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chapter 5 | Organizations, Power, and Empowerment 59 CikguOnline
organizations. These organizations can be classi- Organizational Culture
fied into three types on the basis of their sponsor-
People seek stability, consistency, and meaning in
ship and financing:
their work. To achieve this, some type of culture
1. Private not-for-profit. Many health-care will develop within an organization (Schein, 2004).
organizations were founded by civic, charitable, An organizational culture is an enduring set of
or religious groups. Some have been in exis- shared values, beliefs, and assumptions (Cameron
tence for generations. Many hospitals, long- & Quinn, 2006). It is taught (often indirectly or
term care facilities, home-care services, and unconsciously) to new employees as the “right way”
community agencies began this way. Although or “our way” to assess patient needs, provide care,
they need money to pay their staff and expenses, and relate to fellow caregivers. As with the cultures
they do not have to generate a profit. of societies and communities, it is easy to observe
2. Publicly supported. Government-operated the superficial aspects of an organization’s culture,
service organizations range from county public but much of it remains hidden from the casual
health departments to complex medical centers, observer. Edgar Schein, a well-known scholar of
such as those operated by the Veterans organizational culture, divided the various aspects
Administration, a federal agency. of organizational culture into three levels:
3. Private for-profit. Increasing numbers of health- 1. Artifact level: visible characteristics such as
care organizations are operated for profit like patient room layout, patient record forms, etc.
any other business. These include large hospital 2. Espoused beliefs: stated, often written, goals;
and nursing home chains, health maintenance philosophy of the organization
organizations, and many freestanding centers 3. Underlying assumptions: unconscious but
that provide special services, such as surgical powerful beliefs and feelings, such as a commit-
and diagnostic centers. ment to cure every patient, no matter the cost
(Schein, 2004)
The differences between these categories have
become blurred for several reasons: Organizational cultures differ a great deal. Some are
very traditional, preserving their customary ways of
■ All compete for patients, especially for patients doing things even when these processes no longer
with health-care insurance or the ability to pay work well. Others, in an attempt to be progressive,
their own health-care bills. chase the newest management fad or buy the latest
■ All experience the effects of cost constraints. high-technology equipment.Some are warm,friendly,
■ All may provide services that are eligible for and open to new people and new ideas. Others are
government reimbursement, particularly cold, defensive, and indifferent or even hostile to the
Medicaid and Medicare funding, if they meet outside world (Tappen, 2001). These very different
government standards. organizational cultures have a powerful effect on the
employees and the people served by the organization.
Organizational Characteristics Organizational culture shapes people’s behavior,
The size and complexity of many health-care organ- especially their responses to each other, which is a
izations make them difficult to understand. One way particularly important factor in health care.
to begin is to find a metaphor or image that describes Culture of Safety
their characteristics. Morgan (1997) suggested using
animals or other familiar images to describe an organ- The way in which a health-care organization’s oper-
ization. For example, an aggressive organization that ation affects patient safety has been a subject of much
crushes its competitors is like a bull elephant, where- discussion. The shared values, attitudes, and behav-
as a timid organization in danger of being crushed by iors that are directed to preventing or minimizing
that bull elephant is like a mouse. Using images, an patient harm have been called the culture of safety
organization adrift without a clear idea of its future in (Vogus & Sutcliffe, 2007).The following are impor-
a time of crisis could be described as a rudderless boat tant aspects of an organization’s culture of safety:
on a stormy sea, whereas an organization with its ■ Willingness to acknowledge mistakes
sights set clearly on exterminating its competition ■ Vigilance in detecting and eliminating error-
could be described as a guided missile. prone situations