Organizational hierarchies in Bulgarian hospitals and perceptions of justice

British Journal of Health Psychology (2014), 19, 204–218

© 2012 The British Psychological Society

www.wileyonlinelibrary.com

ORCAB special series

Organizational hierarchies in Bulgarian hospitalsand perceptions of justice

Irina L. G. Todorova1*, Anna Alexandrova-Karamanova2,Yulia Panayotova2 and Elitsa Dimitrova3

1Northeastern University, Boston, Massachusetts, USA2Health Psychology Research Center, Sofia, Bulgaria3Bulgarian Academy of Sciences, Sofia, Bulgaria

Objectives. Health care reform in Bulgaria has been ongoing for two decades. Since

1990, it has been transforming from a socialized system of medical care with free access,

to one which is decentralized, includes private health care services, the general

practitioner model and a National Health Insurance Fund. In this context, we are

conducting an international EC Framework 7 project: ‘Improving quality and safety in the

hospital: The link between organizational culture, burnout, and quality of care’.We focus

on health professionals’ perceptions of organizational hierarchies in Bulgarian hospitals

and how doctors and nurses connect these to organizational justice.

Methods. We conducted seven focus groups and four interviews, with a total of 42

participants (27 nurses, 15 physicians andmedical residents) in three hospitals. Data were

analysed through thematic analysis and discourse analysis with Atlas.ti.

Results. From the perspective of health professionals, health reform has intensified

traditional hierarchies and inequalities and has created new ones in Bulgarian hospitals.

These hierarchies are continuously (re)constructed through language and practices and

also destabilized through resistance. The health professionals protest fact that these

hierarchies are permeated with unfairness and silence voices. All health professions

(nurses, doctors, residents) in our study experience being unjustly positioned and

disempowered in various hierarchies. They connect these experiences to stress and

anxiety.

Conclusions. Participatory action research needs to address multiple dimensions of

organizational relationships in Bulgarian hospitals, including hierarchical relationships and

ways of promoting organizational justice.

*Correspondence should be addressed to Irina L. G. Todorova, Northeastern University, 360 Huntington Ave, Robinson 209D,Boston, MA 02115, USA (email: [email protected]).

DOI:10.1111/bjhp.12008

204

Statement of Contribution

What is already known on this subject? Health care organizations are hierarchically organized.

Organizational injustice can contribute to burnout in health professionals. There is a high level of

stress and burnout for health professionals in Bulgaria.

What does this study add? This study adds understanding of changing hierarchies in hospitals

during health care reform in the post-socialist period. Illuminates how health professionals’

discourse sustains and resists hierarchical relationships in Bulgarian hospitals. Adds understanding of

health professionals’ perspectives on implications of injustice for their well-being.

Ongoing health care reform has been a central feature of the situation in Bulgaria of the

past two decades (Dimova et al., 2012; Koulaksazov, Todorova, Tragakes & Hristova,

2003). Until the mid-1990s, the Bulgarian health care system was based on public sector

provision, where all citizens were entitled to free medical care. In the early 1990s, some

reforms were initiated, with laws allowing private health care services, reestablishment

of medical associations and delegating the responsibility for many health care services to

the municipalities. Since the legalization of private practice in 1991, which was

previously banned in 1972, the private health sector has expanded dramatically. In thelate 1990s, more radical reforms were initiated with the introduction of the general

practitioner model of primary care and the system of social health insurance. In 1998, the

National Health Insurance Fund (NHIF), an autonomous institution for mandatory health

insurance, was established. The NHIF guarantees the financing of a basic package of

health care services. Services in the private sector are paid for out-of-pocket by patients if

the providers are not contracted with the NHIF. The changes also include introduction of

clinical pathways and copayments (and led to under-the-table payments) (Balabanova &

McKee, 2002b) and rationing of care (Balabanova & McKee, 2002a, 2004).Although the reforms are intended to improve health status in the longer term by

assuring better primary care, the financial difficulties, the constant changes and insecurity

created by them have contributed to barriers to access, anxiety and stress in interacting

with the system (Dimova et al., 2012; Koulaksazov et al., 2003). A nostalgia for the older

system of ‘free’ health care is often expressed by patients, as well as by many health

providers (Avramova et al., 2005). A recently published comparative analysis of ten

countries in the Eastern European region (Open Society Institute, 2009) concluded that

much ‘unfinished business’ remains for the transition – in particular, the health caresystems were identified as still being in significant transition.

Organizational culture and well-being in Bulgarian hospitals

In light of these changes in the health care system and all their consequences, an analysis

of the organizational dynamics and their implications for the well-being of hospital

personnel is warranted. Yet, there is very limited research on organizational culture in

Bulgarian hospitals in general and as it relates to well-being and quality of care inparticular. Organizational culture has been the focus of empirical studies in Bulgaria in the

past decade; however, they address mainly the areas of state administration and business

(Davidkov, 2002, 2010; Ilieva, 2006, 2009; Karabeliova, 2011).

In contrast, there is a significant body of research on aspects of well-being among

doctors and nurses, as well as other professionals such as teachers, policemen, managers

Hierarchies in hospitals and perceptions of justice 205

and other groups (Hristov, 2005; Naydenova & Ilieva, 2008; Russinova, Vassileva &

Zhilyova, 1998; Tzenova, 2005, 2009, 2011). In hospital settings, these studies identified

sources ofwork stress, stress levels and burnout for the health professionals. For example,

at the Military Medical Academy Hospital in Sofia, among the main sources of stressreported by health professionals were the lack of adequate payment (64.9%) and the lack

of recognition forworkwell done (40.3%). Additionally, 13.2% reported feeling exhausted

every day and having burnout symptoms, 6.6% were on the edge of overtiredness and

needed preventive measures and 9.2% experienced emotional exhaustion (Nenova,

Rasheva, Tzenova, Daskalov, & Marinov, 2005).

In another large-scaled study, conducted between 1991 and 2003 among 1,000 people

working in the service sector (Tzenova, 2005), health professionals had higher levels of

burnout compared to other professions (teachers, day care centre workers, pharmacists,telephone operators). Importantly, 33% of health professionals felt that their work is not

appreciated, 47% stated that their opinion is not heard, 37.6% that they have been treated

unfairly (Tzenova, 2005).

Examining burnout in doctors and teachers, Hristov (2005) found high and extra-high

levels of affective stress among 61.2% and high depressive symptoms in over 20% of the

doctors. A negative impact of stress on doctors’ health was established (Hristov, 2005).

In summary, research of Bulgarian hospitals has demonstrated a high level of stress, as

well as relationships between certainwork conditions and decreasedwell-being of healthprofessionals. It has also shown wide perceptions of not having one’s work appreciated,

one’s opinion not being heard and being treated unfairly. Most existing studies, however,

relate levels of stress to personal characteristics, personal resources and coping strategies.

It is also imperative to understand the organizational contexts and cultures as well as their

contribution to health risk and ultimately to risks for quality of care (Montgomery,

Panagopoulou, Kehoe & Valkanos, 2011).

To address this need, we are participating in an international project supported by the

Framework Seven Program of the European Commission: Improving quality and safety

in the hospital: The link between organizational culture, burnout and quality of care

(ORCAB).1 Many of the ORCAB partners are from South-East Europe, thus adding their

perspective to the international discussion. The ORCAB project is based on a conceptual

framework that entails mixed-methods approaches to understand these relationships and

has an action research orientation (Montgomery et al., 2011). For a detailed description of

theORCABproject, seeMontgomery, Todorova, Baban&Panagopoulou (2012), from this

series.

In this article, we understand organizational culture as relationally constructed in anongoing flowof actions, interactions and negotiations (Fairhurst &Putnam, 2004; Karatas-

Ozkan & Murphy, 2010). Material practices and objects of daily life in hospitals are also

enfolded in discourses, language and relationships (Mouton, Just & Gabrielsen, 2012;

Yardley, 1997). From a social constructionist view, organizational culture is created by the

people in the hospitals by the processes through which they construct meanings,

identities and social realities in their daily interactions. From such a perspective,

importance is placed on the constructive possibilities of language and all forms of shared

interactions (Karatas-Ozkan & Murphy, 2010). Thus, we focus on the way healthprofessionals construct the culture of their hospitals and mainly the changing organiza-

tional hierarchies in the context of health care reform in Bulgaria, including perceptions

1 http://orcab.web.auth.gr/orcab/Index.html.

206 Irina L. G. Todorova et al.

of (in)justice in hospitals and its connection to health andwell-being.We use a qualitative

approach that is based on focus groups (FG) and interviews conducted in Bulgarian

hospitals.

Methods

The international ORCAB team developed qualitative methodologies for FG and

interviews with health professionals and patients, which were adapted to the specifics

in each country (for a description of the ORCAB project methodology, see Montgomery

et al., 2012, from this series). The purposes of the FGswere as follows: to gain an in-depthunderstanding of the perspectives and experiences of health professionals and patients;

to inform the development of the structured questionnaire; to inform the action research

component of the project. As part of the latter, the conclusions from the FG analysis (as

well as from thequantitative component of theORCABproject) are currently being shared

and discussed with participating hospitals.

Approval for all project activities was obtained from individual participating hospitals

in Bulgaria, as well as from the Bulgarian Psychological Society’s Professional Ethics and

Scientific Affairs Review Board. With the health professionals, we conducted seven FGsand four interviews, with a total of 42 participants (27 nurses, 15 physicians and medical

residents) in three university hospitals in Sofia (Table 1). Participants constituted a

convenience sample, recruited with the help of a contact person in each hospital, who

were also health professionals. Those who agreed to participate met at arranged times in

professionally specific groups (all doctors or all nurses) of up to seven participants. If

groups were not formed due to small number of participants, individual interviews were

conducted. Thiswas the case for four doctorswho could not coordinate their schedules to

be available at the time of the FG. As per requirements for EU Framework 7 projects,participants were not paid for their time in the FG or interview.

Each FG had a facilitator and an assistant facilitator. We used semi-structured FG

protocols, initially developed in English tobeused as a base by allORCAB teams,whichwe

translated and used flexibly depending on the dynamics of the FG. The individual

interviews were conducted using the same protocols. Two types of FG protocols were

developed to be used by the teams – three of the seven FGs in Bulgaria discussed topics

related to experiences of stress in the workplace (they included questions about the

nature of work, typical work day, what are the sources of satisfaction in work, if there aresources of stress in work and what are they, how do they cope in situations of stress,

relationships with management and peers, their opinions about national health policies,

what would help them do their work more effectively and increase the satisfying aspects

of their profession). Four of the FGs discussed topics related to quality of care (they

Table 1. Description of the sample of health providers in Bulgariawho participated in the interviews and

focus groups

Doctors Nurses

N 15 (of which 8 residents) 27 (1 laboratory staff; 6 senior nurses)

Age 25–61 (mean 36.7) 32–57 (mean 56.3)

Gender 7 men and 8 women 27 women

Length of service 0.5–36 years (mean = 13.3) 11–35 years (mean = 22.5)

Length of service in this hospital 0.5–30 years (mean = 9.6) 3–30 years (mean = 18.4)


included questions about what comes to mind when they think about ‘quality of care’,

how is quality of care evaluated in the hospital, what are the difficulties they encounter

when trying to offer good quality of care,what are some of the changes that could bemade

in the hospital to offer higher quality of care).We audio-taped and transcribed FGs and interviews verbatim in Bulgarian, except for

one FG that declined to be taped due to concerns about having their voices identified.

During this FG, the assistant facilitator took detailed notes and later discussed these notes

withthefacilitator.Thesenoteswereusedtoinformthethemesbeingidentified,butdidnot

contribute to thediscursivepartof theanalysis andwearenotquoting fromthemverbatim.

We analysed data through thematic analysis (Braun & Clarke, 2006). Braun and Clarke

(2006) underscore the epistemological flexibility of thematic analysis, and thus, we

proceeded with a constructionist perspective (Charmaz, 1990). Initially, each of the fourauthors read and inductively coded separate transcripts; ongoing team discussions led to

elaboration of the codes, development of a common coding structure, further coding and

recoding and identification of the overarching themes. Our initial readings of each FG and

interview were conducted close to the text and focused on content and health

professionals’ experiences. We then proceeded to identify clusters of codes and thus

superordinate themes across interviews. We later conducted several closer readings

relevant to the identified theme of ‘hierarchies in hospitals’, focusing on the perspectives

of health professionals about the hierarchies and additionally paying close attention tolanguage and its constructive function. Such sequential analysis using different analytic

lenses has been shown to add to the richness of the analysis – for example, Simons,

Lathlean and Squire (2008) have made an argument for sequential use of thematic and

narrative analysis (Simons et al., 2008). Atlas.ti software for qualitative data analysis was

employed in the process.

Results

We identified multiple themes that are relevant to our understanding of the work context

of health care professionals. Participants shared their perspectives on quality of care in

Bulgarian hospitals, as well as sources and consequences of stress and burnout. Examples

of these include feeling overworked, understaffed, underpaid and operating with

insufficient financial and material resources. They discussed doctor–patient relationshipsand relationships between the hospital staff. A continuous source of stress for healthprofessionals is the ongoing health reform, the unpredictability and the constantly

changing policies, requirements, guidelines and procedures. Protective resources that

were experienced as mitigating the consequences of stressors were supportive family

relations and friendships. Many of the doctors and nurses shared that they receive a

high level of fulfilment from their work, which can be protective of stress consequences.

Their perspectives are varied and nuanced and differ depending on their profession and

department.

For this article,we focus onone important aspect of the changing health care situation,which is the dynamics of the organizational hierarchies. We identified the theme of

organizational hierarchies as a prevalent theme, relevant to all the transcripts, with the

following subthemes:

� New hierarchies – entrenched hierarchies;

� Metaphors of invisibility and disempowerment;

� Illuminating unfairness and disrespect.


New hierarchies – entrenched hierarchies

Health care organizations have evident hierarchical structures, and the health profes-

sionals referred to these in their discussions. Hierarchies were not static but

continuously changing through time, and sustained and constructed through language

and practices.

Health care reform contributed to changing hierarchical relations. From the FG

discussions, we come to the conclusion that health reform has on the one hand

entrenched some of the traditional hierarchies and inequalities and on the other hasrestructured relations in a way as to create new hierarchies. All health professionals in

our study (nurses, doctors, residents) explicitly (by spontaneously talking about

‘hierarchies’) or implicitly (by talking about injustices due to social or professional

status) presented themselves as occupying particular positions within these hierar-

chies.

Doctors perceived health care reform as conducted through top-down, non-

transparent, haphazard procedures. They referred to abstract authorities and powerful,

distant entities such as ‘The Ministry’; ‘The Reform’; ‘The System’, ‘The UniversityHospital’. Usually, these entities, which made decisions ultimately shaping the

procedures in the hospital, were beyond even the top management of the hospital.

Doctors did not perceive themselves as connected to the authorities or as having any input

into what was being planned. Changes to health care policies and hospital procedures

came unexpectedly, unpredictably and they felt alienated from them. We can make the

interpretation that the fact that changes and revisions were occurring frequently

increased the providers’ awareness of the existence of these distant authorities and their

power and position higher in the hierarchy; that is, if reform was not so prevalent, theymight not be as visible. In other words, reform can be said to have foregrounded

hierarchical structures that had always existed. On the other hand, however, the change

in the essential format of the system from socialized provision to one based on a

combination of state and private ownership of health care institutions added new

dimensions to physicians’ perception of these authorities. Doctors talked about

themselves as ‘serving’ abstract authorities, and as thus, as powerless to produce changes.

During the FG discussions, we heard an ongoing delineation of professional

boundaries and differentiation from other professions (Fiske, 2010). The physician’sprofession was delineated through juxtaposition with other health and non-health

professions – through ongoing comparisons and thus allocation of ‘them’ and ‘us’ to

particular positions in the professional hierarchy. Doctors used what they saw as the

lower status of other professions to illustrate howdisrespected they felt – andwith this, at

the same time, they re-instated their own higher position in the hierarchy of professions.

The following quote vividly illustrates this point, as the participant compares her work to

that in a restaurant or supermarket (it also illustrates doctors’ fatigue and frustration with

the demands of the ‘new’ patient).

When [the patient] knows that health care is ensured by the government, he comes, pounds

his fist and says – ‘You are required to do this! You have taken an oath, You are, You are, You

are [required]’. I AM! That is true. We are in this position; we have to treat them, but not to

service them. These are two different things.We are not a restaurant; we are not a cafe… Even

when you go to the supermarket, you still have to WAIT at the register in order to buy what

you have. Yet at the doctor’s office, they insist to come in the second they get there. (Woman,

oncology, FG #2 with doctors)


On the other hand, delineation of professional boundaries also served to create

cohesionwithin the particular profession. For example, nurses constructed themselves as

a close team and hierarchies among them were minimized, compared to the interpro-

fessional hierarchies. This created for them a supportive and trusting community inwhichto alleviate some of the work stress.

While doctors perceived themselves as somewhat inconsequential in relation to

institutional authorities and sometimes upper management, the traditional interprofes-

sional hierarchies within the hospital between doctors, residents and nurses were clearly

sustained. Nurses view almost everything that goes on in the hospital through a lens of

hierarchies and express their frustrationwith being seen as consistently at thebottom.This

is tied to their sense of powerlessness, and ultimately helplessness, which we will discuss

indetail in the following sections. Residents and junior doctors share similar experiences ofhaving no input or recognition. The position of residents as voiceless was brought to light

through their narratives, and also played out in the FG dynamics, where hierarchies were

demonstrated and more senior doctors dominated the conversation.

On the other hand, doctors tended to de-emphasize the hierarchical relationships

within their ownhospital and daily relationships, particularly in regard to their own role in

unbalanced relationships, while at the same time sustaining this imbalance:

P: I wouldn’t say that I am trying towoo them [the nurses], but I always take into account that

they are persons, that they can do thework. If theywant to do it - fine; if they don’t want to,

they don’t do it. I never approach things through a hierarchical model, for example by

ordering the nurse that she has to get it done. I do expect accountability if what I have

requested has not been completed. But the situation is such that I can’t use imperatives if I

still want things to move forward the next day. (Man, surgeon, Interview #4)

From the perspective of doctors, a dramatic change in the structure of relations in thehealth care system has come about with the redefinition of patients’ roles and rights.

While previously doctors were the authorities, they now saw themselves as having been

demoted in the hierarchy in comparison with the patients. Yet, at the same time as the

doctor states that patients have acquired a new status, the sarcastic tonewithwhich this is

presented has the effect of re-instating the doctor’s authority and rejecting the

empowerment of the patient.

The patient is not a patient anymore, ladies and gentlemen, the patient is a client. And you

have to discuss with him how to treat him. Yes, but no thanks. (Woman, surgery, FG #3 with

doctors)

Changes in the patient role have happened as a result of the emergence of private

practice and thuspotential choice andhigher expectations, of greater availability of health

information by means of print and online sources, and of expansion of civil society and

patient organizations. Increased economic stratification in Bulgaria has created a (small)

group of patients with significant financial resources. Doctors and nurses see these

patients as arrogant and demanding, having much more economic power and influence

compared to the health providers themselves. In other cases, doctors see patients as

demanding not because of economic power, but because of the increased access to healthinformation. With this information, patients come to the clinics insisting they have

knowledge about their condition and its appropriate treatment. In general, providers

often talk about patients as pretentious, demanding and exhausting.


Nurses also see themselves as being pressured by patients, but this is not such a

dramatic change for them compared to the past, and is not necessarily a redefinition of

previous hierarchies in relation to the patient. The exception to this would be the new

financial power of some patients, which increases the perceived arrogance of the patientcompared to past decades.

P1: So the management has the principle ‘The patients is always right’.

P2: Thepatient says ‘I have paid’ and there is nothing that you can say. They come inwith their

gold bracelets… and you [the nurse] stand there voiceless …[the patient says] ‘who do

you think you are? You’re not going to tell me what to do’. (Woman, FG #7 with nurses)

Thus, patients are blurring boundaries and rearranging hierarchies within thehospital. The crossing of boundaries by patients is further illuminated by the fact that

doctors and nurses are constantly arguing about who should be giving information and

answering patients’ questions – who has the right, the knowledge and which would be

the most efficient policy in this regard. The interprofessional hierarchies were both

destabilized and sustained by these discussions. For example, doctors were critical of

patients who insisted having their questions answered only by physicians, stating that

nurses also have the qualifications and can answer patients’ questions to save time for

the doctors – yet by this framing, they reinforced their own competency and expertposition.

They [the patients] often insist on speaking with the doctor. They do not believe that the

nurses are competent even to give theman answer for example about their lab results –which

they are competent to do. But they insist on talking to the doctor, and thus they take up our

time, and the time for each patient is doubled and then other patients are deprived.

(Woman, FG #2 with doctors)

Many statements from health professionals about how decisions were made or how

hospital procedures worked used the ladder metaphor, with phrases such as ‘decisions

come from the highest step in the ladder’, ‘from top to bottom’, ‘the hierarchy has to befollowed’, in a matter of fact tone. In other words, the existence of hierarchies in hospital

settings was taken for granted, yet positions in the hierarchy had to be continuously

renegotiated and sustained. Even traditional hierarchies had to be re-affirmed in everyday

exchanges and practices, while newly emerging hierarchical relations were both

acknowledged and resisted.

Metaphors of invisibility and disempowermentThe theme of disempowerment is evident in the above discussion of organizational

hierarchies, but in this section, we will further elaborate upon it. In our closer reading

of the materials and our focus on language, many phrases that referred to providers’

self-perception as invisible, forgotten or disempowered were evident – for doctors,

nurses and residents. Disempowerment was constructed through the contrast with other

professions within the hospital or with the past.

P1: That is the way it is… only the doctors and the patients complain. The nurses never

complain, right? In the media, everywhere, the nurses don’t comment. We are simply

faceless.


P2: Yes, yes.

P1: When they talk about health professionals, no one talks about nurses, lab technicians,

midwives.

P2: Yes, yes.

P1: Everyone says doctors want this, doctors want that, the doctors’ salaries are so and so;

P2: Yes, the doctors.

P1: No one talks about the nurses, how I live, with what I live.

P2: That’s right

P1: We are this invisible population

P3: Which has only responsibilities and no rights.

Several nurses: Yes, that’s exactly how it is! (Women, Focus group #4 with nurses)

P1: The truth is that at the moment young doctors are completely forgotten in this situation

with Bulgarian health care. Not somuch in our hospital, but at the level of the state, no one

thinks about us. (Man, resident, radiology)

P2: Yes, not at all. The young Bulgarian doctor is in the most unfavourable situation now,

compared to previous years. (Man, resident, intensive care, FG #2 with doctors)

Phrases such as ‘faceless’, ‘voiceless’, ‘invisible population (profession)’, ‘forgotten’,

‘they laugh at you and look through you’, ‘you are no one here’, ‘we have no input’, ‘for

many things we are in the dark’, were heard frequently. When discussing access to

information or input in decision-making, the phrase ‘nothing depends on me’ was

repeated as a collective chant by the nurses. This was a reflection of the reality of nurses’

work lives, while it also consistently reinforced this reality. Thus, disempowerment could

shift into hopelessness. Nurses in particular talked about giving up attempts to voice

opinions or intervene in any hospital matters. They shared that previous attempts on theirpart to discuss problems have beenmetwith ‘if you don’t like it, you can leave’ or have led

to threats of firing; as a result, some have given up. Nurses felt that no support was

available to them and ‘no one helps us’.

There is nowhere to turn. They [management] just laugh at youor look through you. (Woman,

FG #4 with nurses)

At this point I don’t think that anything can be done. Things have gotten way out of control.

(Woman, FG #7 with nurses)

P1: Yes, we’re just doing meaningless things.

P2: There isn’t much point in our efforts (Women, FG #5 with nurses)

P3: There is no solution

P4: There never will be, I don’t think (Women, FG#5 with nurses)

For others, the experiences of disempowerment or disillusionment led to consider-

ations of emigrating to look for work elsewhere. The following passage illustrates

elements of disillusionment in the future, consideration of emigration, as well as the


perception discussed in the first section that the problems stem from abstract macrolevel

sources, rather than more immediate organizational dynamics.

P: Things are the same [in every hospital]. I have colleagues inmanyplaces. In general I likemy

country, I don’t want to run away [emigrate], but they aremakingme.What can I do? There

is nothing that can be done.

I: [You said] because of the government policies?

P: Definitely.

I: So you don’t attribute it to management?

P: No, on the contrary, I would say that the current management of the hospital did a lot to

improve the hospital. (Man, surgeon, Interview #1)

Health professionals were appreciative of the fact that our research team was asking

their opinion about what can be done to change the situation in hospitals. However, they

were not optimistic about any realistic changes or about our project’s potential to have an

impact in that direction. When we asked what they see in the future of their organization

and health care in Bulgaria, responses were generally pessimistic:

I: So do you think, that you can have in some way an impact on these changes? How…?

P: You see, you are the first people that have askedme such a question. At least me. In a study,

which will take an unknown number of years. And I expect that you will also be the

last.(Man, resident, radiology, FG #2 with doctors)

Illuminating unfairness and disrespect

The hierarchical structures of the hospital or the relationships were not themselves seen

as problematic; what was problematic was that they silenced voices, as seen in the abovesection, as well as that they were permeated with unfairness and disrespect. Disrespect

was experienced as coming from different sources, including from the patients. Again,

this shift towards disrespect was seen as having happened with time and had changed

recently. The neweconomic resources of somepatientswere contributing towhat nurses

in particular were experiencing as disrespectful treatment.

P: There is no respect for health professionals nowadays.

I: Has this changed in recent years?

P: Yes, it has changed. [It is all] in the interest of the patient. In the interest of the patient.

I: Is that because the patient is more central?

P: It is because they have money, and connections. (Woman, FG #7 with nurses)

Nurses sawunfairness, for example, in theopportunities thatdoctorshad forprofessional

development and continuing education, which were not available to nurses. They also saw

unfairness in the way resources were distributed in the hospital, as exemplified in the low

salaries nurseswere receiving. Thiswas not somuch about the official salaries, but about the

opportunities for doctors to receive large under the table payments frompatients, a practice

fromwhichnurses donotbenefit.Nurses receive something in addition to their200europer

month salaries only if ‘the patient tosses something to the doctor and then the doctor tosses

something to us’; otherwise their ‘pockets are empty’.Nurses also shared examples of collective action to protest the way they were being

positioned in the hospital, as they attempted strikes. Although such attemptswere usually


unsuccessful and crushed in their origins, they attest to existing resistance that can

destabilize the unjust practices and relationships.

Last week, the surgical nurses protested, they stopped work, they did not want to go into

surgery because the anaesthesiologists had received some payments through the clinical

pathways, but nurses did not get anything. The hospital director says ‘All of you can send in

your resignations, and so that you don’t waste paper, do it collectively’. They can threaten to

leave, but outside there are 40 other nurses waiting [for a job]. (Woman, FG #5 with nurses)

Health professionals connected the negative emotions associated with communica-

tion along the hierarchies to stress and anxiety. For example, from the perspective of the

nurses, anxiety is provoked often by disrespectful treatment by the doctors such as

‘yelling and screaming’.

The examples of collective action cited above also illustrate how nurses worked

together as colleagues and peers with common experiences of injustice to attempt toachieve changes. In general, a comradeship among nurseswas evident, as some stated that

their relationships are like ‘friendships’. Doctors also help each other with professional

opinions and skills. We can conclude that, to some extent, these supportive relationships

could counteract the experiences of disempowerment and injustice. Similarly, the

intrinsic satisfactionwith and fulfilment from theprofession itself is also a valued resource:

I am extremely satisfiedwithmy profession. I love it verymuch.Whenever I am operating or I

domywork… I like it infinitely and I am fulfilled. [….] When you are operating, the patient is

yours – this brings fulfilment. When you are doing your work. Basically that is why we have

become surgeons. Things are simplewith us – a person has a problem, you operate, you solve

the problem and you are satisfied, if the condition improves. (Man, surgeon, Interview #4)

Discussion

Our current analysis shows that, from the perspective of health professionals, health

reform has intensified traditional hierarchies within hospitals and has created new ones.Existing hierarchical relationships between professions and between providers and

management have been brought into relief by health care reform. New developments,

such as patient empowerment in health care, are redefining these hierarchies, creating a

context inwhich providers seem to be protecting themselves from losing their position as

experts.

While we approached organizational culture as a relationally constructed and

constantly negotiated phenomenon, other studies have addressed organizational culture

in Bulgarian organizations using a typology framework. For example, Karabeliova (2011)has conducted studies of organizational culture based on the competing values

framework (Cameron, 2009). She identifies the hierarchical type organizational culture

as the dominant one according to respondents in different private and public

organizations in Bulgaria during the period of 2000–2010, which do not however,

include health care organizations (Karabeliova, 2011). The preferred valueswere found to

be those of the hierarchical type of organization – related to stability, control and

predictability.

In the quantitative ORCAB study, data from the same Bulgarian hospitals in which theFGswere conducted also showaprevalent evaluation of hospital organizational culture by


its personnel as hierarchical (Todorova, Alexandrova-Karamanova, Panayotova &

Dimitrova, 2012), according to the competing values framework (Cameron, 2009). In

this study, health professionals were asked to rate the values of their organization

according to the typologies of Clan culture, Adhocracy culture, Market culture andHierarchical culture. The hierarchical type was the most prevalent, which resonates with

our findings of the importance of this theme in the qualitative data. Hierarchical culture,

however, was significantly associated with positive indicators of well-being of the health

professionals in unadjusted correlation analysis (i.e., lower levels of burnout – emotional

exhaustion and depersonalization and lower levels of negative affectivity; aswell as higher

work engagement, higher frequency of health protective behaviours and lower frequency

of health risk behaviours). Higher strength of the hierarchical characteristics was also

associated with lower physical work demands, organizational work demands andcognitive work demands (Todorova et al., 2012).

This comparison, although using studies with different frameworks, adds to our

understanding of the organizational complexity in the hospitals. In the competing values

framework, the hierarchical culture orientation is defined as one of control, its leadership

style is one of coordination and monitoring, and its values are efficiency, timeliness,

consistency and uniformity. According to Karabeliova (2011), such organizational

characteristics might be preferred in Bulgarian organizations, considering the insecurity

and unpredictability of the previous decade during the initial shift to market economy.Thus, organizational values and relations characterized by formalized rules and proce-

dures might be perceived by the personnel as providing stability, in contrast to the

instability of the period of initial reforms. In health organizations, considering that health

care reform is still ongoing and is ‘unfinished business’ (Open Society Institute, 2009), the

preference of the health professionals for the values of a hierarchical culture thus defined

seems to be still prevalent. When the health care organization does provide such values

from the perspective of the professional, including stability, predictability and control, it

can be protective of well-being.In other studies, however, hierarchical organizations have been shown to be

characterized by blame and injustice (Khatri, Brown & Hicks, 2009). As we saw in the

Results section, the hierarchical structure of hospitals in Bulgaria in itself is accepted and

taken for granted by the participants, although newly emerging hierarchies, which are

perceived as unfair, are protested. Our qualitative analysis shows that it is the perceived

absence of justice and respect in the hierarchical relationships that is themost frustrating,

rather than theexistenceor structureof thehierarchies themselves.The situation is seenas

leading to disempowerment, helplessness and giving up, which are also concerning interms of health professionals’ well-being and engagement with their work.While some of

thosewhohavegivenupare takingapassiveposition,manyothersareplanningemigration

in search of work where they will feel appreciated. Migration tendencies of doctors and

nurses from Bulgaria to other countries in Europe have been increasing, particularly after

Bulgaria’s accession to the European Union (Beryakova, 2008). At the moment Bulgaria is

experiencing a deficiency of nurses due to the migration of health professionals.

In the examples that the providers gave when presenting their experiences, several

dimensions of justice as defined in the literature were indicated, including distributive,procedural, interpersonal and informational justice (Cole, Bernerth, Walter & Holt, 2010;

Miller, 2001). Health professionals addressed unfairness in the distribution of resources

and informations, in being eliminated from decision-making, in the absence of

acknowledgement of one’s contributions, in the disrespect frompatients and supervisors.

In previous research, perceptions of organizational injustice have been associated with


emotional exhaustion, disengagement and absence of commitment, job dissatisfaction,

turnover intentions, poor self-rated health and depressive symptoms (Cole et al., 2010;

Elovainio, Kivimaki & Vahtera, 2002; Lawson, Noblet & Rodwell, 2009; Leiter & Maslach,

1999; Liljegren & Ekberg, 2009).Our analysis can be seen as an example of the potential of qualitative research for

advancing social justice studies (Charmaz, 2008). Charmaz (2008) acknowledges that any

social entity or organization has hierarchies – but qualitative research is particularly

powerful in answering questions about ‘what are they, how did they evolve and change,

what are their costs, benefits, purposes, how are they related to power and oppression?

Whenwe study topics of justice and injustice permeating these hierarchies,we can look in

depth at the points of struggle and conflict’ (Charmaz, 2008, p. 233).

This qualitative study contains some limitations. For example, the sample was one ofconvenience,whichwas the onlyway to findparticipantswhowerewilling to devote part

of their busy work hours to take part in a study. Additionally, access to the hospitals and

specific clinics could be achieved only through the mediation of management and other

health professionals in administrative roles in the clinics. This approach to recruitment of

participants could have determined who agreed to participate, who felt they could voice

their positions, as well as which voices were silenced or not part of the FGs. Even though

within each FG participants were all from the same profession, any unevenness in the

positions in the hierarchy could have influenced the direction of the conversation andthus furtheredmarginalized some perspectives. Another limitation is that selection of one

overarching theme on which to focus the article in light of the limited space

(organizational hierarchies) creates a one-sided impression of life in the hospital and

limits what can be presented both in terms of other perceived sources of stress as well as

regarding more supportive and fulfilling aspects of health professionals’ work context.

ConclusionsUsing a qualitative approach, we have delineated the intricacies and complexities of how

healthprofessionalsperceive, construct, sustain and resist hierarchical relations (Clavering

& McLaughlin, 2007) through language and practices. Reliance only on quantitative data

would have underscored the preference of health professionals for a hierarchical

organizationalculture inthecurrenthistoricalcontextofBulgariaandwouldhaveobscured

the pervasive experiences of injustices within this culture. Also important is how health

professionals themselves experience the relevance of unjust relationships to their health.

This study has offered the opportunity to listen to health professionals’ experiencesand opinions and to take them into account when jointly developing ideas for

organizational change. The ORCAB project is now nearing its final stage – working in

collaboration with the hospitals to develop an organizational intervention through

participatory action research. During this phase, through ‘collaborative inquiry’, the

health professionals can dialogically address multiple dimensions of organizational

relationships (Gergen & Thatchenkery, 2004), reflect on how they are constructed and

reconstructed in their particular hospital and in the process, shift hierarchical relation-

ships further towards organizational justice (Greenberg, 2009).

Acknowledgement

The research leading to these results has received funding from the European Union’s Seventh

Framework Programme [FP7-HEALTH-2009-single-stage] under grant agreement # 242084.


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Organizational hierarchies in Bulgarian hospitals and perceptions of justice