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When ones' enter in the organisation, regardless working in a small or big organisation, supportive or not supportive environment, all these has reflects the culture of the workplace within an organisation which most people know it as the "personality" of the place (Catalin, 2011). Each organisation represents different "personalities" and culture, which plays an important role within the organisation. It represents a common perception held by the organisation members and acts as an influence of the working behaviour and attitudes (Tsai, 2011).
In the rest of this essay, it will consist of three parts. Firstly, organisational culture and concepts will be defined and discussed. Secondly, the internal and external factors will also be discussed on how it affects the creation and the perpetuation of the organisational culture. Last but not least, the factors will be analysis into nursing context using change management, and critique how organisational culture using change management can promote organisational process and outcomes.
Since research started on organisational culture, it was been defined in different definitions. Saame, Reino & Vadi (2011) stated "the concept of organisational culture is utilized extensively in modern organisational analysis, exploring the values, attitudes and beliefs behind human behaviour in work places." It often reflects organisational members' to understand the expectations and shape differently in order to be effective toward the organisation (Saame, Reino & Vadi, 2011). With that, organisational culture attracts the attention of researchers, and therefore lots of definition was defined for organisational culture. According to Schein (1984), organisational culture defined as "a pattern of basic assumptions that a given group had invented, discovered, or developed in learning to cope with its problems of external adaptation and internal integration, and have worked well enough to be considered valid." From this definition, organisational culture was created when a group of people discovered and shared the same experiences to deal with their problems from an external environment and internal integration. The assumptions must work well in order to teach others the correct ways to perceive, think, and feel in relations of those problems (Schein, 1984). The culture and interaction can be analysed over three levels. There were the artefacts, belief and values and basic assumption (Scott, Mannion, Marshall & Davies, 2003). Artefacts such as technology, vision, mission, and dress codes were the most visible manifestation of culture but often not able to interpret or difficult to express distinctly (McLaurin, 2008). Under this level, it would describe "how" a group had been created in its environment and using "what" behaviour patterns among the group, but often cannot understand the logic "why" the group behaved the way it does (Schein, 1984). In the level of beliefs and values, it consist a greater level of awareness. Values lead to behaviour and begin to resolve problem which influences the way in which people works in the organisation. Examples include such as not to criticize the organisation or to be committed in the organisation (Schein, 1984). In the last level of the framework would be the basic underlying assumption, where the values are invisibles and preconscious. Values at this time will become gradually taken for granted and changed into assumptions (McLaurin, 2008). This is why it is difficult to change a culture when it reaches this level. Examples of this level will be the assumption of patient's right or the assumption of medicine should prolong life.
Another definition by Robbins & Coulter in Tsai (2011), organisational culture defined as "the shared values, beliefs or perception held by employees within an organisation or organisational unit." This definition of organisational culture reflects the values, belief and behavioural norms that exist in the organisational time for very long, which may influences their attitudes and behaviour. From this definition, organisational culture has involved the functionalist perspective, providing the roles of the organisational culture in improving the performance (Tsai, 2011). It should be developed in a way to improve the performance and develop the quality awareness (Shadzad et al, 2012). In order to improve the performance, the employees have to be committed to have the same norms and value as per organisation, to achieve the overall organisational goals.
Healthcare organisations can be characterised as a culture of subcultures as the organisation employ large numbers of professionals from different department with different background (Samme, Reino & Vadi, 2011). For example in National University Hospital, the organisation uses core values, which are the dominant culture, to express, and shared by everyone in the organisation (Carney, 2011). The organisation had been continuously and tirelessly working towards improving care and their patients' overall experience through a variety of means. To align with these goals, the organisation implemented support on organisation's strategy by setting up different ways towards different goals for their employees in order to achieve their aims. For examples, NUHS Way was a program set up by National University Hospital for culture change and continuous improvement. Then followed by service culture course to provide training for employees, assessments to create for a service-oriented culture and improve quality. This is a strong culture when all of their employees influence each other through commitment and developed common aims to work loyally towards to achieve their goals in the organisation together (Plakhotnik & Rocco, 2011). In order to have continuous quality improvements, the organisation must be able to influence the employees using their key values, making employees feel a sense of shared identity and commitment towards the organisation. With that, the employees will feel a sense of secure and comfort staying in the organisation, thus improve the productivity or the performance or the organisation unit (Plakhotnik & Rocco, 2011). However, Catalin (2011) mentioned that strong culture would also be harmful and affect the organisation when the organisation's culture acts as an impediment to the employees in the organisation, who are fighting to achieve the certain status.
However, not all organisation culture has the same impact. If organisational culture has weak culture, which emphasizes lots of formal structures and regulations, it may appear to be negatively associated with quality improvement activity (Scott, Mannion, Davies & Marshall, 2003). The existing employees will pass negative aspects of the newcomer that leads to low morale thus increased employees leaving the organisation (Nandita, 2009, Macintosh & Doherty, 2010).
To create an organisational culture, there are many factors, which will influence the creation of the culture in the organisation. These can be divided into two factors, which involve the internal and external factors. Internal factors are factors affect within the organisation such as the working group of people and leadership in that organisation, the organisational characteristics, and the founder.
The working group are people working in the organisation in different ways. Their personal characteristics such as experiences, attitudes and training in their own ways contribute to the organisation, thus affecting the perception regarding the nature of organisational culture. For example nurses are the main employees working in the hospital. They came from different countries with different experiences, attitudes and training. The general existent characteristics will created an impact and affect the organisational culture (Doina, Mirela & Constantin, n.d.). Sex in the employee also plays a part that affects the organisational culture. For example, there will be more female than male working as a nurse in the organisation, as people believed that male are more aggressive than female. The people believed that female nurses are more caring thus there might be a shortage of male nurses when in need. Leadership in the organisation play an important role. The leaders help to react critical situation such as handling conflict and leading styles, and all these has a considerable effect to the nurses. The positive examples lead to trust in leadership, when employees perceive trust, they will feel motivated to be more productive and efficacy to the group (Dannar, 2011). However, if the leaders are distant from the nurses, the attitude of the nurses can create negative impact upon the culture (Doina, Mirela & Constantin, n.d.).
The organisation characteristics will affect the culture by the types of mission and values that was developed in the organisation (Doina, Mirela & Constantin, n.d.). For example in National University Hospital, the organisational need to use more technologies for the patients to maintain patient safety as compare to the nursing home. However the culture is more homogenous in the small organisation than the big organisation, while the big organisation shaped into sub-cultures (Doina, Mirela & Constantin, n.d.). It can be also different according to the degree of rules, politics and norms and after the degree of decentralisation and autonomy (Doina, Mirela & Constantin, n.d.).
The founder of the organisation plays an important role of creating the vision, mission and values of the organisation (Catalin, 2011). The founder of the organisation will employ people who had the same views as them, and contribute to their organisation (White, 2008). This will put a halt to the other group of people who are not sharing the same views as the founder, to work for them in the organisation.
The external factors that affect the creation and perpetuation are the environment, the government, and the economy. The environment that has rules and regulation in the organisation can influence the culture positively or negatively (Doina, Mirela & Constantin, n.d.). For example, nurses working in the organisation will follow standard of practices that set by the discipline of the department in the hospital. This can be taken as positively when the nurses have the protocol that can be used as a guide to work for the outcomes efficiently. However, in other words, it can be negative when the standards of practices are fixed and not flexible, where the nurses still need to comply with even there are contradictory elements.
The government set a standard set of rules and regulation for the operation of organisation that the organisation required to adhere to. For example, in order to employ a nurse to work in the hospital in Singapore, the nurse required to have a valid nursing certificate and must be registered in Singapore Board (Singapore Nursing Board, 2006). In order to provide sufficient care to all people in Singapore, the government set up different cluster of hospital in all areas for coverage. These causes competitive between the hospitals, the hospitals have to try their best to meet the people and government demands, thus affect the economy of the organisation.
In order to perpetuate organisational culture, the organisational culture required a strong culture to keep the employees having in trust, and satisfactions working in the organisation, as the employees are the major group of people in the organization. With that, employees will not quit from their jobs and thus higher retention rate. This will increase the productivity and reduce cost to the organisation (Ali & Balock, 2010).
Leaders are the main group of working people in the organisation that are related to organisational processes and outcomes. It carries an important role of leadership in order to lead others. It is common that the working organisation has disorganized process, where leadership delivers organisational benefits by stepping in and leads us to improve the outcomes (Sheahan et al, 2007). Today's healthcare organisation face never ending changing as compared to last time, therefore a more adaptive leadership is required. This type of adaptive leadership labelled as transformation leadership, which involved followers to commit a shared vision and goals for the organisation or unit, and to acts in a way to sustain the greater good rather than their own interest (Doody & Doody, 2012). Transformational leadership has always been viewed as the most effective model of leadership in the nursing culture and having a positive effect in nursing. It consists of four components, which involve idealised influence, inspirational motivation, intellectual stimulation and individual consideration (Doody & Doody, 2012).
Leaders process a strong influencing power that influences others to think. For example, nurses working in the wards tend to have leaders to guide them the right way of practice in their workplace. This can sharpen the culture and bring harmony to nursing culture, thus, it can increase the co-operation and reduced conflicts (Sheahan et al, 2007). With this, nurses will have more motivation and enthusiastic to work everyday. This motivation from the nurses will benefit the ward, nursing culture and the organisation.
Today, in healthcare organisation, there is an increase need to optimise process and outcomes. As healthcare organisational culture in healthcare institutions are different from each organisation and in order to optimise process and outcomes, change is important to healthcare organisation to meet certain standards to improve the quality of care given (Seren & Baykal, 2007). Organisation change can be defined as "transformation from the current state of the organisation, either in a planned or an unplanned manner, to another state (Seren & Baykal, 2007). Organisation changes occur in two ways such as environmental and internal factors. These changes help to reduce costs, improve quality, increase efficiency and stimulate the need for organisation change (Weiner, Amick, & Lee, 2007). It was been argued that healthcare facility has been identified as an indicator for implementing change (Callen, Braithwaite & Westbrook, 2009).
To implement the organisation change in healthcare settings, Kurt Lewin theory was one of the common models that applied frequently used in change management (Suc, Prokosch & Ganlandt, 2009). It involves three steps such as unfreeze, move and refreeze. First, unfreeze involves the necessity of change by overcome their problem, and then move aims at strengthen all changing forces in order for the change to actually take place. Lastly, refreeze reinforces the maintenance to prevent reverting to previous state (Suc, Prokosch & Ganlandt, 2009).
In National University Hospital, they make use of this Kurt Lewin theory to make some organisational changes. For example, they make changes on preparing medication for inpatients. Under the unfreeze portion, they noticed that using traditional way of preparing medication will increase the level of human errors and causing increase harm to the patients. Due to these problems, they think of ways to eliminate human errors and bring patient safety to higher level. Therefore, they implemented electronic inpatient medication record system (eIMR), inpatient pharmacy automated system (iPAS) and electronic medication administration system (eMAS) (Henneman et al, 2012). The leaders started to carry out a series of workshop in order to inform all staffs especially nurses who use the most of this system about the background and requirements of this safety process. This is to allow every staffs to know the current problems and convince everybody the need to change. During the Move step, the change was set up in different ward with support and training given, as well as to gather feedback on the acceptance of the new system approach. During the refreeze step, feedback was conducted monthly with the nurses to improve or sustain of this system.
Another example of change management done in my hospital was to use 'FISH!' Philosophy. It is a fun work culture to boost nurses' morale. To have passion for continuous improvement for nurses to the patients, it is important to create a positive environment for them so that they will provide good services to the patient and go extra mile. In order for 'FISH!' Philosophy to work, the top management started to introduce 'FISH!' Philosophy to everybody through communication from leaders, posters and events. Then they inculcate this 'FISH!' Philosophy into a celebration and competition. These are artefacts and eventually become a culture of our hospital. This change contributes a healthy organisational culture includes retention of nurses, providing support from the management which make them a good environment to work toward the organisation's goals.
However, the entire above new working model and new technology had been a halt to nurses hindered by cultures that are resistance to change (Carlstrom & Ekman, 2012). Piderit cited in Carlstrom & Ekman 2012, argued that resistance to change is a multidimensional concept which involve four domains. They are routine seeking, emotional reaction to imposed change, short term focus and cognitive rigidity. Under these domains, the nurses felt that it is not necessary to do a change as they felt comfortable in. They are reluctance and rigid to give up the old habits to participate in the change process. Moreover, it creates a stress on them when they had a change (Carlstrom & Ekman, 2012). Therefore, it is important to overcome and handle the resistance of change during the change process occurs in the organisation. Factors such as education, communication, offering support and buy-in staffs help to deal with resistance of change. Education and communication is one of the components that we need to do in order to reduce the resistance, the staffs need to know why a change has occurs and once the staffs know, it can help to clear the misunderstanding in which they might have (Campbell & James, 2008). Offer support can reduced the fear of the change during the period of change process. Lastly, buy-in staffs help to reduce the resistance and once staffs are able to work smoothly, they will help the organisation to move towards their aims and increased the rate of retention of staffs.