While we may talk about a single defining culture, the truth is that in larger organisations there may be several cultures or subcultures. Manley, Sanders, Cardiff and Webster (2011, p. 4) state that ‘organisational culture in the past has been assumed to be singular and pervasive, monolithic and integrative, but all organisations have multiple cultures usually associated with different functional groupings or geographical locations’. Subcultures can be routinely seen in large hospitals, where individual departments may have cultures that are slightly different from but aligned with that of the organisation overall. Subcultures are commonplace and contribute to the overall feel, function and direction of an organisation.

On the other hand, countercultures – a form of organisational incivility – work at odds with the organisation and can be quite disruptive or destructive to its overall functioning. Andersson and Pearson (1999, p. 457) describe organisational incivility as ‘low intensity deviant behaviour with ambiguous intent to harm the target, in violation of workplace norms for mutual respect’. One of the key responsibilities of a healthcare manager and leader is the cultivation of positive, productive workplace cultures. Schein (1992, as cited in Graber and Fitzpatrick, 2008, p. 194) says that one of the prime responsibilities of leaders is the management and creation of culture.

Typology of workplace cultures

While setting the culture of an organisation is the prime responsibility of the chief executive officer and the executive team, managers are expected to support and promote the desired culture. In order to understand what sort of culture prevails in an organisation, it is necessary to be able to categorise culture types. Categorisation allows the health manager to determine whether there is a need to redefine and change the culture in which they work. Self-aware health managers also need to ask themselves the following questions: How am I contributing to the culture in this organisation? If I don’t like the present culture in the organisation, what am I going to do to change it?

The literature categorises culture in many ways, ranging from three-culture models (Westrum, 2004) to quadrant models (Quinn and Rohrbaugh, 1983; Wolniak, 2013) to cultures depicted as animal types (Line, 1999). A cultural framework that has been used widely in a number of industries, including health, is the Competing Values Framework (Cameron & Quinn, 2011; see Figure 25.1). It categorises four main cultural types and describes how each of these predominantly functions.

Figure 25.1 Competing Values Framework. Adapted from K. S. Cameron & R. E. Quinn (2011). Diagnosing and changing organizational culture: Based on the Competing Values Framework (3rd ed.). San Francisco, CA: Jossey-Bass.

The Competing Values Framework runs along two axes forming a cross. The vertical axis focuses on organisations that have flexibility and discretion through to those with high levels of stability and control. The horizontal axis highlights organisations with a strong internal focus and integration through to those that are externally focused and differentiated. Using these axes, Cameron and Quinn (2011) have categorised four predominant cultures, which are discussed below. Healthcare organisations may identify any one of these types. Each has its benefits and limitations depending on the type of organisation and the direction in which a healthcare facility is heading. Healthcare managers need to be aware of how they impact the culture and how they should support staff in their specific cultural type.

Clan (or cooperative) culture

This culture is characterised by a strong internal focus and flexibility. Organisations with a clan culture exhibit strong family-like, nurturing, cohesive and collaborative traits. Teams within such organisations work with a level of autonomy and self-direction.

Hierarchy (or control) culture

The hierarchy culture is characterised by an internal focus with strong control processes. Organisations with a hierarchy culture have defined hierarchies or bureaucracies, and command and control structures with a focus on policies, procedures, processes and protocols. They aim to be stable, consistent and dependable.

Adhocracy (or creative) culture

This culture is characterised by flexibility and an external focus. Organisations with an adhocracy culture promote rapid change, creativity and innovation, and they can be high-pressured, as they search for the next new product and aim to be ‘ahead of the game’.

Market (or competitive) culture

The market culture has strong internal control and is externally focused. Organisations with a market culture focus on the external customer rather than the internal staff and can be very competitive, as they seek new customers and have an emphasis on customer service.

Measuring workplace culture

There are several ways in which to measure culture within organisations, from the subjective (having a general sense of what the organisation is like) to the objective (validated survey instruments and other qualitative approaches). Researchers have recently tried to understand the scope and range of quantitative instruments to measure workplace culture in healthcare organisations, and Scott et al. (2003) have identified 13 such instruments. However, while all of these examined employee views, perceptions and opinions of their working environments, only two considered the values and beliefs that might inform those views. The authors conclude that ‘it is unlikely that any single instrument will ever provide a valid, reliable, and trustworthy assessment of an organisation’s culture, and so a multi-method approach will always be desirable (p. 942)’. Organisations tend to use a range of approaches to measure their culture, including measurements focusing on staff and patients.

Organisational implications of different workplace cultures

The healthcare manager’s role in proactively managing culture is critical to the overall functioning and success of the organisation. The culture of an organisation can impact positively on its operation, profitability and ability to work through challenging circumstances. While the culture of an organisation may seem a soft, non-core issue to some, the positive and negative impacts of culture can have substantial financial and operational implications.

Workplace culture can lead to positive outcomes in many areas of a health organisation. Along with improved teamwork, cohesion and employee involvement, and patient satisfaction (Gregory, Harris, Armenakis & Shook, 2009), lower patient mortality and improved nurses’ health, job satisfaction, organisational commitment, emotional exhaustion and intention to stay have been recorded (Laschinger, Cummings, Wong & Grau, 2014). Positive culture also leads to more optimism among staff about the organisation’s ability to meet future challenges, improved working relationships, greater accountability and efficiency, better cost management, more devolvement of management to clinicians, and facilities that are more strategically placed and patient-focused (Braithwaite et al., 2005). A reduction in medical errors has also been reported as a result of positive workplace culture (Stock, McFadden & Gowen, 2007), as have improved quality of care (Siourouni, Kastanioti, Tziallas & Niakas, 2012) and positive clinician attitudes in adopting new technology (Callen, Braithwaite & Westbrook, 2007).

However, negative workplace culture, the consequences of which are regularly discussed in healthcare reports and reviews, can manifest itself through unethical and possibly illegal activity (Casali & Day, 2010), higher staff turnover and lower staff morale and productivity (Siourouni et al., 2012). It can also result in a lower quality of care (Mid Staffordshire NHS Foundation Trust Public Inquiry, 2010) and higher levels of workplace bullying (O’Farrell & Nordstrom, 2013).