Organizational Climate for Better Performance in Healthcare · I feel very lucky with my supervisor Professors Sabina Nuti and Chiara Seghieri. I am truly indebted to Professor Sabina

Sant’Anna School of Advanced Studies

PhD Thesis

Organizational Climate for BetterPerformance in Healthcare

Diana Rojas Torres

A dissertation submitted to Sant’Anna School of Advanced Studies

in partial fulfillment of the requirements for the degree ofDoctor of Philosophy in Management, Innovation, Services and

Sustainability

November 8, 2013

Pisa, Italy

Sant’Anna School of Advanced Studies

PhD Thesis

Organizational Climate for BetterPerformance in Healthcare

Candidate:

Diana Rojas Torres

Tutor:

Prof. Sabina Nuti

Supervisor:

PhD. Chiara Seghieri

November 8, 2013

Pisa, Italy

c© 2013, Diana Rojas Torres

All rights reserved.

Printed in Pisa, Italy.

Sant’Anna School of Advanced Studies, Institute of Management -

MeS.

Piazza Martiri della Liberta, 33, 56127

Pisa, Italy

Acknowledgement

Thinking about how to write this last part of the thesis, I remember when I started

my new Italian adventure three years ago. Retrospectively, I think it was one of

the experiences that have made me grow as a person, as professional and has led to

push myself to be better every day and this would not have been possible without

the help of all the people that have surrounded me from the first moment.

I feel very lucky with my supervisor Professors Sabina Nuti and Chiara Seghieri.

I am truly indebted to Professor Sabina Nuti for giving me the opportunity to

work with her, for her valuable guidance and research inputs; and with Chiara

Seghieri for her patience and guidance through the “statistics world”, she patiently

addressed my questions and doubts, and very generously shared her knowledge with

me. They continuously encouraged me to give the best.

I would like to express my sincere gratitude to MeS colleagues for their support and

collaboration, because they did the MeS Lab a pleasant place to work, in particular

I would like to thank: Anna Maria Murante, Milena Vainieri, Francesca Sanna,

Domenico Cerasuolo and Francesco Niccolai for their insights in the correct moment

and I extend my thanks to all faculty members at Stant’Anna School of Advance

Studies.

Over time, many more people made my PhD time unforgettable. I would like

to thank my partners: Lorena, Filippo, Francesco, Elisa, Maria Rosa, Francesca,

Elisabetta, Barbara, Nicola, Eleonora, Kamran, Claudia and Elena. I wish to

thank specially to Lorena, Milagros, Serena, Ilaria and Lorenzo for offered me their

friendship in the right moment.

Agradezco a mi familia, por tenerme presente todos los das sin importar que nos

separen kilmetros de distancia, a mi mami por mostrarme el camino del amor, a mi

papi por su apoyo y cercana, a la familia de Marco por su ayuda en momentos de

ii

necesidad, a mis amigas y amigos Sol, Maria, Jury, Laura, Eliana, Carolina, Alvaro,

Alonso, Drochss y David por su ayuda incondicional. Finalmente a mi hija por ser

la luz en mi camino porque este reto no hubiese sido posible sin la ayuda de ella y

a Marco por su apoyo para sacar este proyecto de vida adelante.

Contents

Organizational Climate in healthcare: An Introduction 1

1 Mapping the Organizational Climate concept with scientific cita-

tion networks 7

1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

1.2 Scientific citation networks methodology . . . . . . . . . . . . . . . 9

1.3 Organizational climate: Review of concepts . . . . . . . . . . . . . . 10

1.4 Data collection and methodology . . . . . . . . . . . . . . . . . . . 15

1.5 Citation networks in organizational climate papers . . . . . . . . . . 17

1.6 Concluding remarks . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

2 Are there gender differences in perceived organizational climate?:

The case of Tuscan healthcare system. 24

2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

2.2 Data and Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

2.3 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

2.4 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

2.5 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

2.A Questionnaires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

3 Organizational climate: Comparing private and public hospitals

within professional roles 40

3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

3.2 The context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

3.3 Data and Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

3.4 Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

3.5 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

4 Does feedback from patient-experience surveys change behavior

of health professionals and improve communication with patients?

The Italian experience 50

Contents iv

4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

4.2 Study Data And Methods . . . . . . . . . . . . . . . . . . . . . . . 52

4.2.1 Surveys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

4.2.2 Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

4.2.3 Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

4.3 Study Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

4.4 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

4.5 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

4.A Multilevel statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

List of Tables

1.1 Most cited authors in Organizational Climate topic . . . . . . . . . 18

1.2 The longest sequence of papers on the main path . . . . . . . . . . 23

2.1 Descriptive statistics in healthcare managers and staff by gender. . 29

2.2 Gender differences of perceived organizational climate at managerial

level. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

2.3 Distribution of male/female respondents by selected questions within

dimension of communication and information processing at manage-

rial level. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

2.4 Gender differences of perceived organizational climate and profes-

sional roles at staff level. . . . . . . . . . . . . . . . . . . . . . . . . 32

2.5 Distribution of male/female respondents by selected questions about

career opportunities . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

2.6 Questionnaire A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

2.7 Questionnaire B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

3.1 Descriptive statistics within hospital status . . . . . . . . . . . . . . 45

3.2 Public Vs. Private differences at professional roles of perceived

climate and job satisfaction . . . . . . . . . . . . . . . . . . . . . . 46

4.1 Mean Patient Experience with Communication (PEC) values across

Tuscan hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

4.2 Model coefficients and variance at the patient and hospital levels . . 58

4.3 Statistics about explanatory variables introduced in the multilevel

model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

4.4 Multilevel empty model . . . . . . . . . . . . . . . . . . . . . . . . . 62

List of Figures

1.1 Calculation of SPNP . . . . . . . . . . . . . . . . . . . . . . . . . . 10

1.2 Number of publications each ten years . . . . . . . . . . . . . . . . 16

1.3 Number of publications per type of journal . . . . . . . . . . . . . . 17

1.4 Main path for organizational climate network . . . . . . . . . . . . 19

4.1 Mean Patient Experience . . . . . . . . . . . . . . . . . . . . . . . . 56

4.2 Awareness of inpatient survey data . . . . . . . . . . . . . . . . . . 59

This thesis is dedicated to the memory of my mom,

who teach me the benefits of love and be loved.

Thanks mom, I love you!

Organizational Climate in healthcare:An Introduction

“Hospitals act in an environment which is characterized not only

by limited financial resources but also by actively involved and edu-

cated health care consumers. Hospitals need to employ and coordinate

specialized knowledge, skills and abilities embedded in their employees

to deliver quality care to patients. As in other service organizations,

intangible resources are particularly relevant to provide high quality

services. It could be argued that among the most important intangible

resources in hospitals are structural knowledge, social competence,

staff motivation, and patient satisfaction. In such human-capital

intensive organizations as hospitals, the overall performance of the

organization depends on the performance of its employees based on

intelligent behavior and their motivation.”

Zigan, Macfarlane, and Desombre (2007)

This doctoral research is a compilation of four essays discussing the issue of organi-

zational climate as a tool for improving performance in healthcare. We studied four

problems in human resource management, first, is the evolution of organizational

climate concept; second, is the gender differences at managerial level; third, the

difference between private and public internal climate and last one the importance

of disseminate surveys results to improve communication between patients and

healthcare providers.

In chapter 1 we seek to analyze the literature in organizational climate topic

investigating the development of the concept and describing the evolution of the

literature during the last fifty years, understanding the central constructs and their

relationships with the existing theory , this paper suggests implications for further

research.


Chapter 2 reveals that there are gender differences in how health workers perceived

the organizational climate considering the professional role, it was found that males

rather higher satisfaction with the work environment than females at managerial

level and at staff level women report higher satisfaction in all organizational climate

dimensions.

Chapter 3 compares the organizational climate within professional roles in private

and public institutions, employees in private hospitals are more satisfied than

employees in public ones demonstrating the hypothesis than in private institutions

are motivated by their economic well-being while in public sector the managers

are more object-oriented and they have a desire to serve the public interest and

strongly oriented towards the common good.

Chapter 4 explores the relationship between feedback and task performance with a

special emphasis on analysis of inpatient survey data that have been disclosed for

public scrutiny. In particular, this study aims to quantify the impact of professional

awareness of patient experience showing that patient experience index significantly

improved by 0.35 points (scale: 0-100) when professionals knowledge of survey

results increased by 1%.

Human resources theories developed mostly by psychologists more than sixty years

ago addressed the issue of motivation in the workplace. Maslow (1943) in his paper

”A theory of human motivation”, he organized human needs in five general levels:

a) Physiological needs (food, water, sex, shelter); b) Safety needs (protection); c)

Social needs (belonging, acceptance); d) Ego needs (status, appreciation) and e)

Self-actualization needs (need to exploit their own potential), where (a), (b) and

(c) are basic or deficit needs and (d) and (e) are follow up when deficit needs are

satisfied. (Maslow, 1943)

Herzberg et al. (1959) in his paper ”The motivation to work” divided need satis-

faction into extrinsic and intrinsic factors; extrinsic factors depend on the salary,

working conditions and job security but there is no correlation with job satisfaction.

The intrinsic factors as recognition, status and achievements are the driving force to

satisfy the worker’s needs for psychological growth and it shows a direct relationship

with job satisfaction and motivation. However, Herzberg’s work has been examined

from methodological point of view because in his analysis not is clear the difference

between job satisfaction and motivation. (Vroom, 1966; House and Wigdor, 1967)


For a long time the concept of organizational climate was ambiguous and it was

important to recognize the difference between organizational culture and organi-

zational climate, because they focus on diverse aspects of organizational analysis.

The term organizational climate began to appear in management literature in the

1970s but at the beginning the concepts of organizational climate and culture were

commonly undifferentiated in the literature, for example Porter et al. (1975) defined

organizational climate or culture like a set of customs and typical patterns of ways

of doing things. (Porter et al., 1975)

James and Jones (1974) presented their essay about ”Organizational climate: A

review of theory and research” in this paper, they defined organizational climate

as a construct referred to the manner in which organizational members perceive

the work environment within that organization and its impact on their individual

psychological well being. In 1990 Payne treated climate as a way of measuring

culture. (James and Jones, 1974; Payne, 1991)

In a meta-analysis of 88 studies, Spector (1986) found positive results in the

organizational climate associated with high levels of perceived control, including

job satisfaction, commitment, participation, performance and motivation levels and

negative results with stress, role stress, absenteeism, intention to leave a job, and

the turnover. (Spector, 1986)

Employee satisfaction has a direct, positive impact on functioning of whole organi-

zation. It strongly affects the institution’s global performance and it is often the key

element that makes the difference (Schneider, 1987; Nuti and Macchia, 2005; Dawson

et al., 2008; Judge et al., 2001). Several literature shows a strong association among

high performance, customer satisfaction and organizational climate and positive

correlation between climate and rewards. Goleman affirmed that ”Organizational

climate is not the only driver of performance. Economic conditions and competitive

dynamics matter enormously. But our analysis suggests that climate accounts for

nearly a third of the results”. (Goleman, 2000)

Several studies have outlined the importance of organizational climate in the

healthcare context, see e.g. (Appelbaum, 1984; Clarke et al., 2002; Gershon et al.,

2004; Jackson-Malik, 2005; Mok and Au-Yeung, 2002; Sleutel, 2000; Stone et al., 2006;

Wienand et al., 2007a). Among organizational factors related to climate, continuing

training and education (Spath, 2002), leadership style, project management, staff


recognition, dedicated time and resources for improvement projects (Thomson et al.,

2002) all have been identified as important factors for health care staff’s commitment

and loyalty toward the organization.

Recently, a renewed interest about the importance of intangible resource in de-

termining organizational performances has increased, in particular some authors

have discussed their relevance as drivers of outstanding performances in hospi-

tals (Douglas and Ryman, 2003; Habersam and Piber, 2003; Zigan et al., 2007).

Meanwhile, other authors are specifically addressed the organizational climate as

predictor of good performance (Brown and Leigh, 1996; Patterson et al., 2005),

it is particular valuable for healthcare services where organizational climate is

therefore, a multidimensional distinctive feature of organization, which results from

a synergic combination of several intangible elements related to human, relational

and structural dimensions of the organization. (Carlucci et al., 2009)

Healthcare organizations are usually considered complex institutions and they have

a particular structure due to the diversity of organizational forms, hospital status,

hospital size and wards that are evolving, this parameters also render difficult their

managerial control.

Clarke et al. (2002) found that staffing and organizational climate influence hospital

nurses’ likelihood of sustaining needlestick injuries, (Clarke et al., 2002). Stone et al.

(2006) found that negative perceptions of organizational climate predicted nurses’

intention to leave within intensive care units (Stone et al., 2006). Dimensions of

organizational climate seem also depending on the particular characteristics of the

work environment (Tovey and Adams, 1999). Cumbey and Alexander (1998), for

instance, found that organizational structure was a crucial determining variable in

predicting job satisfaction among nurses, (Cumbey and Alexander, 1998). Moreover,

some important differences between teaching and community hospitals have been

found for different groups of nurses: nurses working in teaching hospitals reported

lower levels of role tension, and higher levels of job stress and job satisfaction than

their colleagues in the community sites (Hall et al., 2006)


Research Context

The Italian health care system is a National Health Service (Beveridge-like model)

accessible to the full population providing preventive and curative services. The

system is organized at three levels: national, regional and local. The national level

is responsible for ensuring the general objectives and fundamental principles of the

National Health Service. The regional governments are responsible for ensuring

the delivery of the health care through a network of population-based healthcare

organizations (health authorities).

The strong policy of decentralization, which has been taking place since the early

1990s, has gradually transferred several important administrative and organizational

responsibilities from the state to the 21 Italian regions with the aim of making

regions more sensitive to the need to control expenditure and promote efficiency,

quality, and citizen satisfaction.

This devolution process provided regions with significant autonomy in organizing

healthcare services, allocating financial resources to their Local Health Authorities

(LHAs), and in monitoring and in assessing performance (Nuti, 2008; Antonini

and Pin, 2009). Whereas, the central government retains overall responsibility for

ensuring that services, care and assistance are equitably distributed to citizens

across the country.

Since the 1980s the introduction of ”New Public Management” (NPM) (Kettl,

2000; Pollitt, 1995) principles has promoted a number of reforms in public services

organizations in order to improve the performance in the public sector but especially

have started to focus on customer satisfaction and more effective management

(Mouritsen et al., 2005).

The Tuscany region has approximately 3,7 million inhabitants in an area of 22,994

km2 in the center of Italy. It’s healthcare system currently counts about 51,000

employees, including nurses, physicians, technicians and administrative staff, for

a total public expenditure of 6,6 billion Euros. The regional government works

through a network of seventeen public health authorities of which five are teaching

hospitals (THs), integrated with the Universities of Florence, Pisa and Siena (among

them, one is a paediatric hospital and another is a highly specialized hospital on


cardiovascular diseases) and twelve are Local Health Authorities (LHAs). In 2000

the Tuscany region began a process of reorganization of the system that allow them

to work in three operating structures called ”Area Vasta” (AV). Each AV includes a

network of these LHAs grouped by geographic proximity. /citepnuti2013variation.

Since 2004 the Laboratory MeS on behalf of Tuscany region created the ”Multi-

dimensional Performance Evaluation System in healthcare. The system consists

of 50 composite and more than 130 simple indicators. Indicators are classified in

the following six dimensions: population health status; capacity to pursue regional

strategies (i.e. to guarantee that strategic regional goals are pursued in the indicated

time and manner); clinical performance (i.e. quality, appropriateness, effectiveness,

clinical risk management and primary care); patient satisfaction; organizational

climate and finally efficiency and financial performance”. (Nuti et al., 2013).

1

Mapping the Organizational Climateconcept with scientific citation

networks 1

In this research we present the results of an earlier pilot study about citation

networks applied to organizational climate topic. We use citation networks to

study the dynamics of the organizational climate concept in scientific papers

from 1983 to 2012. We identify the most significant papers, then we analyze

the structure of the top path of citation networks to understand the main

scientific trajectory in this field. Our results suggest that these scientific

trajectories are characterized by the presence of a number of papers analyzing

the definition and difference between organizational culture and climate.

1.1 Introduction

This research has the purpose to understand the evolution of organizational climate

concept until 2013. The term ”organizational climate” began to appear in man-

agement literature in the decade of 70’s and the first interpretations confounded

the expression with the definition of ”organizational culture” making the two terms

almost interchangeable (Porter et al., 1975). We focus on studying the development

of this topic in the literature and point out the most representative authors in this

field.

1Acknowledgements:The author wish to thank to David Barbera and Alessandro Nuvolari tomotivate this work.

Introduction 8

We can see an extensive literature about the importance of motivation at work

in human resource management (Maslow, 1943; Herzberg et al., 1959; James and

James, 1989; Glick, 1985); this literature suggest that satisfied employees tend to

be more productive, creative and enthusiastic to their employers. In particular,

it has been pointed out that proper organizational climate has a direct, positive

impact on functioning of the team and is correlated with the performance in the

organization (Spector, 1986).

Organizational climate was defined in 1968 by Tagiuri as a ”quality of the internal

environment of an organization that: (a) is experienced by its members, (b) influ-

ences their behaviour and (c) can be described in terms of the values of a particular

set of characteristics (or attributes) of the organization” (Tagiuri R, 1968). From

a human resources management, this definition present several points of interest.

First, the importance of organizational culture and climate in the organization

because it has been shown that there is an important relationship between them and

organizational performance outcomes (Schneider et al., 2002). Second, the concept

is ambiguously defined and it is important to recognize the difference between

organizational culture and organizational climate. Third, few studies examine the

importance of the climate in healthcare sector and additional research is needed to

understand this complex organizations.

Citation to scientific articles analysis (citation networks) is applied to estimate the

importance of a scientific publication as the number of times that which has been

cited by other authors (Vieira and Gomes, 2010). Our premise is that citation to

scientific articles analysis is a good indicator of prior knowledge that have a positive

impact on the scientific community.

Our discussion relies on the study of an exploratory analysis of citations links among

scientific papers in organizational climate context within Thomson Reuters (Web

of Science, WoS) database. Therefore, we can identify the main paths through

examination of the citation network structure, which concept has been developed

over time.

We adopt the methodology follows by Hummon and Dereian (1989), who have

suggested certain criteria for the identification of the main paths of ”connectivity”

in a network. This methodology is applied to several studies about citation networks

and patent citation networks that used citations to obtain a sequence of patents

Scientific citation networks methodology 9

to follow the technological evolution (Dosi, 1982) in a particular field (Verspagen,

2007; Fontana et al., 2009; Barbera-Tomas et al., 2011).

The structure of the paper is as follows. Section 1.2 illustrates the scientific

citation network methodology. In Section 1.3 we provide a review of concepts in

organizational climate. In Section 1.4 we describe the construction of our citation

analysis data-set and gives a preliminary descriptive analysis of its main properties.

In Section 1.5 we present a short insights of the evolution of the organizational

climate concept using citation networks. In Section 1.6 we conclude the study.

1.2 Scientific citation networks methodology

This research proposed a citation network as a collection of vertices and edges where

the network vertices are papers and a directed edge are connections from paper A to

paper B if A cites B in its bibliography. The analysis of the connectivity structure

allows to identify a set of scientific papers which constitutes the main flow of ideas

in a field of knowledge and link the thematic connections with important scientific

papers. We will consider direct edges, the direction will be from the cited to citing

article, it means from the earlier article to the later one.

We will follow the approach proposed by Hummon and Doreian (Hummon and

Dereian, 1989), they are interested in identifying the main paths of the network.

These main paths are the main flows of ideas in the structure of the network. They

assigned a weight to each citation link based on the position of this structure. In

Figure 1.1 (adapted from (Fontana et al., 2009)), paper A is cited by paper C, which

is cited by paper D. A search path is represented by the sequence A-C-D-F-H-J,

indicating knowledge flow from paper A to paper J through some intermediate

papers.

A complementary connectivity measure proposed by Hummon and Doreian is the

SPNP (Search Path Node Pair). Consider the edge C-D (fig 1). This edge connects

three vertices (A, B, C) to the final stop (D). At the same time, this edge connects

its origin (C) to seven other vertices (D, E, F, G, H, I and J). The SPNP value is

the product of these values (3×7 = 21).

Organizational climate: Review of concepts 10

Figure 1.1: Calculation of SPNP. Source: adapted from Fontana et al. 2009

Once a measure of the importance of the edges is calculates (SPNP or SPLC),

Hummon and Doreian propose to define the main path through a network as the

path along which the sum of SPNP/SPLC over all the edges is maximized, under

the restriction that at each vertex, only the outward edge with highest value among

all outward edges is taken (in case of a tie, both edges are added to the main path).

It is obvious from the definition that the main path must begin at a start point of

the network, and finish at an endpoint. (Verspagen, 2007)

Although there is a degree of arbitrariness in selecting only the maximum value,

or in the way ties are treated, this heuristic procedure corresponds to the idea of

tracing the most important ows in the citation network. Hummon and Doreian

focus most of their attention on the single main path that has the maximum value

of total weights on the edges. But one could also enlarge the denition and define

a main path for each start point in the network, by selecting the outward edge

with maximum weight, and repeating this until an endpoint is reached. This would

create a network of main paths (Hummon and Dereian, 1989).

The result of this measure is that the citation links connected by the higher numbers

of papers contain the most important knowledge flows in the citation network. In

2007 Verspagen defined the top path like the highest sum of SPNP.

1.3 Organizational climate: Review of concepts

In this paper we apply the citation networks methodology to study the evolution of

organizational climate concept. It is widely recognized that intangible resources have

a positive impact on performance (Zigan et al., 2007). Actually, human resources

are considered the most important intangible assets in the organization, where the


organizational culture and climate constitutes the main organizations advantage

and permit differentiate between organizations within a society, particularly in

relation to different levels of effectiveness. (Schein, 1990)

Human resources theories highlight the importance of motivating employees in the

workplace and suggest that satisfied employees are more productive, innovative

and efficient (Maslow, 1943). The theory of motivation was the first attempt to

conceptualize the organizational climate theories.

Organizational climate theory is widely studied in industrial and organizational

psychology. Koffka (1935) studied the behavior environment, Murray (1938) ana-

lyzed the personality problems on a level of depth and concreteness usually found

only in the work of the psychiatrist or psychoanalyst. Lewin et al. (1939) analyzed

the relationship between leadership style and climate. However, in the beginning

the conceptual definition of organizational climate and measurement techniques

were inconsistent.

It was not until 1958 when the term organizational climate began to appear in

management literature with an study made by Argyris (1958) about Some problems

in conceptualizing organizational climate: A case study of a bank, this study

affirmed that organization is composed of elements representing many different

levels of analysis; the climate (or homeostatic state) and leadership represent the

personality level of analysis, norms and values represent the cultural level, employee

satisfaction or dissatisfaction are the interaction of multilevel variables and the

clusters of these variables are namely organizational behavior. (Argyris, 1958)

Forehand and Von Haller (1964) reviewed the organizational climate literature found

in psychology, sociology, administration and education studies until 1964 and they

worked on the problem of variation in the conceptualization of climate term. They

found that organizational climate term means different things to different writers

and they concluded that organizational climate refers to the set of characteristics

that describe an organization and that (a) distinguish the organization from other

organizations, (b) are relatively enduring over time, and (c) influence the behavior

of people in the organization. (Forehand and Von Haller, 1964)

In 1968 an early definition of organizational climate is made by Tagiuri R (1968)

which defines organizational climate as a ”quality of the internal environment of an


organization that (a) is experienced by its members, (b) influences their behavior

and (c) can be described in terms of the values of a particular set of characteristics

(or attributes) of the organization”. (Tagiuri R, 1968)

Pritchard and Karasick (1973) explored the validity of a measure of climate construct

and they presented data on the relationship between climate, job performance

and satisfaction. They concluded that satisfaction relates positively with climate

perceptions and job satisfaction (Pritchard and Karasick, 1973). However, Guion

(1973) conclude that organizational climate represent a fuzzy concept and reinforced

the idea that climate measurement often used the same instruments and techniques

apply to job satisfaction research.

James and Jones (1974) published their work about organizational climate: A

review of theory and research, where they defined organizational climate as a

construct referred to the manner in which organizational members perceive the work

environment within that organization and its impact on their individual psychological

well being. They recommended make a differentiation between climate regarded

to organizational attribute (organizational climate) and climate regarded to an

individual attribute (psychological climate). (James and Jones, 1974)

Schneider (1975) proposed an essay about organizational climate. He presents an

evidence regarding the importance of climate, which refers to the perception of the

people about their work settings, each work organization probably creates different

kinds of climates and is related to the outcome behavior (dimension) and the unit

of analysis (professional role, organization). An important conclusion in this work is

the different conceptualization between organizational climate and job satisfaction

(Schneider, 1975). In previous studies of climate research Litwin and Stringer Jr

(1968) found that different kinds of climate could directly influence levels of job

satisfaction, this result allowed some authors to propose that the two concepts were

the same. (Litwin and Stringer Jr, 1968)

At this point, it is important to discuss the concepts of organizational culture and

organizational climate due to the lack of clarity among themselves. For example,

Porter et al. (1975) defined organizational climate or culture as a set of customs and

typical patterns of ways of doing things. However, the organizational culture and

climate focus in two different aspects of organizational studies.(Porter et al., 1975)


Burke and Litwin (1992) defined climate as perceptions about the workplace of

organizational members and culture is defined by beliefs and values within the

organization, but where the two concepts are interrelated, it means climate is

affected by culture and it is view as reciprocal processes. (Burke and Litwin, 1992)

The term culture began to appear in management literature in the 1970s. Culture

can be conceived as a set of attitudes, values and beliefs that guide organizational

behavior but what really distinguishes culture is what the attitudes, values and

beliefs are about (Brown and Payne, 1990). The broad conclusion has been that

organizational culture develops through social learning mechanisms. (Schein, 1985;

Kilmann et al., 1985; Hofstede et al., 1991) Culture is the way that things are

done and no reference to participants is made. (Schein, 1985) pointed out that

organizational culture is a complex phenomenon and he defined Culture as (a)

a pattern of basic assumptions, (b) invented, discovered, or developed by a given

group, (c) as it learns to cope with its problems of external adaptation and internal

integration, (d) that has worked well enough to be considered valid and, therefore

(e) is to be taught to new members as the (f) correct way to perceive, think,

and feel in relation to those problems. Finally, the actions and behaviors that are

associated with favorable outcomes tend to be repeated, and become norms in the

organizational structure. (Gray, 2004)

The distinction between climate and culture derives from the fact that the two

concepts reinforce each other. According to Kangis et al. (2000) whilst the con-

structs of culture and climate have developed in parallel, they have been driven

by researchers from different disciplines using different methodologies. There has

been little cross-fertilization of methods and ideas and considerable debate among

researchers about the relatedness of the two constructs. (Kangis et al., 2000)

In fact, between the two fields of study still exist a divergence . First, psychological

constructs, particularly those constructs related to group behavior are highlights in

culture studies. But some researchers on organizational climate have also tended

towards a group. Lawthom et al. (1995), after reviewing a number of definitions,

came to the conclusion that a precise and unitary definition of climate is yet to be

found but is possible to distinguish climate as a concept. First, refers to individual

perceptions. Second, it is descriptive rather than evaluative in its orientation. At

the end the definition that fit for climate purposes is what it feels like to work here.

(Lawthom et al., 1995)


Svyantek and Bott (2004) proposed the definitions which help distinguish between

climate and culture. Organizational culture is defined as a set of shared values and

norms held by employees that guide their interactions with peers, management, and

clients. Organizational climate is more behaviorally oriented in that climates for

creativity, innovation, safety, or service, for example, may be found in the workplace.

These climates represent employees perceptions of organizational policies, practices,

and procedures, and subsequent patterns of interaction and behaviors that support

creativity, innovation, safety, or service in the organization. (Svyantek and Bott,

2004)

Researchers in this field have outline the importance of measuring climate and

the typical measure of organizational climate is through questionnaires; asking

individuals whether they are agree or disagree with a series of statements designed

to capture the perceptions about the organization. (Payne, 1991) In the literature

there are a huge number of instruments proposed to measure it, some authors

identify different climate dimensions like psychological leadership (Glick, 1985);

managerial attitudes (Payne and Mansfield, 1978); communication flow (Drexler,

1977); service quality (Schneider, 1980); equity and centrality (James, 1982; Joyce

and Slocum, 1979).

Some authors have proposed that organizational climate is associated with impor-

tant outcomes at diverse levels (individual, groups and organization). There is a

positive correlation between climate and turnover intentions (Rentsch, 1990), job

satisfaction (Mathieu et al., 1993; James and Tetrick, 1986; James and Jones, 1980),

individual job performance (Brown and Leigh, 1996): (Pritchard and Karasick,

1973), organizational performance (Lawler III et al., 1974; Patterson et al., 2004),

and innovation. (Patterson et al., 2005)

In healthcare context several studies have outline the importance of organizational

climate, there is an increasing interest in study the relationship between organiza-

tional constructs and health services outcomes (Clarke et al., 2002; Jackson-Malik,

2005; Mok and Au-Yeung, 2002; Sleutel, 2000; Stone et al., 2006; Wienand et al.,

2007b; Carlucci et al., 2009; Gershon et al., 2004; Appelbaum, 1984)

Regarding to healthcare services, there is a growing need to understand the employees

perceptions and climate generated by their healthcare organization because there is

a positive correlation between climate, high quality service and patient satisfaction.

Data collection and methodology 15

(Sleutel, 2000; Stone et al., 2006)

Clarke et al. (2002) found that staffing and organizational climate influence hospital

nurses’ likelihood of sustaining needlestick injuries. Stone et al. (2006)analyzed

the relationship between organizational climate and intensive care unit nurses’

intention to leave and demonstrated that a satisfactory organizational climate

ensure a stable and qualified workforce. Sleutel (2000) provides a literature review

about organizational factors that influence nursing practice, included organizational

climate. Mok and Au-Yeung (2002) explored the relationship between organizational

climate and empowerment among the nursing staff of a regional hospital in Hong

Kong. The results of their investigation show that organizational climate and

supportive leadership and teamwork are related to empowerment. (Clarke et al.,

2002; Stone et al., 2006; Sleutel, 2000; Mok and Au-Yeung, 2002)

1.4 Data collection and methodology

We propose an earlier pilot study about citation network applied to organizational

climate studies to understand the actual state of the art of this field. We search on

Thomson Reuters (Web of Science, WoS) database all articles about organizational

climate from 1985 to 2013. We restrict the search of the term in the title and refine

results for articles within web of science categories to management, psychology, busi-

ness, educational research, nursing, public administration and healthcare sciences.

We built our database using organizational climate as keyword on the title and we

found 252 articles published between 1985 - 2013 in journals indexed in the Web

of Science (WoS) and classied according to the Essential Science Indicators (ESI)

(Thomson Reuters, 2009a). The ESI is a compilation of statistical information

related with publications, citations and cites per paper for journals, scientists,

institutions and countries referring to 10 years of Thomson Reuters data.

We have information about authors, institutional addresses, number of pages,

journals and citing articles for each document classied as an article. We searched

citations among these 252 papers. Our final database includes 252 papers and 7904

citations (for methodological reasons we decided to take into account only papers

identified by DOI). For the citation network analysis we used pajek software; it is

a free software for noncommercial use. It is a common program used for drawing

Data collection and methodology 16

Figure 1.2: Number of publications each ten years

networks and helpful to calculate most centrality measures.

After discussing the methods we applied in our study, we discuss the number of

papers that emerged over time, the journals in which these papers were published, the

most important authors and the papers most often cited in subsequent publications.

Number of publications: Figure 1.2 shows the number of publications each ten years,

it is clear that, the number of papers increase over time, in the period 1985 1995

we found 35 papers talking about organizational climate in the title; from 1996-2005

the publications raising at twice, but after that year, we identified a huge increase in

the number of publications and the different kind of journals that published it; this

could reflect the increase interest in the topic and the broad fields of research. It is

noteworthy that there were some studies that analyzed the organizational climate

and organizational culture until 1999, after this time we detected studies talking

about climate instead both. We believe, it happens because in the first years there

was an interest to understand the difference between them, after 1999 the most

interesting thing was to propose instruments to measure the climate.

Journals: Figure 1.3 shows the number of publications per type of journal. The

organizational climate papers have appeared in 130 different journals, divided

in five specific areas: Management, Psychology, Healthcare, Social sciences and

Education in which the number of publication in Management is higher compared

Citation networks in organizational climate papers 17

Figure 1.3: Number of publications per type of journal

with the others. The largest number of publications were in this journals: journal

of ethics, journal of applied psychology and journal of organizational behavior

have published. However, safety science, journal of business research, human

relations, international journal of human resource management, leadership quarterly,

journal of management, European journal of work and organizational psychology

are prominently represented. In the database, ten journals contain more than 32%

of the organizational climate papers.

Authors: Table 1.1 shows the most cited authors in organizational climate. Citations

are relevant to know which authors, publications and type of research has been

influential on the literature. It should be noted that information about the number

of times a paper has been cited in later publications is available in WoS. However,

we make reference to a citations in our dataset (252 papers).

1.5 Citation networks in organizational climate papers

In this section we focus on the structure of the network. Figure 1.4 provides an

overview of the development of the citation network for this topic over time. We

calculate the value of SPNP for the complete network. At that point, following the


Table 1.1: Most cited authors in Organizational Climate topic

Reference Number of citations

Schneider B 430

James LR 230

Glisson CA 121

Rousseau DM 115

Schein EH 91

Hoffman DA 80

Reichers AE 71

Ostroff C 70

Podsakoff PM 69

Payne R 68

Meyer JP 64

Hofstede G 60

methodology proposed by Hummon and Dereian (1989), we built the network of

main paths as we explained in Section 1.2. Figure 1.4 shows the largest component

of this network of main paths. This network is characterized by a sequence of most

important articles cited in this topic and it were organized in chronological way.

In the bottom left part of the graph we identify a cluster composed by important

articles about school climate; it was possible to identify that there are several

literature, some of it empirical, that has dealt with understanding the construct of

school climate; this papers consider the development and current status of school cli-

mate research, major instruments and important findings; given that school climate

is a particular construct composed by two research fields; organizational climate

research and school effects research, school climate research can be distinguished as

a separate area of study (Anderson, 1982). We concluded that it was not consistent

with our research objectives and we decided to exclude it from our analysis.

The organizational climate citation network has only one component, which demon-

strates the accuracy and consistency of our keyword search. Citation network

analysis selects 18 papers to form the top path. The top path represented in Figure

1.4 shows the fundamental flow of knowledge in organizational climate field (science

trajectory) in the complete citation network. These articles are listed in more detail

in Table 1.2.

Paper (No. 10.1037/0021-9010.75.6.668) lies on the origin of the trajectory. This is

the paper by Rentsch (1990) ”Climate and Culture: Interaction and Qualitative


Figure 1.4: The largest component in the network of main paths for the organizationalclimate network.

Differences in organizational meanings”; which demonstrate the value of an alterna-

tive approach where some meanings are shared by groups of people in organizations

and he explored the interaction groups as a method of identifying those individuals

whose interpretations of events are likely to be similar.

According to Rentsch (1990), one assumption of climate theory is that organiza-

tional members perceive and make sense of organizational policies, practices, and

procedures in psychologically meaningful terms (James et al., 1988; Schneider and

Rentsch, 1988). The results from this study provide empirical evidence for the

existence of meaning subcultures, or meaning subclimates, defined as a group of

interacting individuals whose behaviors follow a set of norms, who share similar

values and assumptions and who interpret organizational events similarly. The

meaning subcultures studied in the present research were groups of people who

interacted with each other (a) to learn what happened in the firm and why, (b) as

friends, and (c) to get their work done, and who developed similar interpretations

of organizational events.

Porter et al. (1974) discussed the attitude construct of organizational commitment

in addition to job satisfaction and compares their respective predictive powers in

differentiating stayers from leavers among a sample of psychiatric technician trainees,

he found that:The attitudes held by an individual are predictive of subsequent

turnover behavior, with individuals who ultimately leave the organization having

less favorable attitudes than individuals who stay. Patterns of attitudes across

time suggest that this inverse relationship between favorable attitudes and turnover

generally is stronger as individuals approach the point at which they leave the

organization. Based on these results, several points warrant emphasis and discussion.


He affirmed that some attitudes and turnover can be explain by comparing the level

of expectations of employees with the perceived realities of the job environment.

James and Jones (1974) defined organizational climate like a organizational at-

tributes, main effects, or stimuli within the organization. As a first step in recon-

ceptualization, it is recommended that a differentiation be made between climate

regarded as an organizational attribute and climate regarded as an individual

attribute. When regarded as an organizational attribute, the term organizational

climate appears appropriate. When regarded as an individual attribute, it is

recommended that a new designation such as psychological climate be employed.

Schneider (1975) also summarized some ideas which suggests that climate research

has been concerned with a description of the forms or styles of behavior in orga-

nizations. He defined climate perceptions are psychologically meaningful molar

descriptions that people can agree characterize a systems practices and procedures.

By its practices and procedures a system may create many climates. People perceive

climates because the molar perceptions function as frames of reference for the attain-

ment of some congruity between behavior and the systems practices and procedures.

However, If the climate is one which rewards and supports the display of individual

differences people in the same system will not be have similarly. Further, because

satisfaction is a personal evaluation of a systems practices and procedures, people

in the system will tend to agree less on their satisfaction than on their descriptions

of the systems climate.

An important insight about Schneiders work is the difference between organizational

climate and job satisfaction, he proposed independent analysis and definitions for

the two constructs, he studied climate, as a perception of the external world, while

job satisfaction is defined as the study of mans internal affective state. Both clearly

fall in the domain of research called ’attitude research’, but is necessary to maintain

clear differentiation between affect and organizational description respect to the

units of analysis.

Drexler (1977) studied differences in climate among different organizations; differ-

ences in climate across different organizations using groups that serve the same

functions; differences in climate among departments within the same organization

and differences in the relative strengths of organization effects and department ef-

fects. With this study he concluded that organizational climate is an organizational


attribute, where there are differences in organizational climate across departments

in the same organization but the effect of the department is weaker compared

with organizational effects. This work is interesting because gives the idea that is

possible analyzed climate at different levels (leadership, group, or department) vs.

organizational structure.

Mowday et al. (1979) summarizes research aimed to developing and validating

a measure of employee commitment to work organizations. In this paper, they

defined commitment as a global construct, including its goals, values and is stable

over time, while job satisfaction reflects ones response either to ones job or to

certain aspects of ones job. Satisfaction, has been found to be a less stable

measure over time, reflecting more immediate reactions to specific and tangible

aspects of the work environment. This work pointed out the need to incorporate

commitment as a predictor of behavior and proposed an organizational commitment

as construct relates to employee behavior in work organizations. Nevertheless,

organizational commitment makes no reference to the issue of organizational climate

but it relates to the instrument called Organizational Commitment Questionnaire

(OCQ), answer this questions contribute to a broader understanding of the role of

employee attitudes determining employee behavior and organizational performance.

Furthermore, DeCotiis and Summers (1987) defined organizational commitment as

one dimension of organizational climate refers to avoidance and behavior.

According to Schein (1990), culture is a learned product of group experience and

is, therefore, to be found only where there is a definable group with a significant

history. For Schein, the organizations evolve from small groups. However, organi-

zations develop dynamics that go beyond those of the small group so small group

observations must be extrapolated to larger organizations”.

In the 1990s Schein (1990); Rentsch (1990); Denison (1996) wrote several papers for

address the difference between organizational climate and organizational culture.

The term organizational climate began to appear in management literature and it

was often used almost interchangeably with culture. (Denison, 1996) suggests that

a kind of reversal in the terminology took place so that studies which talked about

climate in the 1970s would be thought of as addressing culture by the late 80s. Its

important to distinguish between the two concepts because, although related, they

focus on quite distinct aspects of organizational life and, crucially, managers can

have more influence on climate than they can on culture.

Concluding remarks 22

1.6 Concluding remarks

This paper has analyzed the pattern of scientific change in organizational climate

issue by citation networks. It was possible to use a SPNP proposed by Hummon

and Dereian (1989) to identify the top path and the important characteristics in

the evolution of the concept.

In the case of organizational climate construct, our propose produce fruitful insights.

The top path showed a coherent evolution. Our research present that the concept is

divided by periods, where the first period try to conceptualized the organizational

climate term, the second period study the instruments to measure both, organi-

zational climate and organizational commitment; third, focus on the difference

between organizational culture and climate

With systematic reviews about organizational climate topic other researchers had

already identified the most important articles in this field and that we showed in the

main path. Thus our citation network employing empirical techniques is completely

consistent with the analysis of other researchers.

Concluding remarks 23

Table 1.2: The longest sequence of papers on the main path

DOI P. Year Authors Article Title

10.1037/h0037335 1974 Porter, Lyman;Steers, Richard;Mowday, Richard;Boulian, Paul

Organizational commitment, job satisfaction, andturnover among psychiatric technicians.

10.1037/h0037511 1974 James, Lawrence;Jones, Allan

Organizational climate: A review of theory and re-search

10.1111j.1744-6570.1975.tb01386.x

1975 Schneider, Ben-jamin

Organizational climates: An essay.

10.1037//0021-9010.62.1.38

1977 Drexler, John A. Organizational Climate: Its Homogeneity Within Or-ganizations

10.1016/0001-8791(79)90072-1

1979 Mowday, Richard;Steers, Richard;Porter, Lyman

The Measurement of Organizational Commitment

10.1111/j.1745-3984.1980.tb00831.x

1980 Sirotnik, KennethA.

Psychometric Implications of the Unit-of-AnalysisProblem (With Examples from the Measurement ofOrganizational Climate)

10.1177/001872678704000704 1987 DeCotiis,Thomas; Sum-mers, TimothyP

A Path Analysis of a Model of the Antecedents andConsequences of Organizational Commitment

10.2307/2392857 1988 Victor, Bart;Cullen, John

The Organizational Bases of Ethical Work Climates

10.1037/0003-066X.45.2.109

1990 Schein, Edgar H. Organizational Culture

10.1037/0021-9010.75.6.668

1990 Rentsch, Joan R. Climate and Culture: Interaction and Qualitative Dif-ferences in Organizational Meanings

10.2307/258997 1996 Denison, Daniel. What is the Difference Between Organizational Cul-ture and Organizational Climate? A Native’s Pointof View on a Decade of Paradigm Wars

10.1348/096317904774202144 2004 Patterson, Mal-colm; Warr,Peter; West,Michael

Organizational climate and company productivity:The role of employee affect and employee level

10.1002/job.312 2005 Patterson, Mal-colm; West,Michael; Shack-leton, Viv JDawson, Jeremy;Lawthom, Re-becca Maitlis,Sally; Robinson,David; Wallace,Alison

Validating the Organizational Climate Measure:Links to Managerial Practices, Productivity and In-novation

10.1177/0149206308330559 2009 Kuenzi, Mari-beth; Schminke,Marshal

Assembling Fragments Into a Lens: A Review, Cri-tique, and Proposed Research Agenda for the Organi-zational Work Climate Literature

10.1037/a0018867 2010 Walumbwa, Fred;Hartnell, Chad;Oke, Adegoke

Servant Leadership, Procedural Justice Climate, Ser-vice Climate, Employee Attitudes, and Organiza-tional Citizenship Behavior: A Cross-Level Investiga-tion

10.1146/annurev-psych-113011-143809

2012 Schneider, Ben-jamin; Ehrhart,Mark; Macey,William

Organizational Climate and Culture

10.1002/hrm.21498 2012 Zhang, Haina;Kwan, Ho Kwong;Everett, Andre;Jian, Zhaoquan

Servant leadership, organizational identification andwork to family enrichment: The moderating role ofwork climate for sharing family concerns.

10.1016/.leaqua.2012.10.008 2012 Sun, Li-Yun; Hau,Irene; Chow, Siu;Chiu, Randy;Pan, Wen

Outcome favorability in the link between leader-member exchange and organizational citizenship be-havior: Procedural fairness climate matters

2

Are there gender differences inperceived organizational climate?:

The case of Tuscan healthcare system.1

This study examines the organizational climate considering gender differences

in the professional role within healthcare organizations. Data came from

organizational-climate questionnaires administered in 2010 to 1498 health

managers and 19616 health staff in Tuscany Region (Italy). We applied

exploratory factor analysis to verify the validity and internal consistency

between items and t-test to compare mean perceptions regarding the dimen-

sions across different groups of respondents. We measured five dimensions

’training opportunities’, ’communication and information processing’, ’man-

agerial tools’, ’organization’ and ’management & leadership style’ and overall

job satisfaction. Gender differences in the professional roles were significant

between managers’ and staff’s perceptions (p ≤ 0.05).

2.1 Introduction

In the 20th century the condition of women has greatly improved in several aspects.

However, the gender gap is remarkable in the lack of access to power and leadership

1With: Chiara Seghieri1, Diana Rojas, Sabina Nuti. Acknowledgements: The authors wishto thank the researchers of the MesLab, in particular Manuela Furlan, Domenico Cerasuolo andFrancesca Sanna who are responsible for the management of the organizational climate surveys;Francesco Niccolai for his precious suggestions; the staff of all Tuscan healthcare organizationsand Tuscany region for the financial support of the project.

Introduction 25

positions compared with men, and women managers are still in a minority (Carli

and Eagly, 2001).

Generally, women are less frequently found in leadership positions compared to

men and more frequently in staff positions, consequently they have less opportunity

to demonstrate their competencies (Wiggins, 1996) and even in female-dominated

occupations, men have more opportunity to be promoted to the top (Broadbridge,

2010). The 2011 Catalyst Census showed that in 2010 women held 14.4 percent of

Executive Officer positions and 7.6 percent of Executive Officer top earner positions

(Soares et al., 2009).

When considering the healthcare sector, the promotion of women to senior man-

agement positions in healthcare organizations has been shown to be slower in

comparison with men even when most positions are held by women. The same

happens to financial benefits which seem to decrease for women and expand for men

as their respective careers advance. Moreover, researches in USA have demonstrated

that, in the last years, little has been made to close the gender gap in healthcare

leadership especially among the nation’s top hospitals (Branin, 2009).

The same evidences have been also found in Italy, where independently if public or

private organizations, women have more limited possibilities to advance in their

careers. The percentage of women on boards and senior-executive teams remains

one of the lowest among European countries (7% compared with 33% of women

in Scandinavian countries). Italy, in fact, ranks 74th out of 134 countries in the

Gender Gap Index 2010, immediately followed by Colombia, Vietnam and Peru.

35% of the Italian women in the age of 25-44 is unemployed (21% is the average

in the rest of Europe) and women who work, on average earn 20% less than men

(Commission et al., 2010). Within years, only few policies have been adopted at

national level to support women with young children, networks to help women

navigate their careers and formal sponsorship programs to ensure professional

development (www.womenomics.it).

With regard to the Italian healthcare sector, results from a survey administered

to a sample of 1821 physicians of Padova city (Italy) in 2010 showed that 37,84%

of the respondents declared to be not satisfied of the advancement in their career

and of these, 22% are women while 16% men (http://www.fnomceo.it). Whereas,

results from another survey to a sample of 1549 Italian physician women belonging

Introduction 26

to the medical association in 2011 showed that 27% of the respondents declared to

be discriminated in their work in general and 37.5% in their possibilities of reaching

high job positions. 39% of the women reported that their ideas and suggestions

were not taken in consideration by superiors and 80% reported that they have not

been involved in any training opportunities. Finally 4% of the sample declared to

have received a physical abuse and only 61% was satisfied with their job (Ordine

Provinciale di Roma dei Medici Chirurghi e degli Odontoiatri, (2011)).

Given these premises, the present study intends to contribute to the researches

on gender inequality at work by analyzing results from an organizational climate

survey administered in 2010 to professionals of twelve Local Health Authorities

(LHAs) of Tuscany region (Italy).

The purpose of this study is to determine whether organizational climate charac-

teristics such as training opportunities, communication & information processing,

managerial tools, organization structure and management & leadership style and

overall job satisfaction are differently perceived across men and women at managerial

and staff level within LHAs.

In particular the study aims to test the following hypothesis:

H1. ’Male and female employees of Tuscan healthcare organizations differ signifi-

cantly in terms of perceived organizational climate and job satisfaction’

H2. ’Male and female employees of Tuscan healthcare organizations differ signifi-

cantly in terms of perceived satisfaction in the relationship with their superiors in

terms of communication, motivation, and support’

This information can be used by organizations and human resource professionals

to better understand possible barriers and discriminations perceived by women

within the organization which can negatively affect their attitudes, behavior, and

organizational commitment.

Data and Methods 27

2.2 Data and Methods

Organizational climate is a distinct construct concerned with the way organizational

members perceive the work environment within that organization and its impact on

their individual psychological well being (Jones and James, 1979). This concept can

be traced back to several studies, which have showed the role of the organizational

climate survey to measure organizational characteristics perceived by employees

and better understand those factors which contribute to a work environment (or

climate) that is pleasant, and motivates all employees, regardless of their position,

status and gender, to be committed and effective performers (Lewin et al., 1939;

Koffka, 1935; Phillips et al., 1996).

Especially for those organizations requiring highly skilled employees, such as physi-

cians in hospitals, a working environment which enhance the knowledge, skills,

ability and motivation of employees have been demonstrated to have a greater

impact on the performance of organization.

With regard to the Tuscan healthcare system, organizational climate as perceived

by healthcare professionals, has been always considered an important dimension to

be constantly monitored through the Performance Evaluation System of the Tuscan

healthcare. This system, developed in 2004 by MeS on behalf of Tuscany region

intends to constantly measure and monitor the quality of services provided and

the capacity to meet citizens’ needs by healthcare organization in order to achieve

better health and quality of life standards on one side and, on the other, to preserve

financial equilibrium (Nuti, 2008; Nuti et al., 2009, 2013).

Since 2004, Tuscan healthcare top management and professionals are called to

participate to the organizational climate survey which is carried out about once

every two years within all Tuscan health organizations. This survey is based on two

questionnaires, formulated in 2004 by MeS researchers (Pizzini and Furlan, 2012)

following the international and national review on organizational climate.

Questionnaire ’A’ is directed to all managers with ’management/budget’ responsi-

bilities (i.e ward managers), and questionnaire ’B’ to health employees. The two

questionnaires were similar in size and items investigated.

Results 28

Regarding to the procedures for compiling and sending the survey, MeS Lab provided

the questionnaires on-line using the Computer Assisted Web Interviewing (CAWI)

system: each employee had a login and password that allowed him/her access to

the web platform for collecting data. Secure connection guaranteed the anonymity

of responses and the safety of data transmitted.

Independently from the questionnaire, all questions had a 5-point likert scale

format, ranging from 1 extremely unsatisfied to 5 extremely satisfied. The analysis

extracted information on the survey sample, job satisfaction and organizational

climate dimensions like communication and information processing, management &

leadership style (ward managers and top management for employees and managers

respectively), managerial tools (i.e. budget), company organization and training

opportunities. Along years both questionnaires were tasted and validated and

changes were made in order to assure the validity and reliability of the instrument.

With regard to 2010 survey data, we analyzed results from questionnaires A and

B independently (851, 12576 questionnaires). We calculated descriptive statistics

and the means item scores were quiet low suggesting a general negative staff’s

perception of the organizational climate.

Finally, we applied Factor Analysis to questionnaires A and B separately to obtain

the perception of managers and employees in terms of the dimensions mentioned

above. We performed descriptive statistics, factor analysis and two-tailed test to

examine gender differences in the LHAs. We used STATA software for statistical

analyses (Version12, Stata Corp, College Station, TX).

2.3 Results

Respondents’ characteristics Table 2.1 shows descriptive statistics from gender

point of view. The percentage of responders were 46% for managers and 33% for

the staff. Most of the managers were male (66%), older than 50 years (54%) and

had more than 20 years of working experience (30%). On the contrary, the majority

of non managerial staff was female (72%), in the age class of 35-49 (42%) and had

11-20 years of working experience (25%).

Results 29

Table 2.1: Descriptive statistics in healthcare managers and staff by gender

Managers Staff

Men Women Total (%) Men Women Total (%)

Gender distribution (%) (n=562) (n=289) (n=851) (n=3509) (n=9067) (n=12576)

50.4 26.0 76.4 22.0 57.0 79.0

Age (years) (n=548) (n=284) (n=832) (n=3457) (n=8912) (n=12396)

18-34 4 3 7 (0.84) 276 897 1173 (9.5)

35-49 94 81 175 (21.0) 1652 5243 6895 (55.7)

>50 450 200 650 (78.1) 1529 2772 4301 (34.8)

Seniority (years) (n=558) (n=285) (n=843) (n=3460) (n=8893) (n=12353)

<2 74 19 93(11.0) 576 1679 2255(18.2)

2-5 71 26 97(11.5) 615 1678 2293(18.6)

6-10 158 83 241(28.6) 999 2478 3477(28.2)

11-20 255 157 412(48.9) 1270 3058 4328(35.0)

Top level management, bottomand mid-level management

Professional Role (n=3501) (n=9036) (n=12537)

Administrative 358 967 1325 (10.6)

Highly specialized staff (Physi-cians)

1052 966 2018 (16.1)

Specialized staff (Medical tech-nician, nurses and social work-ers).

1468 5820 7288 (58.1)

Non specialized staff 623 1283 1906 (15.2)

We analyzed 1113 of the 2407 managers (46%) and 15942 of the 47903 staff (33%).

851 managers (76%) and 12576 staff (79%) completed the item about gender: from

manager’s questionnaire 562 (66%) were men and 289 (34%) were women, from

staff 3509 (28%) were men and 9067 (72%) were women.

Organizational climate dimensions Factors were obtained using Principal

Components Factor Analysis, with varimax rotation of the orthogonal axes and in

both cases the percentage of explained variance was about 65%. We calculate for

each dimension Cronbach’s α reliability coefficient above 0.8 confirming the validity

and internal consistency between items on the scale of each factor.

Applying factor analysis to the data we obtained overall job satisfaction and five

organizational climate dimensions (for more details see Appendix 1):

1. Satisfaction with managerial tools was measure by eight items in the ques-

tionnaire A (α=0.96) and four items in the questionnaire B (α=0.96).

2. Satisfaction with training opportunities was measure by six items in the

questionnaire A (α=0.92) and five items in the questionnaire B (α=0.90).

Results 30

Table 2.2: Gender differences of perceived organizational climate at managerial level.

LHAs Men Women

(n=562) n=289)

Dimension Mean Sd Mean Sd

Communication & Infor-mation processing

0.258 0.948 0.073 0.989

p =< 0.05

3. Satisfaction with communication and information processing was measure by

five items in the questionnaire A and B (α=0.90, α=0.86) respectively.

4. Satisfaction with the organization was measure by fifteen items in the ques-

tionnaire A (α=0.96) and four items in the questionnaire B (α=0.90).

5. Satisfaction with management & leadership style was measure by five items

in the questionnaire A (α=0.88) and eighteen items in the questionnaire B

(α=0.96).

Overall job satisfaction dimension was measure by four items in questionnaire A

and B (α=0.80 in both cases) and it is defined as a positive emotional response to

the result of the work performed allowing the fulfillment of an individual’s value

(Locke et al., 1984).

Gender differences in the perception of Organizational Climate Factors

Phase two of the data analysis consists of studying differences between gender and

professional roles groups. We used t-test to compare mean perceptions regarding

the above mentioned dimensions across women and men in both managerial and

staff position. We also analyzed key questions separately which are relevant to

better explore gender inequalities at work. The probability level for all hypothesis

tests was set at p ≤ 0.05.

Gender differences at managerial level In the analysis of gender differences

across high-level managerial positions, Table 2.2 shows that communication &

information processing is the only significant dimension which has been differently

perceived by men and women, with men being more likely to be satisfied then women.

No statistically significant results were observed in the other climate dimensions.

Results 31

Table 2.3: Distribution of male/female respondents by selected questions within dimensionof communication and information processing at managerial level.

Communication and Infor-mation processing

Men Women

(n=562) n=289)

Mean Sd Mean Sd

Feedback informationabout the quality ofwork and achievementsperformed.

3,135 0,053 2,955 0,073

The CEO monitors theproper way in which theobjectives of the organiza-tion are followed.

3,377 0,053 3,059 0,077

To know the aims of theorganization.

3,776 0,043 3,581 0,068

To know the annual resultsof my organization (eco-nomic, health system, pa-tient satisfaction, etc.).

3,576 0,046 3,391 0,066

p =< 0.05

We further explored gender differences with respect to single questions regarding

communication & information processing. (Table 2.3)

The statistically significant results suggest that there are differences in selected

aspects concerning communication dimension between male and female managers.

Results in Table 2.3 confirm that men are more satisfied with communication

and information process. Men more than women tend to report higher scores to

questions regarding the feedback and information received from the top management

and the involvement and knowledge of both strategic long term objectives and the

annual performance results (economic and financial performance, clinical outcomes,

patient satisfaction, etc.).

Gender differences at staff level In this section we focus on the significant

dimensions of organizational climate for healthcare staff according to the gender

differences and professional role separate (Table 2.4). Results in Table 2.4 shows

that, in almost all the dimensions, highly specialized staff (physicians) is likely to

be more satisfied than either specialized staff (medical technician, nurses and social

workers) or unspecialized staff (non medical technicians) this results are according

with the literature (Carlucci et al., 2009; Wienand et al., 2007b). Moreover, from

Results 32

Table 2.4: Gender differences of perceived organizational climate and professional roles atstaff level.

LHAs Men Women

(n=3509) n=9067)

Professional role Mean Sd Mean Sd

Administrative

Managerial tools 0,054 1,017 0,273 0,974

Physicians

Managerial tools 0,312 0,944 0,434 0,964

Organization 0,049 1,086 0,175 1,029

Training 0,052 1,035 0,231 0,965

Specialized staff (Medical technician, nurses and social workers)

Organization -0,386 1,036 0,407 0,98

Training -0,005 1,022 0,112 0,963

Leadership style -0,072 1,02 -0,016 0,972

Unspecialized staff (Non medical technician)

Managerial tools 0,195 0,979 -0,062 0,997

p =< 0.05

gender point of view, women consistently report higher scores in the perceived

organizational climate than men, this is true across all dimensions and within all

the professional roles with exception of unspecialized roles where men declared to

be more satisfied than women about managerial tools.

Gender differences at staff level within professional roles

• Administrative

Women in administrative position, were more satisfied with managerial tools

than their counterparts. No other statistically significant gender difference

across dimensions was observed.

• Physicians

We found statistically significant gender differences in managerial tools, orga-

nization and training dimensions where women were significantly more likely

to report satisfaction in these dimensions compared with men.

• Specialized staff (Medical technicians, nurses and social workers)

Results 33

Table 2.5: Distribution of male/female respondents by selected questions about careeropportunities

LHAs Men Women

Mean Sd Mean Sd Sign. level

Generally, I get feedback on achieve-ments and the quality of my work.

2,994 0,022 2,924 0,013 0,002

In the structure I feel that my improve-ment proposals are considered.

2,984 0,022 2,943 0,013 0,05

In my structure I come helped and en-couraged after making a mistake.

2,951 0,023 2,906 0,014 0,04

the internal organization of myward/operating unit is clear and wellknown.

3,316 0,022 3,224 0,013 0

My organization offers good opportuni-ties for professional growth.

2,627 0,021 2,709 0,012 0

We found that women with respect to men were likely to be more satisfied

with organization, training opportunities and leadership style dimensions.

• Unspecialized staff (Non medical technician)

Managerial tools was the only significantly dimension perceived in the orga-

nizational climate by unspecialized staff. The aspects that pertain to the

rewarding system had evaluated by women with the lowest scores compare

with their counterparts.

Finally, Table 2.5 shows the significant dimensions of organizational climate ana-

lyzing gender differences at staff level within LHAs for specific questions reflecting

possibilities of career advancement, motivation, support and feedbacks from the

management.

When looking at single questions, women in general seem less satisfied than men,

except for the opportunities for professional growth. Similarly to management

positions, men, independently from the role, were significantly more likely to report

satisfaction with the feedback on achievements, the quality of work, consideration

and support received.

Discussion 34

2.4 Discussion

The first aim of the study was to investigate gender differences in the perception of

organizational climate dimensions and job satisfaction across professional roles.

With regards to managerial positions no gender differences were found in both

job satisfaction and organizational climate dimensions except for communication

and information process where men managers seemed more satisfied then women

counterparts. On the contrary, when considering staff positions, women tend to

report in general significantly higher scores then men.

This last result might be due to a real difference in the type of work performed

among staff position. Clark (1985) argued that objectively, women’s jobs are worse

than men’s and those who expect less from working will be more satisfied with any

given work. In this case, greater satisfaction in the perceived organizational climate

may reflect women’ low expectations regarding to the work performed. Moreover,

women, more than men, might also expect to have to accommodate to the needs of

their family (Harriman, 1996; Spector, 1997).

Also, Eagly (1987) argued that gender differences in the work place are due to

the bias of individuals to behave consistently with their social roles. For example,

there are different expectations of behavior for social roles of physicians and nurse.

There is a greater representation of men in the physician’s role, and a greater

representation of women in the nurse’s role. Therefore, the gender differences in

the organizational climate between men and women in these roles can be a result of

differences in the distribution of physicians and nurses.

With regard to the second hypothesis of the study, gender differences were found

in the perception of selected aspects such as: the level of communication of the

organizational planning and strategic objectives between managers and CEOs, the

level of communication of the organizational unit objectives and work program

between staff members and managers, communication and ongoing feedbacks be-

tween staff members and managers on the quality of the work level of promotion

and motivation staff members’ own professional development goals. All of these

aspects are strictly related on the way one’s supervisor handles his workers in terms

of recognition one gets from doing the job, communication of organization/wards

Discussion 35

objectives and strategies, recognition of individual contribute.

Our analysis shows that with respect to these aspects, males are likely to be more

satisfied than their counterparts. This is true across all the professional positions

within the organization.

Even in a female dominated profession such as healthcare the number of women in

supervising positions is less in comparison with men (LaPierre and Zimmerman,

2012; Wiggins, 1996; Walsh and Borkowski, 1999). This masculine environment in

supervisory positions is likely to promote asymmetries that contribute to different

gender perceptions and behaviors in the organization. Females in the Tuscan

healthcare environment may face challenges in the supervision-human relations

aspects which in part maybe due to gender stereotypes that exists between men

and women in these supervisory relationships. Women are often considered by

men as less career-orientated, more committed to the family than their jobs, less

motivated by organizational rewards than their male counterparts and they have to

work harder to demonstrate their competence.

On the other hand women would like to be more involved in the communication

processes and for them is most important to know and to share with the management

staff the organizational goals. Indeed, males have been demonstrated to be dominant,

and unemotional and more task-oriented while females tend to be more emotional,

compassionate, emphatic and supportive, and more interpersonally oriented (Eagly

and Johannesen-Schmidt, 2001).

Burke et al. (1998) showed that women who supervise are more sensitive to the

needs of women on their staffs, they better able to develop closer relationships with

them, and more willing to invest in this relationship than male supervisors. As

a consequence one might expect that men in managerial position would interact

differently with those they supervise if men or women, supporting the fact findings

that females tend to be less satisfied then male in some aspects related to commu-

nication, information, and interaction with supervisors who are for the majority

males.

Conclusions 36

2.5 Conclusions

The results of the present study support the hypothesis that there are gender

difference in how the organizational climate is perceived by managers and employees

in Tuscan healthcare organizations. The analysis showed that the Tuscan organiza-

tional climate questionnaire is a reliable instrument used as a measurement tool for

evaluating working conditions and determining the different factors which satisfies

and motivates employees in the healthcare sector.

This study shows that there are gender differences in how individuals experience

satisfaction within work environment, especially across all professional roles within

healthcare staff. In terms of particular aspects of the job related it was found that

males rated higher than females the interaction with their supervisors.

Women want more from their leaders: they want to participate, to share respons-

abilities by adopting a team working approach. They tend to believe much more

than men in positive effects of training activities and personnel involvement in the

organizational performance. Men with management responsibilities in the health

sector should dedicate more time to their staff especially to women working in their

team in order to facilitate their involvement in the improvement process, and to

guarantying space and development to their contributions.

The use of an organizational climate survey helps management to identify the

critical points in the different dimensions and communicate more effectively within

the structures improving the effectiveness of total quality management programmes.

In fact, a valid internal climate survey can be an useful tool for supporting the

management to avoid perceptual discrepancy and tailor a motivational strategy

that is specific to the employee’s individual needs and aspirations.

Moreover, in order to assure its effectiveness it is important to share and discuss

the results of the internal climate survey with all the professionals being this the

most important prerequisite to support the organizational changes and it is what

the Tuscan health managers are used to do not only with regards to the internal

climate results but also to all the performance measures.

The current research has some limitation; first is a select sample and these results

Conclusions 37

may not extend to healthcare professionals populations; also it is not possible to

generalize the results regarding geographic or political context, second is due to

privacy reasons some respondents failed to report their gender introducing possible

selection biases in the results. Further, there are many other factors that can be

considered to determine employees satisfaction which can be added to expand the

study in future.

Questionnaires 38

2.A Questionnaires

Table 2.6: Questionnaire A

Organizational climate di-mension

Issue mean s.d.

Managerial Tools

In my organization there is a strategic plan that clearly define the objectivesand expected results at organizational level.

3,43 1,13

All levels of the organization are involved in the budgeting. 2,9 1,7

I have possibilities to negotiate the budget with the organization. 2,73 1,72

The budget is a tool for sharing business strategy. 3,08 1,7

There is a linkage between budget and performance evaluation system at man-agerial level.

3,17 1,69

The budget helps me guide my structure / operating unit (simple or complex). 2,99 1,66

During the budget preparation process is discussed and evaluated the degree ofdifficulty of achieving its objectives.

2,59 1,52

The management control support me during the negotiation of the budget. 2,97 1,23

Training Opportunities

My organization offers professional growth opportunities. 3,1 1,2

The organization offers training opportunities. 3,34 1,19

Training requests are received with respect to the needs of the structure. 3,43 1,18

In my organization training is an effective tool to develop personal skills. 3,49 1,15

The training activities that I attended were useful to improve my skills in thework.

3,47 1,07

I’m informed about training opportunities offered by my company. 3,47 1,16

Communication andInformation Processing

I received regular feedback on the quality of my work and achievements. 2,99 1,26

The CEO board over the year highlights eventual variations regard to indicatorsmeasures and implement corrective action.

3,18 1,29

My decisions are supported by data and information provided by the manage-ment control.

3,04 1,2

I’m informed about the annual objectives of my organization 3,64 1,07

I’m informed about the outcome from the organization (economic, financial,healthcare, etc.)

3,46 1,11

Organization

I am responsible for the objectives defined by the Tuscany Health System in theregional health planning 2008-2010.

3,6 1,1

Objectives related to health initiative. 2,96 0,99

Objectives designed to promote the customer satisfaction. 2,87 1,03

Objectives designed to promote the employees’ participation. 2,83 0,99

Objectives designed to improve the structure and promoting health technologies. 3,01 1,01

Management & leadership

The CEO board knows and monitor the performance of my structure. 3,43 1,22

My organization promotes change and innovation. 3,24 1,23

My organization promotes communication between managers and CEO. 3,35 1,11

The CEO is responsible for organizing meetings with the managers of the orga-nization.

2,87 1,15

Manager is able to handle conflict situation. 3,16 1,28

My organization is able to use the available resources in terms of effectivenessand efficiency.

2,98 1,09

My organization is able to disseminate the values of regional healthcare systemand translate them in terms of guidelines of its own action.

3,3 1,09

The CEO considers that team work is an effective tool to achieve results. 3,54 1,13

The CEO inform managers when they have to take important decisions concern-ing to their structure (simple or complex).

3,04 1,43

My organization promotes the exercise of delegated. 3,18 1,15

My company facilitates collaboration between hospital and territory. 3,31 1,15

The CEO board have the ability to formulate hypotheses and alternative scenar-ios in order to achieve the expected results.

3,09 1,1

My organization usually collect suggestions from employees to define businessstrategies.

2,72 1,15

I come helped and encouraged after a failure. 2,76 1,2

In my organization the monitoring and evaluation system is developed properlyin terms of quality, effectiveness and efficiency.

3,08 1,11

Job Satisfaction

I like my work. 4,38 0,86

I’m proud to work for the Tuscan healthcare system. 3,84 1,09

I feel responsible for the quality of the results/services I provide. 4,13 1,02

I’m proud to work in this hospital. 3,57 1,17

Questionnaires 39

Table 2.7: Questionnaire B

Organizational climate di-mension

Issue mean s.d.

Managerial Tools

In my organization the budget is used correctly. 2,13 1,71

The objectives defined in the budget are shared with employees. 2,11 1,77

The objectives defined in the budget are verified along the year. 2,05 1,75

The objectives of the budget help me to direct my job. 1,94 1,68

Training Opportunities

The organization offers training opportunities. 2,94 1,15

Training requests are received with regard to the needs of the structure. 2,91 1,19

In my organization training is an effective tool to develop personal skills. 3,05 1,21

The training activities that I attended were useful to improve my skills. 3,29 1,17

I think being informed about training opportunities offered by my company. 2,78 1,22

Communication andInformation Processing

I’m informed about the quality of services that we provide to users (patients, citizens). 3,48 1,07

I’m informed about customer satisfaction (patients, citizens). 3,03 1,07

I’m informed about the organization of my structure/operating unit. 2,88 1,08

I’m informed about the economic, financial or healthcare outcomes. 2,46 1,1

I’m informed about important decisions and strategies taken by the CEO. 2,24 1,11

Organization My organization offers opportunities for professional growth. 2,63 1,19

My organization supports change and innovation. 2,61 1,18

My organization promotes and facilitates collaboration between structures. 2,6 1,14

The Manager is interested in the situation of my hospital/operating units. 2,58 1,21

Management & leadership

I get feedback on achievements and the quality of my work. 2,91 1,25

Meetings are regularly organized in my internal structure. 3,2 1,38

My manager is easily contactable in case I need to talk to him. 3,83 1,23

In the structure I feel that my improvement proposals are considered. 2,9 1,27

In my work my boss and colleagues help me to develop my skills. 2,93 1,26

Employees have appropriate conditions to develop their work. 2,92 1,17

I come helped and encouraged after making a mistake. 2,87 1,31

My manager is able to delegate. 3,44 1,29

Managers informed employees when they have to take important decisions that affect thestructure.

2,83 1,34

In my work are recognized results achieved by the team. 2,92 1,28

My manager knows how to manage conflict situations. 2,8 1,34

I feel responsible for the quality of the results/services I provide. 3,59 1,2

My services are regularly verified. 3,18 1,23

I receive clear guidelines and instructions about activities I have to develop. 3,1 1,24

In my group, the work is well planned and this allows us to reach the objectives proposed. 3,12 1,22

My job is evaluated in an equitable manner. 2,92 1,26

In my structure objectives are clear and well defined. 3,03 1,24

The internal organization of my structure/operating unit is clear and well known. 3,21 1,24

Job Satisfaction

I like my work. 4,17 0,97

I’m happy to work in this hospital. 3,58 1,14

I’m proud to work in this hospital. 3,1 1,23

I’m proud to work for the Tuscan healthcare system. 3,66 1,15

3

Organizational climate: Comparingprivate and public hospitals within

professional roles1

This study compares the organizational climate differences within profes-

sional roles in private and public hospitals. We focus on how physicians,

administrative, healthcare and non healthcare staff either in the public and

in the private organizations perceived their work environment and each

organizational climate dimension. Data came from organizational-climate

questionnaires administered in 2010 and 2012 to 19616 and 1276 health

employees in public and private hospitals in the Tuscany Region respectively.

We applied exploratory factor analysis to verify the validity and internal

consistency between items in the questionnaire and t-test, one-way analysis

of variance to compare means perceptions regarding to the dimensions across

different groups of respondents. We measured four dimensions: ’training op-

portunities’, ’managerial tools’, ’organization’ and ’management & leadership

style’ and overall job satisfaction. Hospital status within staff perceptions by

professional roles was found significant at (p ≤ 0.05).

3.1 Introduction

It has been identified important elements for healthcare staff’s commitment and

loyalty toward the organization, examples of this elements are: continuing training

1Chiara Seghieri, Diana Rojas, Sabina Nuti

Introduction 41

and education (Spath, 2002), leadership style, project management, staff recognition,

dedicated time, and resources for improvement projects. (Thomson et al., 2002)

But, organizational climate seems to depend also on the particular characteristics

of the work environment (Tovey and Adams, 1999; Cumbey and Alexander, 1998).

Organizational climate is defined as the shared perceptions of the work environment

Jones and James (1979). In the present study we were able to analyze the difference

between hospital status (public or private) and professional roles with respect to

organizational climate dimensions like: Training opportunities, Managerial tools,

Organization Management & leadership style and overall job satisfaction within

twelve public general hospitals and eighteen accredited private hospitals. Our study

include physicians, administrative staff, healthcare employees and non healthcare

employees of the Tuscan healthcare system. There have been no recent studies of

this phenomenon, and none have compared and contrasted organizational climate

and professional roles at the hospital status. This paper is an attempt to address

this gap in the literature.

The general hypotheses developed was whether public and private hospitals within

professional role would differ significantly on how they perceived the organizational

climate. By studying a country like Italy with a particular health system we

hope to give an insight to better understand the persistent barriers restricting the

organizational climate in the professional roles at hospital status.

With regard to Italy, independently if public or private hospital is important the use

of performance measurement to promote a more efficient and effective administration.

With this premise, the Tuscany region with MeS laboratory in 2005 developed its

own Performance Evaluation System (PES) valued as a particularly innovative and

comprehensive system (Carinci et al., 2012; Censis, 2008) it was implemented in

order to follow up the regional objectives based on the needs of the Regional Health

Councillor. The PES measured the quality of services provided and the ability

to meet the needs of citizens in order to achieve better health and quality of life

standards and to preserve financial stability. The 130 indicators are classified in six

dimensions: Population health status; capacity to pursue regional strategies; clinical

performance; patient satisfaction; organizational climate and finally efficiency and

financial performance. (Nuti et al., 2009; Vainieri and Nuti, 2011; Nuti et al., 2013).

PES indicators are linked to the healthcare CEO’s rewarding system in public

The context 42

institutions where annual goals are set separately for each indicator and each

health authority, taking into account the performance level of the year for each

indicator and the standard to be reached /citepnuti2013variation and optional-

voluntary for private ones. Every year each public Health Authority receives its

own report explaining if it was able to reach the goals during the year and doing

a benchmarking comparison. In 2012 PES has been adopted by eighteen private

hospitals as a decision support tool at managerial level, it decision did possible

to apply the organizational climate questionnaire to private institutions, getting

interesting results to compare with the public context.

We reported a contribution on the debate of diversity in management of healthcare

by highlighting the way in which staff perceived the organizational climate and the

variation addressed in the professional roles and hospital status. The implications of

this study can be useful to policy makers, managers and professionals understanding

how the perception of the organizational climate fit as predictor of good performance.

3.2 The context

The Italian health care system is a National Health Service (Beveridge-like model)

accessible to the full population providing preventive and curative services. (Bev-

eridge, 1942) The system is organized at three levels: national, regional and local.

The national level is responsible for ensuring the general objectives and fundamental

principles of the National Health Service. The regional governments are responsible

for ensuring the delivery of the health care through a network of population-based

healthcare organizations (health authorities).

In Italy during the past two decades, the strong decentralization policy, in the

line with ’New-Public-Management’ (NPM) philosophy (Kettl, 2000; Pollitt, 1995)

which aims is that public organizations should import managerial processes and

behavior from the private sector (Box, 1999; Boyne, 2002). With this argument

the government have gradually transferred several important administrative and

organizational responsibilities from the state to the 21 Italian regions with the aim

of making regions more sensitive to the community needs, to control expenditure,

promote efficiency, quality, and citizen satisfaction but specially it has started to

focus on more effective management (Mouritsen et al., 2005).

Data and Methods 43

This model provided regions with significant autonomy in organizing healthcare

services, allocating financial resources to their Local Health Authorities (LHAs), mon-

itoring and assessing performance (Nuti, 2008; Antonini and Pin, 2009). Whereas,

the central government retains overall responsibility for ensuring that services, care

and assistance are equitably distributed to citizens across the country.

The Tuscany region have 3.7 beds for each 1000 inhabitants of which 95% correspond

to public beds and only 5% are privates. The healthcare system works through a

network of seventeen public health authorities of which five are teaching hospitals

(THs) and twelve are Local Health Authorities (LHAs) and eighteen private hospitals

with accreditation.

In 1999, the Region of Tuscany began the accreditation system (LR 8/1999, LR

51/2009). Institutional accreditation is the recognition by the Region of hospitals

that are authorized to provide and develop health services according to the National

Health Service (NHS). Accreditation is compulsory for public institutions and

optional-voluntary for private ones, but if private institutions does not have the

accreditation cannot provide benefits on behalf of the NHS. However, obtain

accreditation, does not allow to perform services on behalf of the NHS, is compulsory

an agreement between subject and accredited Local Health Authorities that specific

times, costs, terms and amounts of benefits payable in agreement with the NHS.

(Lenzi, 2012)

3.3 Data and Methods

In 2010 the Laboratory of Management e Sanita (MeS) with Tuscany region

administered the organizational climate survey to health care professionals in 16

Tuscan Health Authorities (12 General Hospitals1 and 4 Teaching Hospitals), with

a total population of 2407 managers and 47903 staff. In 2012 the survey was

administered to healthcare professionals in 18 private hospitals with accreditation.

The organizational climate is part of the six dimension within Performance Evalu-

ation System (PES). Regarding to the procedures for compiling and sending the

survey; we provided the questionnaires on-line using the Computer Assisted Web

Interviewing (CAWI) system; each employee had a login and password that allowed

Analysis 44

him/her access to the web platform for collecting data. Secure connection guaran-

teed the anonymity of responses and safety of data transmitted (Pizzini and Furlan,

2012).

Independently from the questionnaire, all questions had a 5-point likert scale

format, ranging from 1 extremely unsatisfied to 5 extremely satisfied. The analysis

extracted information on the survey sample, job satisfaction and organizational

climate dimensions like management & leadership style, managerial tools (i.e.

budget), hospital organization and training opportunities. We tasted and validated

both questionnaires and we assure the validity and reliability of the instrument.

We applied Factor Analysis to questionnaires to obtain the perception of managers

and employees in terms of the dimensions mentioned above. We performed descrip-

tive statistics, factor analysis, and two-tailed test to examine gender differences in

the General hospitals. We used STATA software for statistical analyses (Version12,

Stata Corp, College Station, TX).

3.4 Analysis

Respondents’ characteristics

Table 3.1 shows descriptive statistic. In public hospitals 17424 of the 34686 staff

(50.2%) returned the questionnaire while in private hospitals 1276 employees returned

it.

Organizational climate dimensions

Applying factor analysis to the data we obtained overall job satisfaction and four

organizational climate dimensions:

1. Satisfaction with managerial tools was measure by four items (α=0.94). Test-

ing the manager performance concerning to the budget responsibilities and

control system.

Analysis 45

Table 3.1: Descriptive statistics within hospital status

Public (%) Private (%)

(n=17424) (n=1276)

Gender

Men 28 37.4

Women 72 62.6

Age (years)

18-34 8.5 24.5

35-49 50.6 44

> 50 40.9 31.5

Seniority (years)

< 2 18.2 16.9

2-5 18.5 23

6-10 28.8 21.8

11-20 34.5 38.3

Affiliation

Administrative 11.7 14.8

Physicians 16.9 22.8

Health employees 56.3 58.8

Non Health employees 15 3.8

2. Satisfaction with training opportunities was measure by four items (α=0.86).

Testing the correspondence between training needs of employees and hospitals’

structure, it means the effectiveness of the performed training and the diffusion

of information related to educational opportunities offered by hospitals.

3. Satisfaction with the organization was measure by seven items (α=0.89).

Testing the hospital organization and structure.

4. Satisfaction with management & leadership style by fifteen items (α=0.95).

Testing the managerial abilities of the CEO, seniors and managers.

Overall job satisfaction dimension: Measure how content an individual is with his

or her job.

Factors were obtained using Principal Components Factor Analysis, with varimax

rotation of the orthogonal axes and in both cases the percentage of explained

variance was about 65%. We calculated for each dimension Cronbach’s α reliability

coefficient above 0.8 confirming the validity and internal consistency between items

on the scale of each factor.

Analysis 46

Table 3.2: Public Vs. Private differences at professional roles of perceived climate andjob satisfaction

LHAsPublic Private

(n=17424) (n=1276)

Professional roles Mean sd Mean sd

Administrative

Organization 0.0338 0.994 0.8287 1.1208

Training -0.2985 1.031 -0.8346 0.8331

Management & leadership style 0.0248 0.9987 0.4263 1.017

Job satisfaction -0.1317 1.0731 0.1135 1.0802

Physicians

Managerial tools 0.3329 0.9027 0.4356 0.9977

Organization 0.0252 1.0134 0.9341 1.0906

Management & leadership style 0.1998 1.0339 0.6685 0.9625

Job satisfaction 0.0566 0.9826 0.3287 1.0416

Health employees

Organization -0.0779 0.9555 0.6002 1.1281

Training 0.7335 0.9926 -0.0264 0.8585

Management & leadership style -0.0819 0.9697 0.2414 1.0709

Non health employees

Managerial tools -0.166 1.0021 0.2202 1.0989

Organization -0.1142 0.9406 0.844 1.1765

Management & leadership style -0.1177 0.968 0.5712 1.0394

Job satisfaction -0.0396 0.9579 0.3773 0.9459

p > 0.05

Professional roles in public and private hospitals in the per-

ception of Organizational Climate Factors

Subsequently we used t-test to compare mean perceptions regarding to the dimen-

sions obtained across different groups of respondents. The probability level for all

hypothesis tests was set at (p ≤ 0.05)

Table 3.2 shows the significant dimensions of organizational climate in public and

private hospitals analyzing professional roles. It was noted that the dimensions

of organizational climate are important depending on the professional role; for

example for the administrative staff is only significant the managerial tools and this

is understandable because their priority is the budget. However, climate perception

at hospital status reveal significant differences among physicians than the rest of

employees.

Analysis 47

In general, staff working in private hospitals are more likely than those working in

public hospitals. Management & leadership style and organization are significant in

all professional roles regardless of the hospital status, but private hospitals staff are

more satisfy with both of them.

Satisfaction with the organization is the most significantly factor in private hospitals,

but at the same time the most critical one because of the higher gap between two

hospital status. Differences between public and private organizations have been

discussed broadly. The first difference is that private organizations are owned by

private partners while the nation is the owner of public organizations. Public sector

organizations are controlled mainly by the political forces, not market forces. For

this reason the main constraints are imposed by the political system, while in private

organizations, the owners have a direct monetary incentive to motivate managers to

provide better performance. Similarly, the managers themselves are likely to benefit

from improved performance, because their payment is linked with the profit.

The literature pointed out that there are several external aspects that make different

managing public organizations (Boyne, 2002; Arrow, 1974; Angelopoulou et al.,

1998; Bhatia and Cleland, 2004). Public hospitals are complex organizations, Met-

calfe (1993) argues that ’government operates through networks of interdependent

organizations rather than through independent organizations which simply pursue

their own objectives”. Moreover, in the public sector there is more bureaucracy

compared to the private one, also political conditions impacts the policy makers

changing the short-term outlook and pressing to achieve results so fast, results that

can help only for political purposes, whereas private organizations should pursue

the goal of profit.

The results with respect to Managerial & leadership style are significant in all

professional roles. Literature has shown that managerial & leadership style differ

significantly between private and public organizations, managers in private orga-

nizations are motivated more by their economic well-being (Khojasteh, 1993) and

public managers are more object-oriented and they have a desire to serve the public

interest and strongly oriented towards the ”common good”. Nevertheless, these

results support some studies that have found that public sector employees are less

satisfied with their work (Buchanan, 1974; Lachman, 1985).

Highly specialized staff responded more positively all items. Physicians and ad-

Conclusions 48

ministrative employees were more positive about how they perceived their hospital,

particularly the question about the adequacy of infrastructure and physical envi-

ronment.

Training opportunities is significantly less effective in private hospitals. Moreover

employees perceived that career opportunities are not equally guaranteed for all

and there is a lack of information about training opportunities provided by the

hospital. It seemed to be the most critical issue to be taken up.

We found the existence of a discreet difference in the perception of the managerial

tools among physicians and a large difference among non health employees. The

higher gap between professional roles concerned to the existence of a professional

hierarchy in healthcare well established in the literature.

3.5 Conclusions

The results of the present study support the hypothesis that there are differences in

how the organizational climate is perceived by employees within professional roles

and hospital status in the Tuscan healthcare organizations (General hospitals).

The analysis showed that the Tuscan organizational climate questionnaire is a

reliable instrument used as a measurement tool for evaluating working conditions

and determining the factors which satisfies and motivates employees in the health-

care sector. The four dimensions detected showed high variability and different

significance along diverse organizational structures, professional roles and hospital

status.

This study shows that there are major differences between public and private

hospitals in terms of how they perceive the internal climate where the employees in

private hospitals are more satisfied than employees in public ones. On the other

hand, our results suggest that in terms of job satisfaction physicians in private

institutions are in general more satisfied.

Training processes, however, within these organizations, are loosely coupled with

the rest of the organizational processes and often depend on the employee’s ability

Conclusions 49

and willing to ask for targeted training courses.

Finally the use of an organizational climate survey can help management to identify

the critical points in the factor dimensions and communicate more effectively within

the structures improving the effectiveness of total quality management programs.

In fact, a valid internal climate survey can be a useful tool in supporting the

management to make effective innovation process. Moreover, in order to assure its

effectiveness it is important to share and discuss the results of the internal climate

survey with all the professionals being this the most important prerequisite to

support the organizational changes and it is what the Tuscan health managers are

used to do not only with regards to the internal climate results but also to all the

performance measures.

4

Does feedback from patient-experiencesurveys change behavior of health

professionals and improvecommunication with patients? The

Italian experience. 1

Healthcare providers often solicit patient feedback through questionnaires. To

test if health-professional awareness of survey results improves communication

between patients and providers, we analyzed data from 26 Italian hospitals

that documented 8,942 organizational-climate questionnaires administered

in 2010 and 5,341 inpatient experiences in 2011. Statistical analysis showed

that patient experience index significantly improved by 0.35 points (scale:

0-100) when professionals’ knowledge of survey results increased by 1%.

These findings suggest that control systems should pay attention to the

dissemination phase of patient’s surveys among health professionals.

4.1 Introduction

Patient centeredness is seen as a strategic issue of health care systems and great

efforts are made to involve patient within the delivery process. Despite this great

relevance, patient satisfaction is not always included into the planning and control

1With: Anna Maria Murante, Milena Vainieri, Sabina Nuti and Diana Rojas.

Introduction 51

systems in health care because it is considered a difficult issue to be interpreted

(Fitzpatrick and Hopkins, 1983; Williams, 1994) and in turn linked to performance

of professionals and staff. More recently, new metrics have been devised that

incorporate the opinions that patients have about their experience in healthcare

settings (Patient Reported Experience Measure) and about outcome of care (Patient

Reported Outcome Measure). Such methods allow monitoring of process and

outcome during care (Coulter et al., 2009).

Some organizations have adopted multidimensional performance evaluation systems

and have included surveys measuring quality through the patient perspective

(Giordano et al., 2010) as well as comparisons of their results among organizations.

The working assumption in this process is that awareness of the opinions of patients

is a critical issue to be considered in order to strengthen weak areas of service and

thus enhance performance. Hence the systematic monitoring of patient experience

helps organizations to assess if health professionals, so informed of the patient’s

points of view, have adopted effective actions to improve quality of care.

However, survey of patient experience is not sufficient to induce change in behavior

of health professionals and staff. Indeed, Flamholtz et al. (1985) identified a number

of factors that affect organizational performance. Extrinsic factors such as culture

or climate influence performance while other factors are strictly linked to the

management-control system adopted by the organization. The measurement is only

one of the four control core mechanisms, the others are: planning, feedback and

evaluation. In fact, once the phenomenon is measured a critical role is played by

the feedback process.

Feedback in terms of how many employees are aware of their performance in health

care literature has been investigated indirectly: most of the studies in health care

include feedback into the measurement phase or into the public disclosure of data.

Indeed public disclosure can be considered as a way to give back results or feedback.

Reviews and studies on public disclosure in health care generally consider that the

public release is able to empower accountability (Fung et al., 2008) working with the

reputational damage of hospitals and professionals (Hibbard et al., 2005). Moreover,

some authors believe that public reporting reveals provider performance to patients

and thus allows patients to make informed choices (Schauffler and Mordavsky,

2001; Faber et al., 2009; Hibbard and Sofaer, 2010; Øvretveit, 1996). Others stress

Study Data And Methods 52

public disclosure heightens awareness that healthcare workers have of their own

performance which in turn stimulates quality-improvement efforts in health services

(Barr et al., 2006; Laschober et al., 2007; Hibbard et al., 2003; Elliott et al., 2010).

Our study further explores the relationship between feedback and task performance

with a special emphasis on analysis of inpatient survey data that have been disclosed

for public scrutiny. In particular, this study aims to quantify the impact of

professional awareness of patient experience surveys on the communication process;

we focus on communication because previous works have shown that communication

is the main component of patient satisfaction (Sitzia and Wood, 1997).

4.2 Study Data And Methods

In Italy there are few regional healthcare systems that include patient-survey

results in their performance evaluation systems. Regions such as Tuscany, for

example, return survey results directly to providers, while other Regions who

administer surveys do not incorporate patient feedback into the processes of setting

organizational priorities or establishing targets (Vainieri and Nuti, 2011).

As part of a multidimensional performance evaluation system that began in 2004,

Tuscany has periodically surveyed patient experience and employee opinion of

regional health services. This evaluation system monitors 130 indicators of health-

provider performance and is currently used, respectively, by regional administrators

and local managers to set organizational targets and to align budgets. Moreover,

data are reported in comparison and are also publicly disclosed via a website

(http://performance.sssup.it/toscana/) and annual reports (Nuti, 2008; Nuti et al.,

2009).

Fifteen of the indicators elucidate patient evaluation and experience with health

services such as primary care, emergency department service, home care, hospital

service, maternal care, and elderly services. Six of the remaining indicators relate

to the nature of the professional climate perceived by employees and thus focus on

worker training, relationships between workers and managers, and communication

within the organization and between employees. Both patient and worker surveys

are administered every two years according to the planning cycle and control scheme.


In this study, we used data from the climate survey administered in 2010 and

the inpatient survey conducted in 2011. We investigated whether patients in 2011

showed improved inpatient experiences in those hospitals where one year before

healthcare workers reported to be more informed about the most recent survey of

inpatient experience.

Our analysis only considers data from each of the 26 general hospitals within

Tuscany that in the biennium 2010-2011 administered both patient and employee

surveys.

4.2.1 Surveys

In 2010, each of the 14,800 health professionals working among the 26 Tuscan

general hospitals was asked to answer the 80-question organizational-climate survey.

Questionnaires were administered on-line using the Computer Assisted Web Inter-

viewing technique (Pizzini and Furlan, 2012), and along with queries related to

involvement, communication, training and budgeting procedure, respondents were

also asked to comment on the extent to which they felt (on a 1-5 scale, where 1 is

’not at all’ and 5 is ’completely’) to be aware of patient-survey results.

We can address at least two limitations to organizational-climate survey. The first

concerns the well-known selection bias for organizational climate survey that occurs

when survey participation is voluntary (Brick, 2011). The second limitation is

that we were unable to separately survey healthcare professionals who had direct

relationship with patients during treatment from the other ones. For instance, we

cannot separately identified in our database pharmacists and laboratory specialists

and measure their indirect influence on the overall hospital experience of patients.

However, the proportion of all healthcare workers represented by these professions

is small relative to the total size of the sampled workers and thus any statistical

bias introduced thereby is probably slight.

In the following year the Inpatient Experience questionnaire (Murante et al., 2013)

was administered at home by mail, and on demand by phone or web, to patients

discharged by the 26 Tuscan general hospitals. Eligible patients were age 18

or older and had an inpatient stay of at least one night for medical, surgical, or


maternity care. About 20,200 inpatients were invited to answer 32 questions on their

hospitalization experience (reporting style questions), 4 questions regarding overall

evaluations of their hospitalization (rating style questions), and 7 questions related

to patient socio-demographic characteristics including age, gender, educational level,

self-reported health status, job position, reports of chronic disease, and history of

previous hospitalization.

4.2.2 Measures

In accord with a patient-centred approach to healthcare, communication has to be

oriented to patient needs and has to allow patients and their families to participate

in medical decisions (Epstein et al., 2005; Brown, 1999). Thus, to examine the

extent to which communication between patients and professionals (e.g., physicians

or nurses), is better experienced in hospitals where healthcare workers are more

informed about patient feedback, we devised an indicator of Patient Experience

with Communication (PEC) process. In the PEC we considered nine items from

inpatient survey data: (i) information received during admission; (ii) the clearness

of answers from doctors and (iii) nurses; (iv) information about health status and

treatment; (v) information about treatment effects; (vi) information received by

the patients’ family members; (vii) privacy during consultation; (viii) concordance

of information received during hospitalization; and (ix) information received at

hospital discharge. They were report style questions (i.e., responses were ’never’,

’sometimes’ and ’always’ or ’no’,’partially’ and ’completely’).

The PEC indicator was created by averaging the score of each item after trans-

formation to a 0-100 scale with higher scores indicating a more satisfying patient

experience (Brown et al., 2008). The high loadings of factor analysis and the robust

Cronbach’s alpha reliability coefficient confirms the validity and reliability of the

PEC measure (see Appendix).

We next used results from the organizational-climate survey to measure healthcare

worker knowledge of inpatient views. Specifically, we asked health professionals the

question, ’Are you informed about findings from the patient-experience survey?’. As

above, 1-5 point likert scales were transformed to a 0-100 scale with higher scores

indicating a more substantial level of knowledge.

Study Results 55

4.2.3 Analyses

We performed a multilevel analysis to test if PEC varies across hospitals and the

extent to which patient experience is influenced by patient socio-demographics

characteristics such as age, gender, education, health status and hospitalization

ward (at patient level), and the level of healthcare worker knowledge of patient

feedback (at hospital level).

We used multilevel statistical modeling (Bosker and Snijders, 1999) because it

elucidates effects of both individual characteristics and hospital factors on patient

experience. Specifically, patients at the lower level of analysis are nested within

hospitals at the higher level. Due to this hierarchical structure we can therefore

estimate variability in patient experience within each hospital and among hospitals.

Thus, statistical adjustment for hospital characteristics permits comparison of

patient experiences among organizations.

4.3 Study Results

1. Patient experience with communication. Of the total 5,341 inpatients who

returned a completed questionnaire (26% response rate), 62% were women

and 57% had no more than a primary or secondary-school level of education.

Respondents were on average 55 years old and reported a fair (55%) or a good

(33%) perception of their health status versus a bad perception (12%), and

reported at least one stay in a surgical ward.

The PEC index in Figure 4.2 shows an average value of patient experience

of medium-high (mean = 80; SD = 19. In practice, inpatient reported that

nurses and doctors provide concordant information to patients and further

information were provided at discharge about medical therapy and how

to manage one’s own health status at home. However, patients perceive

that less effort is invested in providing information at admission and during

hospitalization about health status and about treatment effects (Table 4.1).

A larger variability is observed in the extent to which patients perceive the

effectiveness of communication at these stages of hospitalization.

Study Results 56

Figure 4.1: Mean Patient Experience with Communication (PEC) indicator (values scale0–100)

2. Healthcare-worker knowledge of patient feedback. A total of 8,298 hospital

health professionals (a 56% response rate) participated in the organizational-

climate survey administered in 26 Tuscan general hospitals. Results show that

healthcare workers are on average poorly informed about patient experience

with health services: the average level of awareness varied among hospitals

from 42.86% to 58.63% (Table 4.2). Younger workers (18-34 years old) and

those with less professional seniority were less informed about inpatient survey

data than other hospital health professionals.

3. Feedback of patient survey data among professionals and effects on PEC.

Variation in patient experience with communication is significantly explained

at the levels of patient and hospital when analyzing an empty model with

a random intercept and without any explanatory variables (see Appendix).

Indeed, most of the total variance in PEC is explained by characteristics of

patients whereas only about 1.74% is explained by features of hospitals.

The next step was to introduce the explanatory variables at patient and hos-

pital levels. First, we observed that age, gender, education, health status and

ward where patients stayed (variables at the patient level) were significantly

associated with PEC. Specifically, PEC values increase when patients are

older, have a primary or secondary school certificate (education), are males

and report good health status.

Study Results 57

Info

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ith

Fam

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mem

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s

Hospital1 69 89 89 92 92 91 85 80 84

Hospital2 56 86 82 85 84 87 76 68 82

Hospital3 57 85 84 91 86 90 76 70 80

Hospital4 70 88 85 91 89 92 84 79 81

Hospital5 58 87 83 89 90 88 77 67 80

Hospital6 70 92 87 92 94 92 85 83 80

Hospital7 61 89 82 89 88 90 80 72 80

Hospital8 53 86 80 89 88 89 72 66 81

Hospital9 52 82 77 86 79 84 73 65 77

Hospital10 58 87 79 87 84 92 79 73 83

Hospital11 55 75 74 81 78 87 67 62 71

Hospital12 66 89 83 91 88 91 78 68 87

Hospital13 61 79 86 89 90 92 78 74 74

Hospital14 59 84 82 89 86 86 76 69 78

Hospital15 54 88 84 89 90 88 71 68 81

Hospital16 68 93 88 92 88 87 84 74 84

Hospital17 40 81 68 90 74 88 58 54 73

Hospital18 62 85 82 86 86 90 76 69 80

Hospital19 59 87 86 89 86 87 77 68 83

Hospital20 55 87 86 89 89 89 79 69 84

Hospital21 57 86 85 87 86 88 75 70 82

Hospital22 61 91 88 89 87 92 79 74 85

Hospital23 60 89 86 91 88 93 80 73 83

Hospital24 61 89 81 90 86 92 81 76 75

Hospital25 58 88 86 92 87 91 78 68 87

Hospital26 61 83 82 88 86 89 76 68 74

Total (mean) 59 87 83 89 87 89 78 71 81

Total (SD) 37 24 27 26 26 24 31 36 31

Table 4.1: Mean Patient Experience with Communication (PEC) values across Tuscanhospitals

We also observed that patient experience is affected by hospital ward, with

patients admitted to surgical wards reporting greater satisfaction than patients

Discussion 58

Table 4.2: Model coefficients and variance at the patient and hospital levels

Fixed Part - Patient level

Constant 44.82

Age 0.04**

Gender (male vs. female) 1.71**

Education (not compulsory vs. compulsory) -2.21***

Health status (passable vs. poor) 13.32***

Health status ( good vs. poor) 18.93***

Hospitalization ward (surgical vs medical) 4.38***

Hospitalization area (maternal vs medical) 1.03

Fixed Part - Hospital level

Employees feedback 0.35***

Random Part

Level 2 variance: hospitals, var (U0j) 1.28

Level 1 variance: patients, var(Rij) 318.38

-2*loglikelihood 41325.27

where: ∗p <=0.05, ∗ ∗ p <=0.01, and ∗ ∗ p <=0.001

admitted to medical wards. In contrast, we did not observed a statistically

significant difference between maternal and medical wards (Figure 4.2).

We hypothesized that patient experience improves when health professionals are

aware of patient-survey results. In support of this hypothesis, our results show that

PEC value increases by 0.35 points (on a 0-100 scale) when health professionals are

more informed about patient surveys by one percentage point (Table 4.2). Moreover,

when we adjusted patient experience for the health professionals’ awareness, the

unexplained variance of patient experience across hospitals (var U0j) decreases

about 79% (i.e., compare the level 2 variance in Exhibit 4 with level 2 variance of

the empty model in Appendix).

4.4 Discussion

Our study reveals that most of the variance in the experience of patients with

communication during hospitalization is explained by characteristics of individual

patients. In particular, we have demonstrated that older individuals with low

education and poor perception of health, and who have also been admitted to

a surgical unit, are more likely to report a satisfying communication experience.

These results are consistent with previous studies that investigated predictors of

Discussion 59

Figure 4.2: Awareness of inpatient survey data among health professionals in Tuscanhospitals.

patient experience with hospital care (Murante et al., 2013; Veenstra and Hofoss,

2003; Stubbe et al., 2007).

Our findings also suggest that organizational factors influence communication

within hospitals. The effect of hospital context, which was revealed statistically

as moderate but significant variance in PEC among hospitals, indicates that the

systems of communication differ among hospitals and may be explained by variation

in methods of processing patients at admission and discharge (e.g., during processing

some hospitals may provide more information regarding care than others). Thus,

patient feedback plays a pivotal role in improving quality in the hospitals, where the

more effort that hospitals make in conveying the patient’s point of view to health

professionals, the better the experience on communication by patients. Indeed,

after taking into account the hospital characteristics, almost 80% of the variance

in patient-communication experience at hospital level is explained by feedback of

survey data to health professionals. We hypothesize that feedback facilitates change

in behavior of professionals by providing the information necessary for self-corrective

action.

It should be noted that even thought the survey data studied here has a focus

on average results at hospital level, in practice, survey results are transmitted to

healthcare professionals also comparing hospital wards. We suggest that future

studies account for more complex institutional structure than we analyzed here and

that more attention be devoted to directing survey results at the lower levels of

organization where feedback effects may be more powerful (Hekkert et al., 2009).

Conclusion 60

The proportion of health professionals who received feedback regarding patient-

survey results varied across health providers (from 43% to 59%). However, our

analysis shows that increasing awareness of survey results by only 1% among

health professionals has a statistically significant effect on patient experience with

communication. Since the PEC indicator was composed of factors related to

continuity and coordination of care, the effects of circulating patient surveys among

professionals may not only improve the experience of patients but may also stimulate

more professional assistance.

Future studies should consider the way to better communicate survey-feedback and

improve the awareness of patient experience by health professional. For instance, it

would have a different impact whether results are distributed by request to interested

professionals or if surveys are received as part of routine but unsolicited reports

on patient experience. Such differences in survey-feedback methodologies could

account for variation among hospitals in survey awareness which, in turn, explains

variation in patient satisfaction. Indeed, (Nuti et al., 2009) found that employees

who request feedback (i.e., the inquiry method) enhance performance more than

employees who do not make such requests or those who receive unsolicited reports

(i.e., the monitoring method).

Finally, this study confirms the value of multilevel modeling as a tool for exploring

the sources of variation in patient experience. This study estimates the influence

of hospitals and patient characteristics on communication process as perceived by

patient that are likely to be more realistic than results from previously published,

single-level studies.

4.5 Conclusion

This paper establishes a statistical link between the opinions that patients hold

about healthcare services and the extent to which health professionals are aware of

and modify their behavior in response to such opinions. Previous work has shown

that communication is the most important component of patient satisfaction,2 and

our analysis further demonstrates that patient perception of communication, in

terms of adequacy and effectiveness, depends on characteristics of both patients

2Regional Law 40 (2005).

Conclusion 61

and hospitals. Although characteristics such as age, gender and health status

strongly affect patient experience results, institutional features of hospitals also play

a moderate but statistically significant role in explaining the variance in patient

opinions about the quality of communication they received from health professionals.

Perhaps most striking is the result showing that a relatively minor increase in aware-

ness among doctors and nurses of patient opinion surveys has consistent feedback

effects on patient satisfaction. Given the benefits of improved patient experience,

planners and hospital administrators might wish to enhance and expand their

schemes for informing their staffs about patient opinion. When health professionals

are aware of evidence regarding the quality of communication perceived by patients,

they are better able to focus their efforts on improving the quality of care.

Multilevel statistics 62

4.A Multilevel statistics

Table 4.3: Statistics about explanatory variables introduced in the multilevel model

Variables Results

Mean age (sd, range) 55 (24.20, 0-99)

Gender (%)Male 38

Female 62

Education*Compulsory 57.1

Not compulsory 42.9

Self-reported health status

Poor 12

Medium 54.6

Good 33.4

Hospitalization ward

Medical 31.8

Surgical 36.9

Maternal 31.3

Health professional knowledge ofinpatient survey data (sd, range)

51.6 (3.5, 42.9-58.6)

*not compulsory education refers to individuals 14 years old or more

Table 4.4: Multilevel empty model

Empty Model PEC Indicator

Fixed Part

Constant 80.0

Random Part

Level 2 variance: hospitals, var (U0j) 6.3

Level 1 variance: patients, var(Rij) 359.0

ICC (%)

var(U0j)/[var(U0j)+var(Rij)] 1.74%

-2*loglikelihood 45414

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Organizational Climate for Better Performance in Healthcare · I feel very lucky with my supervisor Professors Sabina Nuti and Chiara Seghieri. I am truly indebted to Professor Sabina