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Introduction
Organizational culture refers to the values, beliefs, and traditions shared among the members of an organization (Choi, 2010). It is an important factor in determining an organization’s capabilities and potential. The organizational culture that an organization’s members create, learn, and propagate has a strong influence on how they think and behave. In addition, the culture that is shared by the members of an organization has the power to motivate them because it drives their desire to work. Depending on the organizational culture, the working atmosphere and organizational climate affect the emotional and cognitive state of the organization’s members, resulting in different job motivation (Im, 2011). A healthy organizational culture not only enhances productivity and reduces turnover, but it also unites the passion and energy of employees and promotes collaboration and innovation.
The organizational culture measurement tool is based on the Competing Values Framework developed by Quinn, which is the most used in academia. According to the Competing Values Framework, organizational culture measurement is divided into four organizational cultures based on two axes (internal/external orientation and control/autonomy): Clan culture, Adhocracy culture, Hierarchy culture, and Market culture (Figure 1). Quinn emphasizes that these four cultures are complementary, not mutually exclusive, and that leaders must simultaneously embrace these four seemingly opposing values in order to increase organizational effectiveness (Quinn, 1988).
In the health care service field, there has been an ever-increasing interest in organizational culture, and research has been conducted to determine the relationship between organizational culture and performance (Shortell et al., 1994). However, hospitals have been relatively less studied than the general workplace due to their closed and hierarchical culture. A recent study analyzed the job satisfaction of nearly 460,000 cumulative healthcare union members and found high levels of satisfaction with “job stability” (75.5%) and “self-conceit” (71.7%). In contrast, 66.5% of respondents answered “yes” to “intention to leave” based on cumulative data from the 2017–2022 survey (Kim, 2023). This high turnover rate leads to high costs for recruiting new employees. It also demoralizes the remaining employees, increases their workload, reduces productivity, and lowers the quality of healthcare services (Jee & Choi, 2021). Therefore, hospitals are gradually shifting from focusing solely on medical activities to emphasizing the job satisfaction of hospital employees in order to satisfy customers. In addition, the importance of identifying the characteristics of the organizational culture shared by hospital employees is being emphasized in order to improve customer satisfaction.
Hospitals are labor-intensive organizations composed of various professions, and employees interact closely with each other. Therefore, the organizational culture is different from that of general enterprises, and conflicts are more likely to occur, so understanding the organizational culture and successfully managing human resources is a major challenge in the field of hospital management (Heo, 1993).
Public hospitals fulfill a variety of roles that private hospitals struggle to fulfill, including treating vulnerable populations, responding to infectious diseases, and providing public healthcare services. However, because of their public role, many public hospitals face management challenges that require them to simultaneously achieve two often incompatible business outcomes: public and profitable. Public hospitals have been criticized for operational rigidity, lack of investment, lack of patient-centeredness, and inadequate medical services (Jung, Seo, Lee, & Lee, 2005; Shon, 2020). Public hospitals need to face these problems and strive to improve their management through the provision of quality healthcare services.
Since the attitude of hospital employees toward patients affects the quality of healthcare services and patient satisfaction, it also has a significant impact on the business performance of hospitals. Kim (2012) found that positive organizational culture and communication among hospital employees affect organizational performance, and Ostroff and Bowen (2000) found that organizational members’ job attitudes and job satisfaction are correlated with the performance of the organization as a whole. As Millennials and Generation Z (MZ Generation) enters the majority of organizations, private hospitals are making various efforts to improve their organizational culture. Public hospitals also need to make efforts to reduce employee turnover intentions and ultimately improve the quality of healthcare services.
This study aims to identify the differences in organizational culture and communication styles among employees composed of various professionals to provide a basis for creating a hospital with happy employees by reducing employee turnover intentions and ultimately improving the quality of healthcare services.
Case Description
The survey was conducted online (web/mobile) from July 25 to August 19, 2022 using a structured questionnaire. 2,519 responses (62% response rate) from employees (4,047) who have worked at 12 public hospitals for at least one year. The purpose of the survey was to diagnose organizational culture and identify shared beliefs as a group to create an organization where employees, our internal customers, are happy to work. The survey questions asked 9 items about perceptions of four organizational cultures (Clan culture, Adhocracy culture, Hierarchy culture, and Market culture).
The 12 public hospitals are categorized into three types: General, specialty, and psychiatric. The two General hospitals are hospitals with more than 600 beds. The seven specialty hospitals are hospitals with 200 to 300 beds that provide medical services for specific targets or diseases. The three psychiatric hospitals are psychiatric hospitals in Gyeonggi-do with about 200 beds.
General hospitals had the highest number of respondents at 1,258(49.9%). Among the respondent characteristics, occupations were categorized as doctors, nurses, health workers, and administrative officers, with the largest number of respondents in that order: By occupation, 1,257 respondents (49.9%) were nurses, 405 respondents (16.1%) were health workers, 308 respondents (12.2%) were administrative officers, and 191 respondents (7.6%) were doctors (Table 1). By position, 2,122 respondents (84%) responded at the staff, and 59 respondents (2.3%) responded at the Director level. By age, 290 respondents (11.5%) were under 30s, 885 respondents (35.1%) were in their 30s, 667 respondents (26.5%) were in their 40s, and 677 respondents (26.5%) were in their 50s or older. By gender, there were 640 male (25.4%) and 1,879 female (74%).
The organizational cultures of General hospitals and Specialty hospitals showed similar tendencies, with Market culture (3.48 points, 3.46 points) rated highest and Adhocracy culture (3.18 points, 3.15 points) rated lowest. On the other hand, in Psychiatric hospitals, Clan culture (4.28 points) was the highest and Hierarchy culture (2.93 points) was the lowest.
In the case of Market culture, the most important core value is efficiency and the degree to which members’ opinions are collected when making decisions. Because productivity improvement is important through performance-oriented evaluation, it is difficult to communicate smoothly within the organization. On the other hand, in the case of Clan culture, which is prominent in Psychiatric hospitals, the main core elements are harmony and balance, so it can be said to be a culture that values the agreement of members when making decisions and solves problems through friendly relationships (Figure 2).
The perception of organizational culture varies depending on the occupation, position, age, and gender of the employees. By occupation, doctors and health workers rated Market culture (3.68 and 3.59), nurses rated Hierarchy culture (3.54), and administrative officers rated Clan culture (3.69) the highest. By Position, staff reported the highest Hierarchy culture, while managers reported the highest Market culture and directors reported the highest Clan culture.
By age, those in their 20s and 30s are most likely to have a Hierarchy culture, while those in their 40s are most likely to have a Market culture, and those over 50 are most likely to have a Clan culture. By gender, male perceive Hierarchy culture as the lowest organizational culture, while female perceive Hierarchy culture as the highest (Figure 3).
Discussion
Seoul Metropolitan Hospital measured organizational culture among its employees and found that perceptions of organizational culture differed by type of institution and employee characteristics. The groups with a Market culture are doctors and nurses, directors, and those in their 40s by age. The groups with Hierarchy culture are nurses, staffs, 20s and 30s, and female. Clan culture is characterized by administrative, managerial, 50+, and male. On the other hand, Adhocracy culture is low in most groups.
According to a 2019 survey by the Ministry of Employment and Labor, the turnover rate of nurses was 15.2%, which is much higher than the turnover rate of other industries (4.9%). This is 2.3 times higher than the 6.6% turnover rate for other occupations in hospitals, excluding nurses, which means that nurses have the highest turnover rate among hospital occupations (Oh, 2019). This is 1.3%p higher than in 2015, five years ago. In particular, according to the ‘Hospital Nursing Staffing Status Survey’, which has been conducted by the Hospital Nurses Association every year since 1992, the turnover rate of new nurses in 2021 was 52.8% (Hospital Nurses Association, 2013–2022). This is a 17.5%p increase from 2016, and the turnover rate for new nurses has been rising significantly every year. High turnover of new nurses is highly inefficient from a management perspective, as the cost of recruitment and training is high but does not lead to performance. In addition, even experienced nurses are overworked, which can lead to burnout and turnover. This leads to poor patient safety and quality of care. It is therefore urgent to find innovative ways to reduce new nurse turnover.
Understanding and managing organizational culture is essential to achieving organizational goals and increasing organizational effectiveness because it affects all management processes, including daily work processes and interactions among organizational members. However, unlike general organizations, hospitals are composed of a diverse group of professionals, and the perception of organizational culture varies greatly depending on the characteristics of the members. Even within the same hospital, the type of organizational communication will vary depending on the department or position.
According to Chruden and Sherman (1977), formal organizational communication is generally divided into three main types: bottom-up communication, top-down communication, and horizontal communication. Therefore, depending on the organizational culture, the way of organizational communication will be different. In the case of 40s and directors, doctors, and health workers, it is a Market culture where employees’ opinions are only taken into account when decisions need to be made. Therefore, bottom-up communication will be mainly about job descriptions and suggestions. Nurses who have a very high percentage of females, and staffs positions in their 20s and 30s have a Hierarchical culture. Hierarchy culture is characterized by a strong sense of hierarchy, strict control and compliance with regulations, and low flexibility in work. Therefore, it is expected that top-down communication, which mainly includes orders and work instructions, will be conducted, where opinions and communications from the top are transmitted to employees. On the other hand, in the case of managerial or administrative positions over 50 years old, there is a Clan culture that emphasizes employee consensus in decision-making and solves problems through friendly relationships. Therefore, horizontal communication is likely to be dominated by cooperation and help to solve problems among the same level within the organization.
A positive organizational culture strengthens organizational cohesion and increases organizational effectiveness to survive in the highly competitive healthcare environment. It encourages long-term employee retention and yields direct, tangible results for the organization. A decisive factor that lowers turnover intentions and keeps employees rooted in the organization is an organizational culture that makes employees feel cohesive and attached to the organization (Jeon & Yom, 2014). Therefore, it is necessary to look at organizational culture through the behaviors and perceptions of the people in the organization (Curran & Miller, 1990).
Among the various respondent characteristics, nursing and younger employees have a higher turnover rate, and the analysis of this study shows that their perceived organizational culture is a Hierarchy culture. Hierarchy culture is a type of bureaucratic culture in which employees are united around formalized rules and emphasize control and order. Control and management are achieved through procedures and rules, hierarchical communication, and managerial control (Choi, 2005). In this culture, employees wait for instructions and orders from their superiors and are bound by procedures and regulations, so it is difficult to expect self-motivation.
Hierarchy culture is a type of bureaucratic culture that emphasizes control and stability, and in this culture, the more control is exercised, the less motivated employees are. In such an organizational culture, employees are passive and unwilling to take risks, and their creativity is significantly reduced, resulting in low job satisfaction (Kim, 2002; Lee & Seo, 2023; Park & Kim, 1995). In this context, Hierarchy culture will have a negative impact on job motivation. Park (2018) found that Clan culture, Adhocracy culture, or Market culture, rather than Hierarchy culture, has a positive effect on employees’ job performance, job satisfaction, and turnover, as well as organizational productivity. Kim (2006) also reported that Hierarchy culture decreases employees’ intention to stay in the organization. The researcher emphasized that in order to increase employees’ intention to stay, an organization should develop an organizational culture that reinforces a task-oriented, friendly, and enterprising culture to accommodate employees with less experience. In addition, training and methods for effective communication should be activated (Kim, 2013), and job satisfaction can be increased through the strengthening of a cooperative and accurate communication system.
Therefore, organizational managers need to develop effective communication strategies and plans for improving organizational culture to increase job motivation while improving Hierarchy culture for new nurses at low position. This is because good organizational communication promotes the integration and cooperation of individuals within the organization and has a positive impact on employees’ job attitudes (Kim, 2013). A desirable organizational culture is an effective strategy for providing quality healthcare services, and if organizational members are satisfied with organizational communication, it will have a positive impact on organizational culture.
Conclusion
In this study, we attempted to identify differences in organizational culture awareness by employee characteristics and provide basic data for establishing detailed strategies to improve the organizational culture of public hospitals. The organizational culture of the 12 Seoul Metropolitan Hospitals was in the following order: Market culture > Clan culture > Hierarchy culture > Adhocracy culture. By hospital type, General and Specialty hospitals had a Market culture, and Psychiatric hospitals had a Clan culture. There were differences in the perception of organizational culture by employee characteristics, and by occupation, doctors and health workers had a Market culture. Nurses had a Hierarchy culture. In particular, the younger the age group, the more likely it was to have a Hierarchy culture.
This means that diverse and heterogeneous sub-organizational cultures exist in hospitals. In particular, nurses and new employees with high turnover rates had a Hierarchy culture. Hierarchy culture mainly consists of downward communication, which has a negative impact on job motivation. Public hospitals have been struggling to find enough healthcare workers in the wake of COVID-19. Therefore, for the sustainability of hospitals, it is necessary to identify factors that can cause various internal motivations among employees. In addition, it is necessary to understand the organizational culture and establish detailed human resource management plans for each occupation. Furthermore, it is necessary to look at cases of improving the organizational culture of private hospitals and general companies, and make efforts to improve the actual organizational culture of public hospitals and establish an effective communication system.
