Identifying the Components of Organizational Culture in Hospital Environments: A Qualitative Study

Saffari, Masoud; Roshanian, Elham; Karimizadeh, Mohadeseh; Rajabipoor, Alireza; Bahariniya, Sajjad

doi:10.18502/jchr.v13i18.16391

Volume 13, Issue 1 (1-2024) JCHR 2024, 13(1): 158-171 | Back to browse issues page

‎ 10.18502/jchr.v13i18.16391

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Saffari M, Roshanian E, Karimizadeh M, Rajabipoor A, Bahariniya S. Identifying the Components of Organizational Culture in Hospital Environments: A Qualitative Study. JCHR 2024; 13 (1) :158-171
URL: http://jhr.ssu.ac.ir/article-1-1034-en.html

Identifying the Components of Organizational Culture in Hospital Environments: A Qualitative Study

Masoud Saffari¹

, Elham Roshanian²

, Mohadeseh Karimizadeh¹

, Alireza Rajabipoor¹

, Sajjad Bahariniya ^*

1- 1. Management of organization development and administrative transformation, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
2- 2. Department of Business Administration, Faculty of Economics, Management and Accounting, Yazd University, Yazd, Iran
3- 3. Department of Healthcare Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran , sajjadbahari98@gmail.com

Keywords: Organizational culture, hospital, nurses, employee performance and productivity

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Identifying the Components of Organizational Culture in Hospital Environments: A Qualitative Study

Masoud Saffari ¹ , Alireza Rajabipoor ² ,Elham Roshanian ¹ , Mohadeseh Karimizadeh ¹ ,

Sajjad Bahariniya ³*

Management of organization development and administrative transformation, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
Department of Business Administration, Faculty of Economics, Management and Accounting, Yazd University, Yazd, Iran
Department of Healthcare Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran

ARTICLE INFO		ABSTRACT
*Original Article* Received: 11 Nov 2023 Accepted: 26 Mar 2024		Background: Weak organizational culture is one of the main factors of inefficiency in hospitals. Identifying the type of organizational culture of hospitals is an important step in increasing productivity. Therefore, this study was conducted with the aim of identifying the components of organizational culture. Methods: This qualitative study was conducted in Shahid Sadoughi Hospital in Yazd in 1400. The statistical population included the nurses of Shahid Sadoughi Hospital in Yazd. The sampling method used in this study was purposive and snowball sampling. To collect data, semi-structured interviews were used. The content analysis method was used to analyze the texts using MAXQDA version 10 software. Results: In this study, 13 experts were interviewed. The results of the data analysis showed that the 11 main components of organizational culture at Yazd University of Medical Sciences are rational, ideological, agreement and participation, hierarchical, constructive, passive, work and open culture, club, stronghold, flexible, Learner, and value orientation. Conclusion: The identified components of organizational culture can help healthcare managers and policymakers to improve service quality, job satisfaction, and organizational commitment of employees, improve organizational performance, and increase patient satisfaction. Keywords: Organizational culture, hospital, nurses, employee performance and productivity


Corresponding Author: Sajjad Bahariniya sajjadbahari98@gmail.com

How to cite this paper:
Safari M, Roshanian E, Karimizadeh M, Rajabipoor A, Bahariniya S. Identifying the Components of Organizational Culture in Hospital Environments: A Qualitative Study. J Community Health Research 2024; 13(1): 158-171.

Introduction

Today, culture has found its place in the growing body of studies conducted in higher education; it has, however, been associated with ambiguities and difficulties (1). The importance of culture in benefiting from people's capacities in the organization is undeniable (2). Organizational culture can put people in motion and has a great impact on various sectors in an organization (3). The impact of organizational culture on employees of an organization is such that by examining its angles, the behavior, feelings, views, and attitudes of its members can be understood and their possible reactions to various developments can be predicted (4,5). According to Thomaidou et al. (2021), organizational culture creates compatibility outside and harmony inside the organization and acts as a social controller to strengthen specific behaviors and dominant values (6).
Hospitals have a different culture from other organizations due to their mission, commitments, matrix structure, and technology, and this culture affects all the aspects of a hospital (7). The organizational culture of the hospital expresses the common ways of thinking, feeling, and behavior of the employees in the hospital. A hospital consists of many departments and units; and clinical, administrative, and support staff work together and in a coordinated manner to provide the health services needed by patients. Therefore, in addition to a dominant organizational culture, there are many subcultures in the hospital, each of which has its unique characteristics (8). Adherence of managers and employees to negative cultural values such as utilitarianism, indolence, not prioritizing the patient, and accepting poor quality standards, ultimately leads to a big scandal for the hospital (9). Organizational culture plays a key role in the success or failure of an organization. About 50 to 55 percent of success in organizational hospital programs depends on the organizational culture (9). An optimal organizational culture improves the quality of working life, job satisfaction and organizational commitment of employees, the quality and safety of hospital services, the performance of the organization, and patient satisfaction (10-12). Weak organizational culture is one of the main factors regarding the inefficiency of healthcare organizations, especially hospitals (13).
In the healthcare sector, organizational culture plays an essential role in the quality of services in areas such as support, nursing, and systematic improvement of administrative processes; therefore, it is necessary to investigate such culture (14). In other words, in centers with a more efficient organizational culture, it is expected that people use up-to-date and useful techniques to satisfy and improve the provision of services to patients and give high priority to their health (15). According to the approach adopted in this study, nurses have been considered as the study population. Such methodology will apply to all the components of the current healthcare system. Nevertheless, as independent workers, nurses need to act independently and use their power. Power and professionalism are interrelated and when nurses have power, they can control their actions (16, 17).
Similar studies have been conducted regarding the state of organizational culture in hospital environments. Mossadegh Rad et al. (2023) conducted a study to investigate the organizational culture of the hospitals affiliated with the Tehran University of Medical Sciences. The results of this study showed that managers should improve the organizational culture of hospitals by strengthening the internal cohesion dimension of the organizational culture and the components of teamwork and responsibility. Furthermore, measures should be planned and implemented to strengthen the values and beliefs regarding the organizational culture (18). In another study, Rihani et al. (2017) examined the relationship between organizational culture and manpower productivity in hospitals affiliated with Mashhad University of Medical Sciences. In this research, based on multiple regression, a significant relationship was observed between organizational culture and productivity manifestations; in general, the higher the level of organizational culture is, the more examples of productivity can be observed in the organization. Considering the fact that culture can increase productivity, hospital managers can play an effective role in increasing the productivity of human resources by emphasizing the organizational culture through existing solutions such as training and culture-building. (19) In another research, Bahmani et al. (2016) studied the relationship between organizational culture and knowledge management in teaching and non-teaching hospitals in Hamedan. In this study, the nurses' score for organizational culture was 5.2, and their knowledge management score was 16.3, which was satisfactory. A positive and significant relationship was seen between organizational culture and knowledge management, and all the components of organizational culture had a positive and significant correlation with knowledge management. By improving the organizational culture and its components, the level of knowledge management and quality of medical services will increase as well. In the process of establishing knowledge management in medical centers, the structural and cultural dimensions of the organization should be taken into account, especially the development of individual creativity, leadership style, and cohesion and integration (20). Therefore, it is of paramount importance to pay attention to organizational culture in all areas.
Identifying the type of organizational culture in hospitals is the first step towards engineering organizational culture in order to increase their productivity. Therefore, this study was carried out with the aim of identifying the components of organizational culture, which addressed the question ‘What components affect the organizational culture of Shahid Sadoughi University of Medical Sciences and Health Services, in Yazd?’
Methods
Type of research: This study was conducted with a qualitative method and a directed content analysis approach to identify the components of organizational culture in Shahid Sadouqi Hospital of Yazd in 2021.
Statistical population: The statistical population included nurses from Shahid Sadoughi Hospital in Yazd whose experiences regarding the components of organizational culture in hospital environments were extracted.
Research sample: Due to the necessity of gathering collective views of key people regarding the subject of research, a purposive sampling method was used. The samples examined in this sampling method were purposively and non-randomly selected (21). The snowball sampling method was also used as a supplementary method. Accordingly, the sampling continued until data were saturated with 13 interviewees.
Data collection tool: Qualitative data were collected using the interview method. Therefore, an interview form including guide headings was used as a data collection tool. The prepared guide was used as a test in two interviews; the results were discussed with professors, and where necessary, the interview guide was modified.
The criteria for entering and exiting the study: The most important criterion for entering the qualitative part of the current study was having sufficient knowledge and experience regarding the selected people. Moreover, working in the field of health and treatment, having at least a master's degree and 5 years of management experience, willingness to participate in the study, and giving informed consent were other criteria for entering the study. These people had the necessary knowledge, awareness, and experience.
Data collection method: According to the purpose of the research, which was to obtain the opinions of key people related to the research topic, a semi-structured interview was used. In the present study, two in-depth interviews were conducted first to develop an interview guide, and then, two other interviews were conducted as a pilot to ensure that all the information related to the research topic was obtained using these interviews.

Before conducting the interview: Make arrangements with the interviewees, explain the objectives, set the interview schedule, and finally, prepare the interview schedule. One of the important points in this section was the time and place of the interview. It was tried to conduct the interviews in an informal atmosphere, without prejudice and direction and giving comments.
During the interview: Before the interview, the consent of the respondents to participate in the research was obtained while restating the objectives of the research. To avoid possible problems, the interview sessions were recorded through an electronic device. At the same time, the important statements of the interviewees were also noted down by the interviewer.
After the interview: immediately on the same day, the written content as well as the important key topics extracted from each interview were summarized in a special form. In this form, in addition to the basic characteristics of the interviewee, the executive position of the interviewee, the date and time of the interview, and other necessary information were also included. At the end of the interview, the interviewee was asked for any possible questions in the future; in cases where there was ambiguity after rewriting the interview text, the interviewee was contacted again, and new data were added to the interview text.

Data analysis method: In this study, the content analysis method was used to analyze the texts via MAXQDA version 10 software. Descriptive thematic analysis was used to identify important and coherent themes about the components of organizational culture. Overall, an inductive approach was used in this study, that is, findings were generated from data rather than imposing predetermined structures for analysis.
To determine the validity and reliability of the study, Lincoln and Guba's criteria were used, and in this context, and concerning credibility, parts of the interviews and coding were provided to the participants to achieve the same concepts in the contexts of the conversation. (22). To ensure verifiability, the researchers tried to compare what was collected with the intended content of the participants neutrally and categorize similar codes by regularly collecting data, recording, and writing the steps and process of the research accurately. To confirm the reliability, taking notes and implementing the interviews were done as soon as possible, and at the end, for transferability, direct quotes and examples were provided. The analysis method was performed and addressed briefly in the following steps. Before starting the process of transferring and organizing the data, the researcher in charge became familiar with the range and diversity of data and formed a general view of the things he obtained from the interviews. Familiarity, in the real sense of the word, means immersion in data, which was achieved through listening to tapes and reading manuscripts and notes.
Results
The process of qualitative data analysis begins when the researcher identifies meaningful statements and expressions related to the subject. This analysis began with a frequent review of the data and was coded after identifying the meaningful propositions related to the research topic.
The practical process of conducting data analysis included four stages: preparation, familiarization, coding, and obtaining the main theme (23, 24).
Data preparation: In this part, the data obtained from the interview was written down. After that, each interview was given an interview code.
Reviewing the interviews: At this stage, the interviews were read repeatedly and relevant and interesting materials were identified, which was actually the answer to the main research question. Due to the large amount of data, all the contents have not been presented.
Labeling and coding: In this step, the data identified in the previous step, were labeled. In fact, labeling was done to reduce the amount of data and simplify them. In the current research, coding was done through n vivo software, and the researcher used three items to code the data. After transcribing the interviews with Word software, the codes of each interview were specified. So, a code containing three items was assigned to each of these specified statements.
Consider the following example
Teamwork was the most important principle in this organization (9F20). This code was divided into three items. The first number from the left indicated the code number in this interview; in this example, it was the 20th code in the interview. The English letter placed between the two numbers indicated the interviewees. The last number on the right also showed the interview number; number (9) in the example above suggested that this code was related to the ninth interview.

Table 1. Quotations from the interviewees

Some quotations from the interviewees	Interviewees
Many of the problems we have in the system pertain to the organizational culture. Today, the relation between organizational culture and an organization is compared with the relation between personality and an individual; this shows the nature of organizational personality. There is confusion in organizations in this regard because we do not have an organizational culture to rely on, the one that people are obligated to observe.	Interviewee 2
Basically, process-centered, criterion-centered, and rule-centered approaches create limitations for a manager. The manager does not like to be limited. Some cultures are in such a way that they cannot work without rules because their minds are used to order.	Interviewee 5
The level of employees' resistance to changes in organizational culture is related to the level of their connection with the organization's management. If these two get synchronized, the employees feel the changes that the manager feels and go along with him/her.	Interviewee 5
The degree of resistance of the organizational culture to changes is not considered resistance as long as these changes are not to the detriment of patients and employees. But if it ends up harming our patient or colleague, the resistance will increase.	Interviewee 8
Since our department has relatively young personnel, they are more motivated to work. On the other hand, both in terms of training and culture, the personnel are very happy and active. Maybe, we can say that work does not make them tired because a nurse with sufficient knowledge knows that a patient's recovery is the result of his/her efforts. They also have cultural cooperation, and if God forbids, something bad to happen, they will cooperate with the department.	Interviewee 9
In my opinion, we feel the lack of several organizational cultures, and we are seriously seeking to build them. One of them is teamwork which is weak here and we need to work on it. Teamwork is one of the requirements of the culture of organizational belonging. Cultural work requires teamwork, that is, instead of focusing on the chief and two or three other people in the hospital, there should be a management team consisting of 10 to 15 people who are well-connected, have a comprehensive view, and are aware of towards the communication issues, programs, and conditions of the hospital.	Interviewee 10

Based on the findings of the present study in Table 2, primary sub-themes were extracted. In this table, the components of organizational culture were identified. Sub-themes refer to the indicators of organizational culture. The mentioned sub-themes were the background whose completion in the next stage was an attempt to answer the main question of the research (Table 2).

Table 2. Primary sub-themes

Frequency	Interview code	Sub-theme	Row
3	11F₄, 15F₅, 25F₆	Conscious performance	1
2	18F₇, 6F₁₄	The necessity of clarifying a standard performance	2
3	20F₄, 5F₅, 16F₈	Preference for spiritual reward over material one	3
4	15F₁₀, 11F₁₀	The relationship between spiritual reward and motivation to work	4
3	12F₁, 27F₆, 19F₇, 12F₈	The relationship between performance and financial support	5
3	5F₉, 9F₈, 9F₁₀	Better performance of women	6
2	20F₄, 18F₁₄	Procedural justice	7
2	16F₄, 8F₇	Organizational justice	8
3	12F₁₄, 6F₁₉, 1S₂₆	Religious beliefs	9
4	17F₁₀, 10F₁₁, 7F₁₂, 4F₁₄	Beliefs	10
2	7F₆, 15F₁₂	Material rewards	11
7	16F₄, 19F₅, 8F₆, 18F₇, 6F₁₃, 8F₉, 5F₁₂	Intersectoral cooperation	12
2	₉F _15,3F₃	The direct relationship between work experience and management	13
6	18F₂, 8F₄, 17F₆, 5F₉, 9F₈, 9F₁₀	Being adapted to the system	14
6	8F₁, 7F₄, 10F₇, 11F₉, 10F₁₀, 1F₁₂	Non-toxic relationships in the organization	15
5	1F₁, 11F₅, 3F₉, 8F₁₀, 16F₁₃	Emphasis on enforcing the rules	16
3	12F_6,19F₁₂, 18F₁₄	Clarity of the rules	17
2	18F₁, 14F₄	Direct supervision of the supervisor	18
10	29F₁, 7F₂, 17F₃, 20F₄, 5F₅, 16F, 16F₉, 18F_10,4F_12, 17F₁₄	Sympathy	19
9	14F₁, 6F₃, 6F₄, 18F₅,6F₇, 16F₁₀, 16F₁₁, 3F₁₃ , 20F₉	Appreciating teamwork	20
2	2F₅, 6F₇	Having patience against changes	21
2	30F₆, 11F₁	Influence of work environment on job satisfaction	22
4	2F₅, 14F₁₀, 26F₆, 13F₇	Self-control	23
3	4F₂, 26F4, 15F₉	Social behavior	24
5	14F₂, 1F₃, 29F₄, 4F_5,31F₆	Accountability	25
4	27F₄, 3F₆,6F₁₁, 7F₁₄	Lack of cooperation by management	26
2	16F₆, 5F₁₁	Lack of cooperation between employees	27
3	13F₂, 21F₄, 16F₅	Embracing new ideas	28
5	7F₁, 9F₅, 6F₈, 12F_9,4F₁₁	Medical staff’s lack of job satisfaction	29
8	22F₁, 2F₄, 6F₆, 9F₇, 4F₉, 3F₁₀, 2F₁₁, 12F₁₃	Embracing change by staff	30
3	18F₄, 29F₆, 11F₁₁	The staff’s distrust due to job insecurity	31
1	12F₃	Lack of disciplinary protocols for doctors	32
11	20F₁, 9F₂, 9F₃, 10F₄, 6F₅, 9F_6,9F₁₀, 6F₁₂, 9F₉, 6F₁₁, 14F₁₃	Adapting to work environment	33
4	16F₁, 25F₄, 16F₇, 15F₁₁	Cultural differences due to different education levels	34
2	11F₃, 2F₆	Doctors’ non-compliance with legal rules due to having connections	35
2	9F_1,6F₆	Ignoring useful suggestions	36
2	14F_8,12F₇	Lack of organizational support	37
3	2F₁, 22F₄, 20F₁₃	Increasing motivation by providing rewards	3
2	13F₁, 22F₃	The staff’s level of loyalty to the organization	39
1	13F₈	Experienced employees support inexperienced ones through their good reputation	40
2	25F₃, 21F₁₂	Work commitment	41
4	25F₁, 12F_6,11F₁₂, 18F₁₃	relationship between organizational climate and the frequency of the staff’s transfer	42
2	8F_5,12F₇	Emphasis on multi-faceted learning	43
2	12F₁₀, 5F₁₄	The management’s support of the staff	44
5	19F₃, 17F₄, 18F_6,17F₇, 11F₈	Organizational coordination	45
1	21F₄	Attitude	46
4	6F₁, 16F₂, 5F₇, 7F₁₀	Increasing motivation	47
2	17F₉, 8F₈	Mutual respect between the staff and management	48
10	12F₁, 13F₃, 24F₄, 14F₅, 28F_6,15F₇, 9F₁₂, 12F₁₁, 15F₁₀, 4F₈	Resistance to change	49
6	23F₁, 5F₂, 19F₄, 2F5, 6F₇, 18F₁₄	Flexibility	50
1	14F₃	Organizational dynamics	51
8	2F₂, 16F₃, 1F₄, 14F₅, 3F₇, 1F₁₀, 8F_11,20F₁₃	Customer orientation	52
2	24F₃, 21F₁₃	Organizational trust	53
2	9F₉, 12F₁₂	Relationship between education and conscious behaviors	54
4	15F₁, 5F₆, 5F₈, 4F₁₀	God’s awareness of the individual's deeds	55
1	7F₈	Burnout	56
2	12F₄, 3F₈	The staff’s unresponsiveness	57
4	20F₁,7F₃, 15F₄, 4F₅	Suitable positions for difficult staff	58
6	3F₁, 4F₂, 2F₃, 28F₄, 15F₅, 10F₆	Hard work	59
4	3F₂, 19F₇, 17F₂, 6F₁₄	The organization’s support of the staff	60
2	20F₆, 13F₁₄	Cooperation with staff	61
2	13F₆, 21F₆	Difference in capabilities	62
7	19F₁, 4F₄, 24F₆, 7F₉, 5F₁₀, 9F₁₁, 3F12	Adapting to working conditions	63
3	11F₂, 10F₃, 17F₉	Turning weaknesses into strengths	64
5	26F₃, 7F₇, 14F₉, 1F₁₁,14F₁₃	Communication management	65
4	10F₂, 5F₃, 7F₁₂, 11F₁₄	Confidentiality of patient information	66
3	12F₂, 9F₄, 15F₈	Discriminatory behaviors	67
3	5F₄, 8F₆, 10F₁₃	Giving feedback	68
5	5F₁, 10F₅, 7F₆, 2F₉, 1F₁₀	Having work ethics	69
2	15F₂, 11F₆	Having long work experience	70
3	27F₁, 25F₃, 21F₇	Technology	71
1	22F₁₃	Lack of workforce and facilities	72
3	32F₆, 20F₇, 13F₁₂	Incorrect judgment	73
1	28F₁	Organizational maturity	74
4	8F₂, 30F₄,1F₅, 2F₉	Respecting the staff’s values	75
2	15F₆, 10F₉	Organizational conflict	76
3	1F₂, 4F₇, 2F₁₀	Honesty	77
2	19F₂, 5F₄	Lack of a systemic view	78
6	10F₁, 4F₃, 3F₄, 1F₈, 3F_11,1F₁₃	Developing agility	79
2	2F_8,2F₁₂	Organizational loyalty	80
2	18F_9,10F₁₂	Empowerment	81
8	23F_1,6F₂, 15F₃, 18F₄, 3F₆, 11F₇, 10F₈, 19F₉	Job stress	82
7	24F₁, 20F₃, 23F₄, 13F₅, 27F₆, 14F₇, 12F₈, 18F₉, 13F₁₀, 14F₁₁	Organizational discipline	83
1	4F₁	Clarification	84
1	21F₁	Lack of systematic training	85
1	17F₁	Punctuality	86

In the phase of counting the main themes, the obtained sub-themes were examined, and finally, the main themes were formulated in answer to the research question. The researcher put together the sub-themes with the most semantic affinity and created new meanings and words. In fact, the researcher classified sub-themes in the form of main themes. The final results are shown in the table below. As can be seen, in studying the sub-themes, after revisions and corrections, there were 86 indicators, which were converted into 11 main themes (Table 3).

Table 3. Indicators (subtopics) and components (main topics) regarding organizational culture

Sub-themes	Main themes
Conscious performance, the necessity of defining standard performance, the superiority of women's performance, the relationship between performance and financial support, ignoring useful suggestions.	Rationally
The staff attitude, mutual respect between the management and staff, the organization’s support of the staff, interaction with staff	Ideologically
Cooperation between the departments, valuing teamwork, Adapting to the system, informal relationships in the organization, social behaviors, work commitment, management support of the staff, organizational adaptation, organizational trust, sympathy, employees’ loyalty to the organization	Agreement and cooperation
Organizational order, organizational discipline, emphasis on the implementation of the rules, clarity in implementation of the rules, direct supervision by the supervisor, doctors’ non-compliance with legal rules due to having connections, resistance to change, and discriminatory behaviors.	Hierarchical
Adapting to working conditions, turning weaknesses into strengths, providing feedback, procedural justice, material rewards, increasing motivation through encouragement, increasing work motivation, up-to-date technology, developing agility, empowerment	Constructive
Lack of interaction between colleagues, lack of organizational support, management lack of participation, lack of job satisfaction regarding treatment staff, incorrect judgment	Passive/defensive
Valuing and welcoming new ideas, adapting to the environment, staff flexibility, the relationship between training and conscious behaviors, the effect of the work climate on liking one’s job, self-control, the direct relationship between the organizational climate and the staff transfer rate, the difference in skills, organizational maturity, information clarification, confidentiality.	Professional and open culture
The direct relationship between work experience and staff management, accountability, experienced employees’ support of inexperienced ones through their good reputation, communication management, long work experience, organizational loyalty	Club
Staff lack of trust due to job insecurity, cultural differences due to differences in education level, hiring difficult employees, burnout, hard work, lack of workforce and facilities, organizational conflict, lack of systemic view, job stress, lack of systematic training	Fortress
Flexibility, organizational dynamics, customer orientation	Flexibility
Emphasis on multifaceted learning	Learning-oriented
Punctuality, respecting people's values, work conscience, God’s awareness of the individual's deeds, religious beliefs, having patience against changes, the priority of spiritual rewards over material rewards, the relationship between spiritual rewards and motivation, honesty, and rectitude	Value-oriented

Discussion
According to the results of qualitative data analysis, the components of organizational culture at Yazd University of Medical Sciences included rational, ideological, agreement and participation, hierarchical, constructive, passive, work and open culture, club, fortress, and flexibility. receptive, learning-oriented, and value-oriented. The results of the conducted interviews, in general, indicated that the dimensions of the organizational culture in this medical center were satisfactory. A healthy organizational culture provides an open, sincere, trusting, creative, cooperative, experimental, scientific, and rational environment in the organization and is essential for the productivity of healthcare organizations.
Agreement and participation are considered one of the main categories of organizational culture, which includes sub-categories of cooperation between departments, valuing teamwork, adapting to the system, informal relations in the organization, social behaviors, work commitment, management support of the staff, organizational coordination, organizational trust, sympathy, loyalty of employees to the organization. This means that the mentioned organization is based on teamwork and develops the capabilities of human resources at all levels (25). In such an organization, the members of the organization are committed to their work and feel themselves as part of the organization's body. People, at all levels, feel that they play a role in the decisions made that affect their work, which links their work directly to the goals of the organization (26). The reason is that this is considered one of the categories with utmost importance; therefore, it is suggested to create as many spaces for negotiation and learning as possible in the form of discussions and debates to create a suitable platform for teamwork, loyalty, organizational commitment, etc. (27, 28). In their study, Körner et al. (2015) investigated the relationship between organizational culture, teamwork, and job satisfaction in German rehabilitation clinics and concluded that 35% of job satisfaction can be predicted by a structural equation model that included both organizational culture and teamwork. The results of the study emphasized the importance of interprofessional teamwork in healthcare organizations. To strengthen interprofessional teamwork, team interventions can be recommended, and in fact, they should be supported (29). The results of the research were consistent with the findings of the present study. On the other hand, Adeoye et al. (2020) empirically examined organizational culture and employee retention and loyalty in Nigeria. The findings indicated a relationship between organizational culture and employee retention, as well as a strong relationship between organizational values and employee loyalty. This study addressed the importance of considering the employees’ loyalty to the organization as one of the components of organizational culture (30), which was consistent with the findings of the present study.
The constructive category is presented as another category of organizational culture in the organization under study, which has sub-themes of compliance with work conditions; turning weaknesses into strengths; providing feedback, procedural justice, material rewards, increasing motivation through encouragement, increasing work motivation, up-to-date technology, developing agility, and empowerment. According to this category, internal integrity and external adaptability can be considered as an advantage regarding the superiority of this organization over others(28). Constructive organizations are driven by customers, turn their weaknesses into strengths, become agile, and continuously improve their capacities to value themselves and their customers. be (31, 32). According to the obtained results, it is suggested to give feedback to the employees regarding their work; in this case, they will be aware of their weaknesses and strengths, and with more effort, they will try to turn their weaknesses into strengths. On the other hand, considering that the reward and motivation system in the mentioned organization was in a good state, this organization should continue with the same process. In a study, Rohim et al. (2019) examined the effect of organizational culture as a moderator regarding the relationship between organizational rewards on knowledge sharing and employees’ performance. Material rewards provided for example in the form of allowance regarding employees’ performance, significantly influence individual attitudes towards knowledge sharing. The cross-impact between reward variables and tribal culture had a significant effect on knowledge sharing. These findings suggested that tribal culture was a net moderating variable that strengthened the relationship between rewards and knowledge sharing. The results of this research showed that the cross-impact between the wage variable and the culture of adhocracy did not have a significant effect on knowledge sharing. Also, there was a significant and negative relationship between the reward variable and hierarchical culture regarding knowledge sharing. The effect of market culture on moderating the relationship between rewards and knowledge sharing was not proved as well. However, market culture variables directly and significantly affected knowledge sharing (33), which was consistent with the results of the present study regarding the effect of material rewards on strengthening organizational culture. In another study, Paais et al. (2020) investigated the effect of motivation, leadership, and organizational culture on employees’ satisfaction and performance. The results of the coefficient of determination test revealed that 57.4% of staff job satisfaction was influenced by motivation, leadership, and culture variables, while 73.5% of the staff performance was influenced by motivation, leadership, culture, and job satisfaction variables (3), which was consistent with the findings of the present study.
Hierarchy is another category of the organization under study which was presented with sub-themes of organizational order, organizational discipline, emphasis on the implementation of the rules, transparency regarding implementation of the rules, direct supervision by the supervisor, doctors’ non-compliance with legal rules due to having connections, resistance to change, and discriminatory behavior. One explanation of this result is that it was a governmental organization in which the spirit of obeying the laws and implementing government policies was institutionalized (34). Therefore, it is suggested that employees try to create a friendly environment by holding various gatherings to increase interaction between the employees. On the other hand, by removing unnecessary regulations and simplifying processes, they tried to increase the flexibility of the organization (35, 36). ). In a study, Anning and Dorson (2021) examined organizational culture and leadership as a preliminary factor for organizational flexibility. The findings showed that although organizational culture and leadership may affect the competitiveness of a service organization, Using these resources at the organizational level to create market flexibility was more effective. This suggested that when culture and leadership encouraged flexibility, the service organization was able to connect, coordinate, and synchronize functional units to benefit from new product and market opportunities (37), which was consistent with the findings of the present study.
Staff lack of trust due to job insecurity, cultural differences due to differences in education level, hiring difficult employees, burnout, hard work, lack of workforce and facilities, organizational conflict, lack of systemic view, job stress, lack of systematic training were regarded the sub-themes of fortress category. According to these themes, the employees in such an organization do not have enough trust in the organization, there is a conflict, and on the other hand, a cultural difference is observed in such an organization (38). Therefore, according to these results, it is suggested to create an atmosphere in the organization where the employees can enjoy higher job security, in addition to trusting the organization (39). On the other hand, different strategies and measures should be provided to minimize job stress, and there should be a learning environment to transform difficult staff into productive ones (40) with special attention to the whole system as well as systematic training (41, 42). In a study, Hafidhah et al. (2019) investigated the effect of perceived organizational support, job stress, and organizational culture on job performance. The results of this study showed that perceived organizational support and organizational culture had a positive and significant effect on performance. Also, job stress had a negative and significant effect on performance. Also, the results showed that there was a cross-impact between independent variables and dependent variables. There was an increase in employees’ performance because employees must have a high level of perceived organizational support, a good organizational culture, and low job stress levels (43), which was consistent with the results of the present study on the effect of job stress on organizational culture.
Emphasis on multifaceted learning was considered as the only theme of learner-oriented culture. Therefore, it was suggested that by creating a continuous learning culture with an emphasis on human development through education as a process to improve and enhance the capabilities, staff knowledge and awareness would improve and their attitude would change (44, 45).
Conscious performance, the need to clarify standard performance, the superiority of women's performance, the relationship between performance and financial support, and not welcoming suggestions were considered themes of the category of rational culture. According to these themes, it is suggested to receive employees' opinions about organizational issues to increase their participation in organizations and reduce constant supervision of employees' performance as much as possible in order to reduce their job stress. should also be reduced (46). In their study, Oladimeji et al. (2023), concluded that the level of employees’ participation in the organization had an effect on the relationship between organizational culture and employees’ productivity. Moreover, the findings highlighted the importance of focusing on employees’ commitment and improving their productivity (47), which was consistent with the findings of the present study regarding the importance of employees’ participation in the organization.
The direct relationship between work experience and staff management, accountability, experienced employees’ support of inexperienced ones through their good reputation, communication management, long work experience, and organizational loyalty were considered as 8 sub-themes of the club culture category. According to the obtained themes, it is suggested to make necessary arrangements in this organization to boost their spirit and commitment.
Punctuality, respecting people's values, work conscience, God’s awareness of the individual’s deeds, religious beliefs, having patience against changes, the priority of spiritual rewards over material rewards, the relationship between spiritual rewards and motivation, and honesty were considered as themes of a value-oriented culture (48, 49). According to this category, it is suggested to pay attention to the dispositions and human values of individuals and groups; on the other hand, more emphasis should be placed on the mental and psychological aspects of employees and their values and behaviors. In a study, Alimudin et al. (2017) addressed the effect of spiritual leadership on organizational culture and employees’ loyalty. The research results showed that spiritual leadership had a significant and positive effect on organizational culture. A significant and positive relationship between organizational culture and employees’ loyalty, and also a positive but insignificant correlation between spiritual leadership and employees’ loyalty was observed (50), which was consistent with the findings of the present study.
Conclusion
The identified components of organizational culture can help healthcare managers and policymakers to improve service quality, job satisfaction, the staff organizational commitment; improve organizational performance; and increase patients’ satisfaction. Managers should promote the components of organizational culture in hospitals by strengthening their internal cohesion. Also, measures should be planned and implemented to strengthen individuals' values and beliefs regarding the organizational culture. Improving organizational culture can be the foundation for other successful changes in the hospital and help managers systematically predict priorities for change and develop better strategies for the successful implementation of management techniques and processes. Healthcare managers should consider the components of organizational culture and try to improve the performance of hospitals by creating a suitable environment and strengthening the organizational culture.
Acknowledgments
We thank all the experts and professors who accompanied us in this research project.
Conflict of interest
The authors declared no conflict of interest.
Funding
This research did not receive any grant from a funding agency.
Ethical considerations
Ethical considerations were carefully addressed and implemented in the research study, including obtaining informed consent from participants, ensuring their privacy and confidentiality, and conducting the study by relevant ethical guidelines and regulations.
Code of ethics
IR.SSU.REC.1399.173
Authors’ contribution
All authors (M. S., E. R., M. K., A. R., and S. B) had an equal contribution and were involved in all aspects of study conception and design, data collection, data analysis, interpretation, drafting of the manuscript, and critically revising the manuscript for intellectually important content. All the authors have read and approved the final version of the manuscript and agreed to be accountable for all aspects of the work.
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Review: Research | Subject: Health care management
Received: 2023/11/11 | Accepted: 2024/03/26

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