THE RELATIONSHIP BETWEEN HOFSTEDE ORGANIZATIONAL CULTURE AND EMPLOYEES JOB BURNOUT IN HOSPITALS OF TEHRAN UNIVERSITY OF MEDICAL SCIENCES 2014-2015

Abstract

Objective:

Organizational culture plays a supportive role in modification of structure and implementation of new management systems. So, the management of organizational culture with cultural elements recognition plays an important role in improving the efficacy and effectiveness of the organization. On the other hand, the health sector requires healthy and motivated practitioners and staff to achieve these goals. Job burnout as a response to environmental stressors causes some changes in attitude and behavior towards work and work environment, and factors such as organizational culture effect on it. This study aimed to clarify the relationship between organizational culture and employee’s burnout.

Material and Methods:

This is a descriptive and cross-sectional study. The study population included all clinical staff (physicians and nurses) and nonclinical (administrative and financial) in hospitals affiliated to Tehran University of Medical Sciences in 2014-2015. Among them, 387 participants were selected using simple stratified random sampling. In order to collect the required data, the Maslach Burnout Inventory (1981) and Hofstede’s organizational cultural questionnaire (1988) were used. Also Cronbach’s alpha obtained 0.836 and 0.913 for them, respectively. In order to analyze the data, the Kolmogorov-Smirnov test, multiple regression, independent t-test and binomial test were performed using SPSS 20.

Results:

Results showed that organizational culture in studied population were masculine, collectivism with high uncertainty avoidance and relatively equitable power distance. Mean score for emotional exhaustion was (31.4) and most of participants 315 (40.6%) had average emotional exhaustion. Mean score for depersonalization was (21.16) and most of participants 315 (82.1%) had high depersonalization. Mean score for personal accomplishment was (30.02) and most of participants 280 (73.2%) had high personal accomplishment. Multiple correlation coefficient showed that there is a significant relationship between the components of organizational culture including masculinity/femininity, individualism/collectivism, uncertainty avoidance and power distance with job burnout (r=0.305, p>0.001). R² also showed that 9.3 percent of the variance of job burnout is related to the mentioned factors.

Conclusion:

The overall result is that some staff health issues rooted in their culture; so, the organizational culture assessment by hospital managers to plan and goals achievement is essential. If necessary, improving organizational culture, creating a healthy environment, enhancing tolerance and individual adjustment and stress control can help to reduce staff burnout.

1. INTRODUCTION

In the past few decades, the concept of organizational culture has found a unique place in the organization and management. Organizations like people have their particular culture which is the reason for the distinction between them. Organizational Culture is an integrated pattern of beliefs and thinking which provides deep understanding and insights for members of the organization about organizational performance (1, 2). Due to the current researches, organizational culture has various effects on the objectives, actions, behavior, motivation, satisfaction, creativity, participation, commitment, stress level, decision-making and many other factors (3). Different behaviors of the staff reflect the different cultures of their organizations. Several researches of Hofstede on the organizational culture in different countries revealed that four cultural dimensions explain the causes of the different behavior in the different cultures. These dimensions include masculinity versus femininity, individualism versus pluralism, risk, and distance of power. The first dimension represents the difference between the situations that the material, courage, and success expose to considering the quality of life. The second dimension relies on the preference of people to protect their interests and their relatives against the support of the working groups and other people. The third dimension or the risks is the extent which people feel threatened in the unexpected and ambiguous situations while the distance of power is the extent which individuals and organizations accept unequal distribution of power (4, 5).

Understanding of existing culture in health organizations especially hospitals have a particular importance in terms of human health and having a strong and dominant management on the culture in the hospital management system (6, 7). The management of organizational culture with the help of cultural aspects plays a strong role in order to improve the effectiveness of the organization. Health Sector requires healthy and motivated therapists and staff in order to achieve this effectiveness (8, 9). However there is high probability for dealing health personnel with a kind of syndrome related to their jab called Job Burnout because of confrontation with many stressors including psychological, emotional, physical, managerial and interpersonal factors rather than the employments of other organizations (10). Burnout is a syndrome consisting of emotional exhaustion, depersonalization, and lack of individual success components and also has many side effects such as fatigue, sleep problems, negative trends in others, withdrawal, dissatisfaction, failure feeling, and extortion and decreased job performance (11). This syndrome has the power to affect and be affected by various internal and external factors while organizational culture is known as one of the external affecting and affective factors (12, 13). In our country there are few researches about the organizational culture of hospitals based on the Hofstede’s model.

This study defines the organizational culture and the job burnout of staff who involved in the research community so that managers and administrators can manage burnout using its results.

2. MATERIALS AND METHODS

2. 1.Statistical population, sample and sampling method

The population of this research includes all clinical staff (physicians and nurses) and non-clinical staff (financial and administrative- support) in 16 hospitals covered by Tehran University of Medical Sciences. Due to the extensive differences in the research population of health and treatment sector, simple random classification method was used in this research. Each classification includes a hospital covered by Tehran University of Medical Sciences. Since the purpose of this research was evaluation of the relationship between two variables, sample size by 95% of confidence and test power of 80% was estimated as if the correlation is equal or higher than 2.0 then it is statistically significant; finally, the obtained number was multiplied in the coefficient of 2 as the factor of sampling pattern and the total number of samples achieved as followings:

Then the list of hospitals were prepared with the staff population and then the number of samples was split to the ratio proportional to the size of each class while finally, the data were collected.

2. 2.Research tool and scoring method

The first applied questionnaire in this research included questions related to the Hofstede’s cultural dimensions which was designed based on the questionnaire represented by Dorfman and Howell (1988) and evaluated the four dimensions including masculinity / femininity, individualism / pluralism, ambiguity aversion, and the distance from power at the individual level. Response scale to 25 questions about organizational culture was in Likert with five spectrum (strongly disagree = 1 to fully agree = 5). In fact, it was asked people to define their understanding from the current situation of each item using this scale. The average score of 1- 9 expressions was considered as the masculinity / femininity, average score of 10- 14 phrases was considered for the individualism / pluralism, average scores of 15-19 phrases was allocated to the ambiguity aversion, and the score of 20- 25 expressions was allocated for the distance of power. If the obtained score for masculinity / femininity is greater than 3 the organizational culture is masculinity, if it is less than 3, then the culture of organization is femininity, and if the score is obtained 3 then there is a cultural balance in the organization. If the achieved score for individualism / pluralism is greater than 3 the organizational culture is pluralism, if it is less than 3, then the culture of organization is individualism, and if the score is obtained 3 then there is a cultural balance in the organization. If the achieved score for ambiguity aversion is greater than 3 then the organizational culture is aversion of unreliability, if it is less than 3, then the culture of organization is risks, and if the score is obtained 3 then there is a cultural balance in the organization. If the achieved score for distance of power is greater than 3 then the power distribution is unfair, while if it is less than 3 then there is considered relatively fair and if the score is obtained 3 then there is a cultural balance in the organization (5). The second questionnaire of this study was Maslach Burnout Inventory (1981). This questionnaire included 22 articles which evaluated the emotional exhaustion (questions 9- 1), lack of personal accomplishment (questions 17-10), and depersonalization (questions 22-18). The articles of questionnaire were scored based on the 7-point Likert Scale. In this test 0 score was considered for “Never”, 1 was allocated for “very low”, 2 was pertained to “average”, 4 was considered for “average to above”, 5 was allocated for “high” and finally 6 was pertained to “very high”. When the scores of people are identified for any specific question then three tests can be calculated by gathering the scores.

2. 3. Validity and reliability of research method

Nazariyan studied the managerial levels of medium and large private organizations in Iran in 2014, and obtained higher than 0.70 for Cronbach’s alpha coefficients by Hofstede organizational culture questionnaire for all the studied dimensions (14).

Rashedi obtained validity index of content as 0.78 for organizational culture questionnaire while its reliability for each of the subscales of organizational culture of the masculinity, individualism, risks, and distance from power was obtained as 0.85, 0.72, 0.78, and 0.73 respectively using Cronbach’s alpha coefficient (15). In this research, Cronbach’s alpha coefficients were achieved as 0.836 for the entire questionnaire of culture. Validity and reliability of Maslach Burnout Inventory also was approved for the first time by Philippines (1992) in Iran who reported its reliability by test-retest method as 0.78 (16). In the present research, Cronbach’s alpha coefficient was obtained as 0.913 for the entire questionnaire.

3. RESULTS

Participants of the research were 27% male and 73% female among the participants in the study. 5.5% of participants had diploma or associate degree, 65.8 % had a bachelor’s degree, 11.2% had a master’s degree, 7.3% had a Ph.D, and 10.2% were residents. Based on the research results the forms of employment were contraction in 22%, thesis in 28.1%, contractual in 7.9%, and official in 42% of participants in the studied hospitals. The findings of this study showed the age range of participants as following: 52.7% in the range of 20- 30 years; 32.2% in the range of 31- 40 years; and 15.1% in the higher than 41 years age range respectively. 41.2% of participants were single whereas 58.8% were married.

The job experience of statistical samples included: 12.3% without experience or less than one year job experience, 38.4% with 1- 5 years, 24% with 6- 10, 8.6% with 11- 15 years, 8.9% with 16- 20 years, and 7.8% with over than 20 years of job experiences. 304 participants equal to 79.8% were medical staff whereas 77 of them equals to 20.2% were hospital staff.

Table 1 shows Average and Standard Deviation (SD) of job burnout components. Based on the findings, job burnout was observed in emotional exhaustion moderately (in the range of 26- 39); personal adequacy at low levels (≤36), and at the high levels in the area of depersonalization (15≤). The following table shows that, 40.6% of participants had moderate burnout in the area of the emotional exhaustion, 82.1% of them fought with the high burnout in the depersonalization area, and finally 73.2% of these people showed low level of burnout in the personal accomplishment area.

Table 1.

Distribution of frequencies and the statistics obtained from descriptive average of job burnout components

The results of Kolmogorov-Smirnov test in order to examine the data distribution showed that organizational culture variable and masculinity and femininity components had normal distribution while the components of individualism / pluralism, ambiguity aversion, and the distance from power had an abnormal distribution. Therefore single-sample t-test and binomial test were applied in order to determine the status of organizational culture based on the distribution of variables. Due to the results, masculinity culture is dominant among the evaluated staff (Table 2). The results of binomial test also suggest that pluralism cultural, avoidance of uncertainty culture, and a fair distribution of power among the staff is dominated (Table 3).

Table 2.

Results of single simple t-test in the analysis of masculinity / femininity components

Table 3.

The results of the binominal test in analysis of the organizational culture components

The results of the multiple correlation coefficients (Table 4) showed that there is a positive and significant correlation between masculinity / femininity, individualism / pluralism, ambiguity aversion, and the distance from power with job burnout (p<0.001, r= 0.305). The coefficient of R² determination which represents the determined variable change percentage from the considered variable changes by the predictor variables showed that 9.3% of the job burnout variance is related to the organizational culture while 90.7% is related to some factors which are outside of the model.

Table 4.

Results of multiple correlations between masculinity / femininity, individualism / pluralism, uncertainty avoidance and power distance with staff burnout

The results of multiple regression analysis (Table 5) revealed that masculinity / femininity (p =0. 016, t= 2.428), individualism / pluralism (p =0. 002, t=0. 054), ambiguity aversion (p=0. 042, t=2.045), and the distance from power (p =0.002, t=3.130) had qualification of forecasting the job burnout of the staff. Standardized coefficient of beta (β) is also can be used as a scale of the relative importance of the variables. Therefore comparison of masculinity/ femininity (0.13), individualism/ pluralism (0.16), the avoidance of ambiguity (0.11), and the distance from power (-0.17) demonstrated the more importance of power distance variable for anticipation of changes in the job burnout of staff rather than other variables. Therefore regression equation between the variables of organizational culture and job burnout of staff based on the data in Table 5 is as followings:

Table 5.

The results of regression analysis between masculinity / femininity, individualism / pluralism, ambiguity aversion and distance from the power with the employee burnout

Y = a + b₁x₁ + b₂x₂ -b₃x₃ + b₄x₄

Y =4.3040.185 +0 (x¹) +0.178 (x2) -0.200 (x3)+ 0.241(x4)

x¹= Femininity- Masculinity

x2= Ambiguity aversion

X3= distance from power

X4= pluralism- individualism

Based on the above equation, the level of staff burnout (Y) will change per masculinity/ femininity (X₁), ambiguity aversion (X₂), distance from power (X₃), and the avoidance of pluralism/ individualism (X₄); in the other words a part of the job burnout of employees is determined directly by masculinity / femininity, individualism / pluralism, ambiguity aversion components whereas distance from the power determines it indirectly.

4. DISCUSSION

The results of research analysis about four Hofstede’s cultural dimensions indicate that culture of democracy is dominated in the universities of medical sciences (Table 2) and therefore the dominant values of the organizations include: success, courage, and physical issues. Despite the lack of studies about Hofstede’s organizational culture in the research environment of hospital in this country, the results of this research is consistent with the results of Anderkhura et al (2004) and Rashedi et al (2012) on the staff of Welfare Organization (15, 17). As well as pluralism and avoidance of uncertainty is dominated in the hospitals of medical sciences university (Table 3) and therefore because of the pluralism in this culture, the tendency of people to dependency on the groups or communities and taking care of each other is high due to their commitment and also by avoidance of uncertainty from exposure to ambiguous situations. The results of this research are consistent with the researches of Anderukha et al (2004) and Rashedi et al (2012) (15, 17). Dargahi and colleagues (2010) also in their study demonstrated that the risk level of the current status of organizational culture in the hospitals of Medical Sciences covered by Tehran University is less than desirable. This means that managers of these organizations don’t believe in the giving the opportunities and personal independence to the staff in order to handle the hazardous actions and welcomed to the difficult situations (18). Based on the results, power distance is lower than its average in the evaluated population (Table 3) and therefore people essentially love their job and are willing to do it. In this type of culture, the people appeare younger than what they really are and powerful people do not want to boast their power. In this type of culture, people who place at high levels of organization, deal with the people in the lower levels of organization effectively however the differences in the position of director always is clear (19). Accordingly based on the perspective of Hofstede it can be concluded that hospitals are no longer centralized and high structures in which people in the operational levels have low qualifications for job specification and problems don’t be solved. The unequal distribution of power in the research hospitals is less acceptable and other people do not follow the superiors in blind (17). Nazaripour and colleagues concluded that the score of power distance in the Iranian organizations has been declining (20). The results also showed that the specialists in the studied hospitals have had little power distance (21).

The results of the present study revealed that job burnout is moderate in the emotional exhaustion area, high in the area of depersonalization, and low in the area of personal accomplishment among the participants. Emotional exhaustion shows the distance from job; while it is a condition that person loses his/ her emotional forces and gets into trouble in their relationships and these conditions are moderate in the studied population. Depersonalization also reveals the unsentimental, harsh, and irrelevant responses of staff to clients that have highly been observed among the staff. Despite these features, studied hospital staff had positive impressions to their efforts that is following of their good results in the job; then they have high personal accomplishment; as personal accomplishment is created when people can have positive impressions on the policies of the organization and by this way they can display their capabilities; in this case they will feel confident and also have more power and dominance to do their duties (22). The level of job burnout has been reported in various internal and external investigations; so that Talaie and colleagues (2008) have reported the average scores of emotional exhaustion and depersonalization in low levels (23). Wang et al (2014) have performed a research with the title of studying the job burnout and its related factors in the doctors of Shanghai that doctors in all three dimensions including emotional exhaustion, depersonalization, and personal accomplishment had average burnout (24).

Avgresta et al (2008) found average emotional exhaustion and depersonalization, and high decrease in the performance in the staff of psychiatric hospitals (25). Farzianpour and colleagues (2013) reported the average of emotional exhaustion as 28.4, depersonalization as 32.6, and the average of personal accomplishment as 29.1 (26). The differences may be due to working conditions, organizational atmosphere, or personal variables such as the values, beliefs, and sense of control over the environment. Since different people work under the various conditions, then the requirements of service recipients will also be varied and therefore they have different levels of job burnout. The present study (Table 4) showed that there is positive and significant relationship between the components of organizational culture and job burnout (p <0.05, r=0.305). Rahimnia and Hassan Zadeh (1391) revealed that there is a significant negative relationship between the job burnout and organizational culture while job burnout can attenuate the organizational culture (27). The research of Pinz (2004) also demonstrated that job burnout is related to the dimensions of organizational culture including the power distance, individualism, uncertainty and women / masculinity (28). Rashedi et al. (2012), demonstrated that organizational culture (individualism / pluralism and risk) has a significant positive correlation with job burnout (15).

According to Table 5, as the organizational staffs accept masculinity, they will more expose to the job burnout. Isler and colleagues (1988) found that stress is associated with sex so that men have more stress associated with masculine roles while masculinity is associated with the increasing anger, violence, and decrease in the health behaviors among men and women. When men believe that do activations better and are premier rather than others, they assumed more responsibilities and incur additional workload (29). The present study also showed that as people accept more teamwork and excellence groups, they will expose to the job burnout. It seems that individualistic cultures are more suitable amplifiers for creativity because creative thinking is more flourished individually. Additionally, the risk grows with high races in the different cultures with individualism. The research of Rashedi and colleagues (2012) in their research showed that the severity of personal accomplishment increases along with increasing pluralism in staffs (30). Noteworthy when people with high willingness to the teamwork and pluralism culture place in the groups and their characters are defined based on their groups; they are supported by their groups; but this support is followed by some costs. Since people should be careful of others and respect to their demands, then this provides an unwritten but powerful control on the group. In this type of culture, individual is impressed by decisions of their families and friends and by this was stress is imposed on him. On the other hand the decision-making of group can lead people to feel their performance is not successful and provides a lack of personal accomplishment (31). According to the present study, as there are more tendencies to the distance from the power, there will be less job burnout. These findings can be explained by the following reasons including: 1. Job burnout is not only based on the work-related stress, but it is related to the overall style of life and many other factors. In this situation, the job loses its importance and people deal with constant fatigue, pessimism and anger, suspicion, irritability and impatience and so on (32). 2. Although people emotionally tend to have lower power distance; in reality the reduction of power distance means the decision-making of managers with the help of staff, asking their opinions, opposition of staff with management ideas, and acceptance of some important tasks for the staff. While it seems the responsibilities of employees increased and consequently the stress from good performance is imposed on them. 3. Power Distance may be related to the leadership style of organizations. The leader is an individual who has different talents and skills and focuses on the followings in order to achieve the objectives of the organization. It causes to use intellectual, emotional and physical energies in the form of coordinated efforts willingly and enthusiastically. Appropriate behavior patterns of director in each organization results in providing a strong spirit in employments and increase their job satisfaction. Managers can increase satisfaction and organizational commitment of employments and performance of their organization through the proper leadership style. The research of Densten (2005) revealed that inspired behaviors of directors reduces job burnout of subordinates by helping them to recognize and understand that includes decreasing of frustration, increasing self-efficacy, and confidence (33). In fact if the power distance in the organization is low but the behavior of leaders lead to fear and anxiety among employees, then their job burnout will increase. 3. Although the distance of power is low in the organization however employments sometimes encountered some cases which create inequality feeling in them. Cropanzano (2010) found that despite there is low power distance in some organizations, the perception of inequality and distance of power in the organization and jobs are like toxins for the organizations. When people do not understand the system fairly, they tend to the reduction of the energy, idleness, and truancy to give them a sense of justice (34). Greenberg believes that managers should behave fair to make the organization effectiveness and they should be sure that subordinates will interpret their activities fairly. The perceived unfairness in the organization leads to a sense of dissatisfaction in individuals so that their works will not be successful (35).

5. CONCLUSION

It can be concluded that some health issues related to the staff health is based on their culture; therefore, the evaluation of organizational culture by managers of hospitals is required in order to achieve success planning for organization by strengthening the organizational culture, preserving personal independence within the work groups, creation of a healthy environment, enhancing their tolerance and risks and individual adjustment, stress management, etc. which it will help employments to be health and reduce their job burnout.