Organisational culture andchange: implementingperson-centred care

Eric D. Carlstrom and Inger EkmanSahlgrenska Academy, Institute of Health and Care Sciences,

University of Gothenburg, Gothenburg, Sweden

Abstract

Purpose The purpose of this paper is to explore the connection between organisational culturesand the employees resistance to change at five hospital wards in Western Sweden. Staff hadexperienced extensive change during a research project implementing person-centred care (PCC) forpatients with chronic heart failure.

Design/methodology/approach Surveys were sent out to 170 nurses. The survey included twoinstruments the Organisational Values Questionnaire (OVQ) and the Resistance to Change Scale(RTC).

Findings The results indicate that a culture with a dominating focus on social competencedecreases routine seeking behaviour, i.e. tendencies to uphold stable routines and a reluctance to giveup old habits. The results indicate that a culture of flexibility, cohesion and trust negatively covariatewith the overall need for a stable and well-defined framework.

Practical implications An instrument that pinpoints the conditions of a particular healthcaresetting can improve the results of a change project. Managers can use instruments such as the onesused in this study to investigate and plan for change processes.

Originality/value Earlier studies of organisational culture and its impact on the performance ofhealthcare organisations have often investigated culture at the highest level of the organisation. In thisstudy, the culture of the production units i.e. the health workers in different hospital wards wasdescribed. Hospital wards develop their own culture and the cultures of different wards are mirrored inthe hospital.

Keywords Sweden, Hospitals, Nurses, Change management, Organizational culture, Person-centred care

Paper type Research paper

IntroductionPublic healthcare organisations are considered to be difficult to change (Arrow, 1963).There are several examples of how professional territorialism and organisationalinertia cause slow routines and long waiting times (Ouchi, 1977; Ouchi, 1980; Ahgren,1999; Street and Blackford, 2001; Scott et al., 2003b). A critical challenge facinghealthcare systems throughout the world is to meet the complex and costly care andtreatment needs of the already large and growing population of persons with long-termillnesses. To effectively meet this challenge, healthcare systems must realigntraditional clinical practices and organisations to better accommodate illnessmanagement as a central goal of care and treatment (Palmqvist and Lindell, 2000;Olofsson et al., 2009). However, new working models and new technology have beenhindered by cultures that are resisting change processes (Holmberg, 1997; Benders andVan Hootegem, 1999).

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Journal of Health Organization andManagement

Vol. 26 No. 2, 2012pp. 175-191

q Emerald Group Publishing Limited1477-7266

DOI 10.1108/14777261211230763

Culture may be defined in a number of different ways, but an established andsimple definition is that culture is the glue that makes up a common identity betweendifferent individuals (Smircich and Morgan, 1982; Smircich, 1983; Wilkins and Ouchi,1980). The definition of culture in this paper is based on Vygotski (1978), whoidentifies culture as a link or transition between individual and collective behaviour.This refers to the idea that an organisational culture is embodied in individuals, butshared by the collective (Leontev, 1978; Vygotski, 1978, Valler, 2003; Miettinen andVirkunnen, 2005).

Established organisational cultures are expected to induce inertia, maintain socialstructures and promote unitarianism (Schein, 1985; Young, 1989; Borum and Pedersen,1992). Despite this, organisational cultures have not always displayed the level ofcohesion that has come to be expected. Harris and Ogbonna (1998) associate culturalinfluences with a low willingness to change, they also identified that subcultures cancontribute to a translation of the culture into modifying values. Elwing (2005) hasshown, for example, that a communicative culture and the feeling of belonging to acommunity had a favourable effect on readiness for change.

Different concepts of culture such as symbols, metaphors, anecdotes and artefactshave not proven to be the socialising tool that dissolves conflicts and other types ofdifferentiation (Barker, 1993; Barner, 2006; Berlin and Carlstrom, 2010). These can takeon certain values and make people act in a different way than expected (Smircich andMorgan, 1982; Smircich, 1983; Wilkins and Ouchi, 1983). The perception that conceptsof organisational cultures are always closely connected to cohesion has therefore beencriticised (Berry et al., 1995). They can even divide homogenous structures andpromote organisational change (Hatch, 1993; Ford and Ford, 1994; Van de Ven andPoole, 1995).

Earlier studies of organisational culture and its impact on the performance ofhealthcare organisations have often investigated culture in management, i.e. thehighest level of the organisation (Davies et al., 2007). The culture of middle and seniormanagement from different hospital clinics and wards has often been generalised tohospital performance (Mannion et al., 2005; Davies et al., 2007). However, according toMichie and Williams (2003), hospital wards develop their own culture and the culturesof different wards can be mirrored in different parts of the hospital.

The overall aim of this study is to identify the impact of the underlying culture of ahealth organisation during a process of change from a disease and medical focus to aperson-centred and patient-focused care.

The purpose is specifically to explore the co-variation between differentorganisational cultures and the employees willingness to participate in changeprocesses. This includes the presumption that certain organisational cultures can,whether they are stable or not, contribute to the development of an organisation.

BackgroundStabilising culturesCultures developed in organisations function as stabilisers in order to resist change(Schein, 1993). Change represents a situation of imbalance and is considered a threat(Appelbaum and Wohl, 2000). This relationship is especially evident in publicorganisations. Public organisations are often state financed monopolies and aretherefore stable and rarely threatened by bankruptcy (Knudsen, 2002). Appelbaum and

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Wohl (2000) maintain that healthcare workers are more skilled at reinforcing the statusquo than they are at implementing something new. The development of cultures inhealthcare settings is often driven by professionals who share similar values and goals(Edmondsson, 2003). Foucault (1969) describes in his analysis of the birth of modernmedicine how health care was organised in accordance with natural scientificprinciples, without considering the complexity of human relations and behaviours. Inline with this, Davies (2002) has shown how subgroups of various medicalsubspecialties dominate cultural values starting during education and training.

Cultures in public healthcare are therefore characterised by collective pathdependency meaning that they represent an accepted, conventional behaviour and astandardisation, which creates a dominant and collectively accepted opinion(Rutherford, 1984). Sweden has one of the worlds oldest comprehensive publichealthcare organisations. Its roots date back to the sixteenth century (Gustafsson,1989) and though it is modern and well-developed it has been identified by slowsequential working methods as an effect of deeply rooted traditions (Axelsson, 2000;Brorstrom and Siverbo, 2004).

Symbolic values are considered to play an important role when it comes tomaintaining traditions. It is well known that cultural values that preserve the values ofconservative traditions can maintain a strong influence over long periods of time.Gagliardi (1990) exemplifies this with a company which, having been owned by thesame family and located in the same geographical location for a long time, can developstrange salient features. The routines become set in stone, the organisation fossilises,unaffected by the external world. Such organisations also tend to demand loyal,uniform behaviour from their employees. Schein (1985) uses the expressionanxiety-avoidance when he describes conservative, cultural forces in organisations.

Collectives in healthcare organisations also tend to preserve their distinctivecharacter. This happens both internally and externally. The internal distinctivecharacter consists of the organisations culture and the external distinctive character ofits image. On the one side, an organisations members interact with each other and, onthe other side, these members externalise their identity outwards (Wenger, 1998).Toseland et al. (1986) believe that healthcare organisations, i.e. hospital wards, oftensignal a stable identity. When a team from a certain ward meets with a patient for onlya short period of time, a confidence-boosting culture can function as a substitute forpersonal acquaintance (Rozakis, 2007). They can consist of behaviour, equipment andclothing that signal reliability (Meyerson et al., 1996; Davison and Sloan, 2003).

The culture is deeply rooted in assumptions that are hard to identify and grasp tothe newcomer (Hatch and Schultz, 2002; Hatch and Cunliffe, 2006). If the organisationsnewer members display well-known artefacts to their more experienced colleagues, itincreases their chances of being accepted. They signal stable values to the world(Alchian, 1977; Weick, 1996; Rozakis, 2007). Specific languages with intern terms andexpressions constitute a culture that symbolises affiliation (Davison and Hyland, 2002).Terms signalling familiarity are repeated by team members and become a part of theculture. Competence and ability are signalled when the right words are used(Czarniawska-Joerges, 1988; Czarniawska-Joerges and Joerges, 1990). Language codescan be uttered in order to establish sorting, evaluating, and caretaking. They alsosignal inclusion or exclusion to the healthcare team (Davison and Hyland, 2002).

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Organisational culture supporting changeSinclair (1991) emphasises that even if no excellent model of managingorganisational change exists, cultures can influence organisations in various and notnecessarily negative ways. A study of the implementation of an electronic medicalrecord system showed that a cooperative culture combined with a consensus-buildingleadership led to effective adoption decisions (Scott et al., 2005). According to Erez andGati (2004) the interplay between different levels of cultures is a dynamic entity inchange processes.

Martin (1992) articulates three different perspectives of organisational culturessupporting change. The first one, the integration perspective corresponds to thetraditional view of culture promoting strong and conservative consensus andmaintaining social structures. The two other types; the differentiation andfragmentation perspectives describe culture as a collection of subcultures ofcontradiction and ambiguity. Such diverse cultures contribute to conflicts and playa central role in change processes (Hatch, 1993). A diversity of organisational cultureshas been registered in public healthcare settings and has been proven to producevarious types of effects. They can, on the one hand contribute to conservatism andorganisational inertia, but on the other hand improve communication, collaborationand coordination of activities (Berlin and Carlstrom, 2008). The ability of culturalartefacts to improve safety has been studied, as well as their central role in promotingchange. Xiao et al. (2001, 2004) describes for example that integrative culturalcomponents have supported rapid and dynamic collaboration in hospital teams.According to Firth-Cozens (2001), a supportive culture in teams is a powerful sourcethat benefits change processes between different professions.

Cultural variables are also involved in organisational development and the creationof new behaviours. They have been shown to be of strategic importance duringchanges (Pfeffer, 1981). For example, within industry, artefacts have been consideredas development tools in production processes. This can be a question of classic design,or equipment details comprising rudimentary vestiges from previous products, andwhich no longer fulfil a practical function (Bertelsen, 2000). Another example ofcultural change is Thornes (2000) description of physicians, whom she calls culturalchameleons. She describes their evolution from medical representatives toadministrators through a multicultural transition phase. Thorne (2000) has shownhow physicians have undergone hybridisation and thereby developed a new identity,which has made its mark on generations of new colleagues (Kurunmaki, 2004). Theyhave been influenced by economists and they have toned down the medicalimperatives that previously characterised the profession (Stone, 1997; Kurunmaki andMiller, 2006).

In a study by Miller and Xiao (2007), culture had a central role in accomplishingresilience during high trauma patient cases. It simplified the workflow and facilitatedthe decision-making process. New technology in the form of printed graphs, wallcharts, request books, and whiteboards supported social interaction among staff.Gauthereau (2004) shows how cultures in hospital wards can develop patient safety. Aculture of flexibility improved the ability to adjust the caretaking processes to localsituations.

The symbolic values, as a consequence, can be both conservative and contributiveto the development.

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Theoretical frameworkThis study is based on the two concepts of organisational culture and resistance tochange. The covariation between these two concepts is measured by questionnairesbased on theories of organisational culture and resistance to change.

Organisational cultureThe concept of organisational culture in this paper rests upon a theoretical model, theCompeting Values Framework (Quinn and Rohrbaugh, 1981, 1983; Scott et al., 2003a).The model is developed on the idea that organisational culture consists of oppositevalues (Quinn, 1988). Quinn and Rohrbaugh (1983) have shown how effectiveorganisations display apparently inconsistent cultures simultaneously. Theframework is based on two dimensions:

(1) internal/external; and

(2) flexibility/control.

Internal refers to the wellbeing and development of the members of an organisation;external refers to the wellbeing and development of the organisation itself. The otherdimension of flexibility control refers to structural polarities that consist ofadaptability, innovation and initiative on the one hand, and management control,command and authority on the other hand. From these two dimensions, an instrumenthas been developed that mapped organisations in four different settings (see Figure 1).They are:

(1) Human Relations (HR);

(2) Open Systems (OS);

(3) Rational Goal (RG); and

(4) Internal Processes (IP).

HR is characterised by flexibility, cohesion, trust and belongingness. OS is an extrovertoutgoing organisational character. It is characterised by benchmarking, experimentsand the ability to run projects independently. RG favours planning, goal setting and

Figure 1.Four different cultural

settings in a framework oftwo dimensions

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economy in order to improve effectiveness and efficiency. It is characterised bycompetitive behaviour with an emphasis on winning. An IP organisation seeksstability and continuity by maintaining control, routines, rules and hierarchies(Cameron and Quinn, 1999). These dimensions are the cornerstones in the instrumentused in this study. The Organisation Values Questionnaire (OVQ) instrument is basedon the concepts of Competing Values Framework (Reino et al., 2007).

Resistance to changePiderit (2000) argues that the individuals resistance to change is a multidimensionalconcept comprising affective, cognitive and behavioural domains. Oreg (2003) hasidentified the following four sources of resistance to change:

(1) routine seeking (RS);

(2) emotional reaction to imposed change (ER);

(3) short-term focus (SF); and

(4) cognitive rigidity (CR).

These dimensions are based on seven studies and represent a four-facet structure ofresistance to change (Oreg, 2003). RS corresponds to a reluctance to give up old habits.Organisational members prefer to act within a well-defined and familiar framework. Inthe ER dimension, change is a stressor. Individuals with a high ER score suffer from alack of resilience and are reluctant to participate in change processes. The SF focusidentifies an individuals ability to adjust to new situations. A high score can indicate aresistance to change because it involves more work in the short-term. CR correspondsto dogmatism. Dogmatic individuals resist change because of rigidity and a closedmindset. Oreg (2003) underpins that the dimensions can be used to select and involveparts of an organisation with the necessary qualifications of contribution to theimplementation of a new model.

MethodSurveys were sent out during the autumn of 2009 to 170 nurses at five hospital wardswithin one clinic in a hospital in Western Sweden. A key inclusion criterion was thatstaff had experienced extensive change.

The context of the surveyThe aim of the particular project was to investigate if the implementation of aperson-centred care (PCC) model could enhance the effectiveness and efficiency of thecare. The hospital wards included had all been subject to a research projectimplementing PCC for patients with chronic heart failure. The staff went fromstandardised care based on diagnose specific flowcharts and a sequential distributionof work to care based with individually shaped care plans and daily team decisions.

The health care system in Sweden has increased the patient turnover and decreasedthe amount of hospital beds. To accomplish this standard operating proceedings havedeveloped to be an essential part of the health industry. The diagnosis has become thepoint of departure for standardising treatment, performance and length of stay. Theunique situation of the patient including aspects of family, a patients home, a socialnetwork and potential collaboration during the care process are, however, often

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neglected (Wolf et al., 2008). This has been proven to make the patient passive andinstitutionalised. They tend to be pressed for time, under-informed and disregarded(Anthony and Hudson-Barr, 2008).

To break this pattern, the PCC model includes a new type of introduction duringregistration, a realistic plan based on the patients resources and an agreement ofcollaboration between the patient and the staff. The staff and the patient pledge tofollow an individualised plan. This embraces far-reaching changes of working routinesthat influence all of the health workers daily routines since it reinforces the central roleof the patient as a person in the clinical encounter (Coleman et al., 2004). Thisnecessitates a change from standard practice values to a commitment topatient-centred care (Davies, 2002).

Features of PCC take its care beyond a somatic disorder model into abiopsychosocial one. The biopsychosocial model recognises that biological,psychological, and sociocultural factors all interact and bear on the pathogenesisand course of most disorders (Engel, 1977; Mead, 2000). The model has proven toreduce the average length of stay (Olsson et al., 2006, 2007). It has also been proven toreduce the frequency of discharge to long-term care, rehospitalisation (Coleman et al.,2004), increase patient-satisfaction and quality of care (Wolf et al., 2008).

ProceduresThe survey included registered and assistant nurses. Supervisors, physicians andpersonnel connected to more than one hospital ward or other parts of the hospital wereexcluded from the survey. Informed consent was obtained from the head of the clinicbefore the study started and each nurse was given written information and couldchoose whether or not they would participate in the survey.

The nurse managers of the wards were contacted and informed about the study andin addition to this letters explaining the aim of the study together with aself-administered questionnaire collecting descriptive data were sent out. Responseenvelopes labelled with a code for each ward were included in the letters. The answeredquestionnaires were sent anonymously back to one of the authors. One reminder notewas sent out after three weeks.

Since there was no Swedish version of the OVQ instrument, it was translated andback-translated according to recommended scientific procedures (Polit and Beck, 2008).The OVQ scale was translated into Swedish by a native Estonian-speakingprofessional translator. This version was scrutinised by a team of three seniorlecturers. Minor adjustments where then made to the first Swedish draft. Anothernative Estonian-speaking professional translator back-translated the Swedish draft.The questionnaire was then sent to Anne Reino, the originator of the instrument (Reinoet al., 2007). Her comments on the questionnaire were considered by the team and a fewmore adjustments were made. After that a semantic interpretation was performed by aprofessional linguist and a few more minor adjustments were made.

To assure the conceptual equivalence of the translated questionnaire, the surveywas validated through two pilot studies. First, a committee reviewed the conceptualand measurement issues of the survey qualitatively. After that, eight experiencednurses tested the questions. This led to a small adjustment to clarify some of thequestion structuring (Trost, 2001).

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The homogeneity of the items of the subscales was analysed through a calculationof Cronbachs a. The results varied between 0.67 and 0.84, which, according to Braceet al. (2006), is considered to be satisfactory. The surveys were numbered and variableswere defined in the computer program Statistical Package for the Social Sciences 17.0(SPSS). Statistical significance was established at p , 0:05 and all tests weretwo-tailed (Altman, 1991). The analysis stems primarily from descriptive data andregressions (bivariate and multiple). Means and standard deviations were used fordescriptive purposes.

The surveyThe survey included the two instruments i.e. the Organisational ValuesQuestionnaire (OVQ) developed by Reino (Reino et al., 2007) and the Resistance toChange Scale (RTC) developed by Oreg (2003). The two instruments used differentLikert-type scaling. They were converted to a common six-point scale by lineartransformation (Daves, 2008). OVQ was based on the Competing Values Framework(CVF) measuring the four dimensions of HR, OS, RG and IP. It contained 52 itemsprimarily with alternative answers of the Likert type ranging from strongly disagree tostrongly agree. The dispositional Resistance to Change Scale (RTC) (Oreg, 2003) wasused to assess the nurses reactions to change. The 17 items of the RTC scale aredivided into the following four dimensions; RS, ER, SF and CD. Each item wasanswered on a Likert scale ranging from strongly disagree to strongly agree. Averageswere calculated for the total OVQ and RTC scale and for each subscale; a high scoreindicates strong agreement.

ResultsParticipantsA total of 117 nurses (69 per cent), 105 (89 per cent) women and 12 (11 per cent) men,agreed to participate by answering the questionnaire. The response rate was 69 percent. Their ages ranged from 23 to 63 years (M 38:9, SD 9:9). Seventy-two (59 percent) of the participants were registered nurses and 45 (36 per cent) were assistantnurses. As many as 34 nurses answered the questionnaire in ward number five; ofthese, 56 per cent were assistant nurses (AN). In ward number two, 26 nursesparticipated (54 per cent AN) and in ward number four 23 nurses (65 per cent AN)answered the questionnaire. In ward number three only 18 nurses participated (44 percent AN), and in ward number one as few as 16 nurses (63 per cent AN) participated.The nurses professional experience had a range of 37.5 years from 0.5 to 38 years inservice (M 11:5, SD 10:2). The nurses hours of duty were from 20 to 40 hours perweek (M 35:2, SD 14:1) and their average number of years working on the samehospital ward was 6.6 with a range of 29.5 years (SD 7:7).

Fifty-three nurses (31 per cent) did not respond and two of them returned theenvelope unanswered without explanation. A total of 15 items were not answered inthe 117 returned questionnaires.

Resistance to changeThe nurses mean resistance to change, reported on the six-point RTC scale, was as lowas 2.72 (SD 1:14). The mean for the four RTC subscales ranged from 2.49 to 3.27. Thenurses strongly disagreed with Short-term focus (SF) (M 1:99, SD 0:98). This

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result reveals that the group of nurses was ready to endure a period of learning andchange to adjust to the new situation implementing PCC. The Emotional reaction (ER),i.e. stress during a change process as an effect of lack of resilience, was slightly higher(M 2:49, SD 1:4) than the SF. This subscale is based on the presumption that lessresilient individuals are reluctant to make changes. These two subscales were closelyfollowed by RS and CR (Table I).

Organisational cultureThe dimension of Human relations (HR) dominated the hospital wards (M 4:28,SD 0:69) and was closely followed by Rational Goal (RG) (M 3:82, SD 0:59),Open Systems (OS) (M 3:58, SD 0.70) and Internal Processes (M 3:57,SD 0:49). This reveals that cultures of flexibility, cohesion, trust andbelongingness were dominant among the health workers. There was however aslight difference between the wards. Two of them (ward 4 and 5) were stronglydominated by HR and one of the wards (ward 1) was slightly dominated by RG,i.e. planning, goalsetting, focus on economy and efficiency. The rest of the wards hadan almost equal mix of the four different cultures (Table II).

Bivariate and multiple regressionsThe effect of HR, OS, RG and IP cultures on change resistance behaviours was tested ina number of bivariate and multiple regressions. Either OS, RG or IP were howeversignificantly correlated to RTC, and HR was not significantly correlated to the RTCdimensions of short-term focus (SF) and cognitive rigidity (CR). The onlysignificant correlation was between the OVQ dimension of HR and the RTCdimensions of routine seeking (RS) and emotional reaction (ER).

The HR view that social competence was important contributed to a decreased RS(R 20:28, R 2 0:08). The same was true for tolerance to make mistakes(R 20:20, R 2 0:04). An open-minded, informal culture (R 20:20, R 2 0:04)combined with flat non-hierarchical structures (R 20:18, R 2 0:04) contributed toa low RS as well. The ability to take part in joint events (R 20:17,R 2 0:03) and to

RTC subscale Ward 1 Ward 2 Ward 3 Ward 4 Ward 5 All

Routine seeking 2.69 2.60 3.41 3.56 3.38 3.13Emotional reaction 2.53 2.16 3.05 2.22 2.51 2.49Short-term focus 2.01 1.59 2.36 2.11 1.91 1.99Cognitive rigidity 3.30 3.18 3.2 3.47 3.21 3.27All 2.63 2.38 3.0 2.84 2.75

Table I.Mean values for the 117

nurses answering theRTC scale, divided intosubscales and hospital

wards (n 117)

OVQ subscale Ward 1 Ward 2 Ward 3 Ward 4 Ward 5 All

Human relations 4.11 3.87 4.05 4.86 4.50 4.28Open systems 3.01 3.21 3.75 4.33 3.64 3.58Rational goal 4.18 3.65 3.67 3.97 3.69 3.82Internal process 3.92 3.37 3.65 3.52 3.39 3.57All 3.81 3.53 3.78 4.17 3.81

Table II.Mean values for the

nurses answering theOVQ scale, divided in

subscales and hospitalwards (n 117)

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be helpful to each other (R 20:15,R 2 0:03), however, showed a somewhat weakerimpact on RS (Table III). The only covariation of significance between HR and ER was inthe HR-item there is a tolerance to mistakes (R 20:22, R 2 0:05).

In a multiple regression it was seen that statistically significant HR factors togetherexplained 21 per cent (R 2 0:21) of the decreased routine seeking behaviour. It meantthat 79 per cent was still accounted for. One variable was still significant socialcompetence is important. The remaining variables displayed low t-values and werelacking significance on their own. The reason could be that they covariate or that theywere present as an earlier link in connection to the cause. The result indicates that anHR culture, i.e. a hospital ward with a dominating focus on social competence,decreases routine seeking behaviour, i.e. tendencies to uphold stable routines, theidea that change is not good and appreciation of the same old things (Table IV).The results indicate that a culture of flexibility, cohesion and trust negatively covariate

Independent variables (HR items) Pearsons R R 2 F-value t-value Sign.

1. We are helpful to one another 20.15 0.03 2.94 8.62 0.052. It is a flat, non-hierarchical structure here 20.18 0.04 3.78 15.60 0.033. We are proud of belonging to this ward 20.04 0.01 0.19 8.68 0.664. Internal co-operation is important 20.04 0.02 0.19 8.21 0.655. Different duties are no strictly divided 20.11 0.01 1.44 11.07 0.236. There is a tolerance to mistakes 20.20 0.04 4.33 11.72 0.047. We gladly take part in joint events 20.17 0.03 3.42 9.22 0.058. We see each other after working hours 20.18 0.00 0.03 9.26 0.849. The management trusts us 20.14 0.02 2.25 10.11 0.09

10. We are like one big family 20.06 0.00 0.43 13.53 0.5011. We often talk about our private issues 20.19 0.04 4.15 10.04 0.0412. Social competence is important here 20.28 0.08 9.40 10.74 0.0013. Working here induces confidence 20.25 0.01 0.07 9.76 0.78

Notes: Dependent variable: routine seeking; n 117

Table III.Bivariate regression ofitems of the HRdimension and the RTCscale (sign p , 0:05)

Independent variables

Bivariateregression

standardised b

Multipleregression

standardised b Difference t-value Sign.

1. We are helpful to each other 0.15 0.00 0.15 0.36 0.422. It is a flat, non-hierarchical

structure here 0.18 0.15 0.03 1.52 0.136. There is a tolerance to

mistakes 0.20 0.09 0.11 0.89 0.377. We gladly take part in joint

events 0.17 0.05 0.12 0.52 0.6011. We often talk about our

private issues 0.28 0.08 0.20 0.52 0.4712. Social competence is

important here 0.25 0.18 0.15 1.98 0.05

Notes: Dependent variable: routine seeking; n 117; R 2 0.35, R-square 0.21

Table IV.Multiple regression ofitems of the HRdimension and the RTCscale (sign p , 0:05)

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with the overall need for a stable and well-defined framework. A human-relation typeof culture improves the ability to cope with change.

DiscussionOrganisational theorists have emphasised the importance of being aware of the culturein an organisation in order to obtain success in change processes (Peters andWaterman, 1982; Wilkins and Ouchi, 1983; Denison, 1996; Hemmelgarn et al., 2006).

In this study, culture was measured in the staff of five hospital wards within oneclinic in a hospital. The study reveals that a culture of HR decreases change resistantroutine seeking behaviours. The results also showed that flat hierarchal structures andsocial competence contributed to a decreasing tendency to resist change to the care ofPCC. This supports the idea that change is induced by cooperative and supportivecultures (Firth-Cozens, 2001; Scott et al., 2005). HR stands out in contrast to the otherthree types of organisational culture, OS, RG and IP, as the only one that reached alevel of significance.

Even if the development of cultures is driven by professionals who share similarvalues and goals (Edmondsson, 2003), hospital wards do develop their own culture(Michie and Williams, 2003). Wards characterised by a rational goal culture withcompetitive behaviour can, according to Dutton et al. (1997) induce rivalry. This pointsto the fact that change processes need broad collaboration and an awareness ofcommon values and ideologies (Tedeshi, 1981; Schneider, 1981; Schlenker andWeigold, 1992).

HR stands out as the most important culture in order to facilitate an organisationfrom inertia and path-dependent routines to the acceptance of new standards. This isespecially evident when the HR culture consists of a high tolerance to mistakes and flathierarchical structures. The opposite, i.e. a low tolerance and steep hierarchies, caninduce fear in the collective, which restrains change processes and hinders thedissemination of innovations in healthcare (Berwick, 2003).

A greater insight of organisational culture as an important factor on changeprocesses will influence the selection of hospital wards into change projects becausethe underlying culture of an organisation is considered to have considerable impact(Fischer et al., 2005). An instrument that pinpoints the conditions of a particularhealthcare setting can improve the results of a change project. Furthermore, managerswho are aware of the organisational culture in their wards can use instruments such asthe ones used in this study to investigate and plan for change processes.

A HR culture stands out in contrast to the other three types of organisationalculture, and the different wards showed a surprisingly low resistance to change.Results from the present study therefore indicate that, even in an old public health carebased on long traditions and characterised of standardised care models carrypossibilities for changes towards an individualised humanistic care where the patient,as an individual, is at the centre and not the pathological processes or the disease itself.

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Further reading

Firth-Cozens, J. (2001), Cultures for improving patient safety through learning: the role ofteamwork, Quality in Health Care, Vol. 10 No. 2, pp. 26-31.

About the authorsEric D. Carlstrom is Associate Professor in Public Administration at the Sahlgrenska Academy,Institute of Health and Care Sciences. His previous research has been focused on integration,teamwork and collaboration in health and medical care services. Eric D. Carlstrom is thecorresponding author and can be contacted at: eric.carlstrom@hv.se

Inger Ekman is a Professor at the Sahlgrenska Academy, Institute of Health and CareSciences. Her previous research has been dealing with evaluation of changes in care systems.

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