Association between organisational and workplace cultures, and patient outcomes: systematic review
Jeffrey Braithwaite, Jessica Herkes, Kristiana Ludlow, Luke Testa, Gina Lamprell
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Introduction
Among policy-makers, managers and clinicians, culture is a much-discussed construct. The discourse is often centred on normative considerations, proposing that an effective, functional or productive culture is preferable to one that is ineffective, dysfunctional or even toxic. A healthier organisational or workplace culture is believed to be related to positive patient outcomes, such as reduced mortality and length of stay, increased quality of life and decreased pain level. However, no review has been conducted to weigh the evidence for such beliefs. We examined the extent to which this putative association between culture and patient outcomes holds in healthcare settings.
Across the literature, culture has been defined in numerous ways. Famously, Kroeber and Kluckhohn found 164 definitions of culture in 1952. Since then, there are most likely many more variations and definitional stances on the culture theme. It is not easy to synthesise these different perspectives, but most experts would agree that culture signifies features of institutional life which are shared across a workplace or organisation, between the members, such as their cognitive beliefs, assumptions and attitudes; and their activities, such as their behaviours, practices and interactions. These shared ways of thinking and behaving become normalised, and reflect what comes to be seen as legitimate and acceptable within the workplace or organisation. The cultural expressions also become taken for granted by members of the workplace or organisation. They are the normative, social and cognitive ‘glue’, which bind people within the culture together; culture, then, is ‘the way people think around here’ and ‘the way things are done around here’.
Based on these conceptualisations, we define culture in a summarised way, as the sum of jointly held characteristics, values, thinking and behaviours of people in workplaces or organisations. For this systematic review, culture is classified in two ways. The first category concerns the overarching culture of an organisation, including consistent practices, beliefs and attitudes, for example, within a whole hospital, general practice group, aged care facility or other institutional setting. The second category relates to more localised cultural dimensions; workplace cultures, which are specific to group characteristics of the organisation, for example, those identifiable subcultures that manifest in wards, departments or within employee groups such as doctors, allied health professionals or nurses.
These definitions arise from, and are underpinned by, much conceptual work which has enriched the idea of culture and the way it manifests. Theoretically, there are multiple stances taken in conceptualising culture. One way is to think of culture as a composite, and enduring but relatively static phenomenon; a sort of concrete, tangible, matter-of-fact organisational variable. Here, it is a noun: the culture. Another way is to think of it as dynamic, emergent, longitudinal phenomenon, more a verb than a noun. This distinction is a deep one, springing from a social science perspective which asks whether phenomenon of this kind are a being-realism or a becoming-realism.
Yet another theoretical distinction lies in whether culture is better understood with reference to shared meanings or shared practices. Scholars including Martin and Alvesson see that culture can be construed and understood theoretically in many different ways depending on the observers’ interests, ideologies and interpretative or reflexive stance. All in all, theoretically we take the view that culture is a composite, complex construct which changes dynamically over time, but there are enduring behavioural and cognitive patterns to its manifestations in situ.
In this review, we aimed to investigate ways in which organisational and workplace cultures are associated with patient outcomes across a range of healthcare settings. On the basis of the foregoing, we formulated a hypothesis: positive organisational and workplace cultures are related to positive patient outcomes and negative organisational and workplace cultures are related to negative patient outcomes. By positive we mean a cohesive, supportive, collaborative, inclusive culture, and by negative, we mean the converse. We anticipated that this review would provide information for those, such as policy-makers, managers, clinicians, researchers and patient groups who seek to understand, shape or enhance healthcare cultures or subcultures. We expected that such an analysis would provide insights into the evidence for culture and subcultures, and recognise that cultures are deeply embedded in systems and settings in terms of their interacting agents, capacity to evolve and adapt and emergent behaviours.
Abstract
Design and objectives
Every organisation has a unique culture. There is a widely held view that a positive organisational culture is related to positive patient outcomes. Following the Preferred Reporting Items for Systematic Review and Meta-Analyses statement, we systematically reviewed and synthesised the evidence on the extent to which organisational and workplace cultures are associated with patient outcomes.
Setting
A variety of healthcare facilities, including hospitals, general practices, pharmacies, military hospitals, aged care facilities, mental health and other healthcare contexts.
Participants
The articles included were heterogeneous in terms of participants. This was expected as we allowed scope for wide-ranging health contexts to be included in the review.
Primary and secondary outcome measures
Patient outcomes, inclusive of specific outcomes such as pain level, as well as broader outcomes such as patient experience.
Results
The search strategy identified 2049 relevant articles. A review of abstracts using the inclusion criteria yielded 204 articles eligible for full-text review. Sixty-two articles were included in the final analysis. We assessed studies for risk of bias and quality of evidence. The majority of studies (84%) were from North America or Europe, and conducted in hospital settings (89%). They were largely quantitative (94%) and cross-sectional (81%). The review identified four interventional studies, and no randomised controlled trials, but many good quality social science studies. We found that overall, positive organisational and workplace cultures were consistently associated with a wide range of patient outcomes such as reduced mortality rates, falls, hospital acquired infections and increased patient satisfaction.
Conclusions
Synthesised, although there was no level 1 evidence, our review found a consistently positive association held between culture and outcomes across multiple studies, settings and countries. This supports the argument in favour of activities that promote positive cultures in order to enhance outcomes in healthcare organisations.
