’. These descriptions of
workplace culture hold true and describe the unique and
often hard-to-define ‘feel’ of an organisation. Scott, Mannion,
The particular beliefs, norms or values
of an organisation that distinguish it
from other similar organisations
Davies and Marshall (2003, p. 925) describe workplace
culture as ‘a wide range of social phenomena, including an organization’s customary
dress, language, behaviour, beliefs, values, assumptions, symbols of status and authority,
myths, ceremonies, and modes of deference and subversion; all of which help to define
an organization’s character and norms’.
While we may talk about a single defining culture, the truth is that in larger organisations
there may be several cultures or subcultures. Manley, Sanders, Cardiff and Webster
(2011, p. 4) state that ‘organisational culture in the past has been assumed lo be singular
and pervasive, monolithic and integrative, but all organisations have multiple cultures
usually associated with differem functional groupings or geographical locations’.
Subcultures can be routinely seen in large hospitals, where indi·idual depanmems may
have cultures that are slightly cliflerem from but aligned with that of the organisation
overall. Subcultures are commonplace and contribute lo the overall feel, function and
direction of an organisation.
On the other hand, countercultures – a form of organisational incivility- work at odds
with the organisation and can be quite disruptiw or destructive lo its overall functioning.
Andersson and Pearson (1999, p. 457) describe organisational incivility as ‘low intensity
deviant behaviour with ambiguous imenl lo harm the target, in violation of workplace
norms for mutual respect’. One of the key responsibilities of a healthcare manager and
leader is the cultivation of positive, productive workplace cultures. Schein (1992, as cited
in Graber and Fitzpatrick, 2008, p. 194) says that one of the prime responsibilities of
leaders is the management and creation of culture.
Typology of workplace cultures
While setting the culture of an organisation is the prime responsibility of the chief
executiw officer and the executive team, managers are expected to support and promote
the desired culture. In order to understand what son of culture prevails in an
organisation, it is necessary LO be able to categorise culture l ypes. Categorisation allows
the health manager to determine whether there is a need lo redefine and change the
culture in which they work. Self-aware health managers also need to ask themselves
Chapter25 Building positive workplace cultures
the following questions: How am I contributing to the culture in this organisation? If
I don’t like the present culture in the organisation, what am I going to do to change it?
The literature categorises culture in many ways, ranging from three-culture models
(Westrum, 2004) to quadrant models (Quinn and Rohrbaugh, 1983; Wolniak, 2013)
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to cultures depicted as animal types (Line, 1999). A cultural
framework that has been used widely in a number of industries,
including health, is the Competing Values Framework
(Cameron & Quinn, 2011; see Figure 25.1). It categorises four
main cultural types and describes how each of these predominantly
functions.
Competing Values Framework
Flexibility
Clan Adhocracy
(or cooperative) (or creative)
culture culture
A research-informed framework which
describes four key culture types: clan,
hierarchy, adhocracy and market
(Cameron & Quinn, 2011)
lnternality Externality
Hierarchy Market
(or control) (or competitive)
culture culture
Control
Figure 25.1 Competing Values Framework. Adapted from K. S. Cameron & R. E. Quinn (2011 ).
Diagnosing and changing organizational culture: Based on the Competing Values Framework (3rd ed.).
San Francisco, CA: Jossey-Bass.
The Competing Values Framework runs along two axes forming a cross. The vertical
axis focuses on organisations that have Oexibility and discretion through to those with
high levels of stability and control. The horizontal axis highlights organisations with a
strong internal focus and integration through to those that are externally focused and
differentiated. Using these axes, Cameron and Quinn (2011) have categorised four predominant
cultures, which are discussed below. Healthcare organisations may identify
any one of these types. Each has its benefits and limitations depending on the type of
organisation and the direction in which a healthcare facility is heading. Healthcare managers
need to be aware of how they impact the culture and how they should support staff
in their specific cultural type.
Clan (or cooperative) culture
This culture is characterised by a strong internal focus and flexibility. Organisations with a
clan culture exhibit strong family-like, nurturing, cohesive and collaborative traits. Teams
within such organisations work with a level of autonomy and self-direction.
Hierarchy (or control) culture
The hierarchy culture is characterised by an internal focus with strong control processes.
Organisations with a hierarchy culture have defined hierarchies or bureaucracies, and
command and control structures with a focus on policies, procedures, processes and
protocols. They aim to be stable, consistent and dependable.
Adhocracy (or creative) culture
This culture is characterised by flexibility and an external focus. Organisations with an
adhocracy culture promote rapid change, creativity and innovation, and they can be highpressured,
as they search for the next new product and aim to be ‘ahead of the game’.
Market (or competitive) culture
The market culture has strong internal control and is externally focused. Organisations
with a market culture focus on the external customer rather than the internal staff and
can be very competitive, as they seek new customers and have an emphasis on customer
service.
Measuring workplace culture
There are several ways in which to measure culture within organisations, from the subjective
(having a general sense of what the organisation is like) to the objective (validated
survey instruments and other qualitative approaches). Researchers have recently tried
to understand the scope and range of quantitative instruments to measure workplace
culture in healthcare organisations, and Scott et al. (2003) have identified 13 such instruments.
However, while all of these examined employee views, perceptions and opinions
of their working environments, only two considered the values and beliefs that might
inform those views. The authors conclude that ‘it is unlikely that any single instrument
will ever provide a valid, reliable, and trustworthy assessment of an organisation’s culture,
and so a multi-method approach will always be desirable (p. 942)’. Organisations
tend to use a range of approaches to measure their culture, including measurements
focusing on staff and patients.
Organisational implications of different
workplace cultures
The healthcare manager’s role in proactively managing culture is critical to the overall
functioning and success of the organisation. The culture of an organisation can impact
positively on its operation, profitability and ability to work through challenging circumstances.
While the culture of an organisation may seem a soft, non-core issue to
……….. Chapter25.Building.positiveworkplace cultucessome,
the positive and negative impacts of culture can have substantial financial and
operational implications.
Workplace culture can lead to positive outcomes in many areas of a health organisation.
Along with improved teamwork, cohesion and employee involvement, and patient
satisfaction (Gregory, Harris, Armenakis & Shook, 2009), lower patient mortality and
improved nurses’ health, job satisfaction, organisational commitment, emotional exhaustion
and intention to stay have been recorded (Laschinger, Cummings, Wong & Grau,
2014). Positive culture also leads to more optimism among staff about the organisation’s
ability to meet future challenges, improved working relationships, greater accountability
and efficiency, better cost management, more devolvement of management to clinicians,
and facilities that are more strategically placed and patient-focused (Braithwaite
et al., 2005). A reduction in medical errors has also been reported as a result of positive
workplace culture (Stock, McFadden & Gowen, 2007), as have improved quality of care
(Siourouni, Kastanioti, Tziallas & Niakas, 2012) and positive clinician attitudes in adopting
new technology (Callen, Braithwaite & Westbrook, 2007).
However, negative workplace culture, the consequences of which are regularly discussed
in healthcare reports and reviews, can manifest itself through unethical and possibly
illegal activity (Casali & Day, 2010), higher staff turnover and lower staff morale
and productivity (Siourouni et al., 2012). It can also result in a lower quality of care (Mid
Staffordshire NHS Foundation Trust Public Inquiry, 2010) and higher levels of workplace
bullying (O’Farrell & Nordstrom, 2013).
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