J Med Syst (2008) 32:317–325 DOI 10.1007/s10916-008-9136-x
ORIGINAL PAPER
Military Medical Graduates’ Perceptions of Organizational Culture in Turkish Military Medical School Mustafa Ozer & Bilal Bakir & Abdulkadir Teke & Muharrem Ucar & Turker Bas & Adnan Atac
Received: 20 November 2007 / Accepted: 30 January 2008 / Published online: 5 March 2008 # Springer Science + Business Media, LLC 2008
Abstract Organizational culture is the term used to describe the shared beliefs, perceptions, and expectations of individuals in organizations. In the healthcare environment, organizational culture has been associated with several elements of organizational experience that contribute to quality, such as nursing care, job satisfaction, and patient safety. A range of tools have been designed to measure organizational culture and applied in industrial, educational, and health care settings. This study has been conducted to investigate the perceptions of military medical graduates on organizational culture at Gülhane Military
M. Ozer Military Health Services, Gata Askeri Sağlık Hizmetleri Etlik, Ankara 06018, Turkey B. Bakir (*) Department of Public Health, Gulhane Military Medical Academy (GMMA), Ankara 06018, Turkey e-mail:
[email protected] A. Teke Health Services Management, Gata Sağlık Hizmetleri Yönetimi Etlik, Ankara 06018, Turkey M. Ucar : A. Atac Medical History and Ethics, Gata Tıp Tarihi ve Deontoloji AD Etlik, Ankara 06018, Turkey T. Bas Management, Turkish General Staff, Ankara Turkey 06100, Medical History and Ethics, Turkish General Staff, Anakara Turkey 06100, Bakanlıklar, Ankara 06018, Turkey
Medical School. A measurement of organizational culture, which was developed by the researchers from Akdeniz University, was applied to all military medical graduates in 2004. This was a Likert type scale that included 31 items. Designers of the measurement grouped all these items into five main dimensions in their previous study. The items were scored on a five-point scale anchored by 1: strongly agree and 5: strongly disagree. Study participants included all military physicians who were in clerkship training period at Gulhane Military Medical Academy in 2004. A total of 106 graduates were accepted to response the questionnaire. The mean age of participants was 25.2± 1.1. At the time of study only 8 (7.5%) graduates were married. The study results have showed that the measurement tool with 31 items had a sufficient reliability with a Cronbach's alpha value of 0.91. Factor analysis has resulted a final measurement tool of 24 items with five factors. Total score and the scores of five subdimensions have been estimated and compared between groups based on living city and marital status. The study has shown the dimension of symbol received positive perceptions while the dimension of organizational structure and efficiency received the most negative perceptions. GMMS has a unique organizational culture with its weak and strong aspects. Conducting this kind of studies contribute to improve organizational culture in order to increase educational and research capability. Keywords Organizational culture . Medical school . Military physicians
Introduction Organizational culture is the term used to describe the shared beliefs, perceptions, and expectations of individuals
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in organizations. Because of its shared nature and implicit understanding about organizational norms and values, culture can have a dramatic effect on efforts to change specific procedures or processes. For better or worse, organizational culture affects any effort to implement change. Characteristics of organizational culture have also been linked in the literature to various aspects of organizational performance: financial performance, customer and employee satisfaction, and innovation. In the healthcare environment, organizational culture has been associated with several elements of organizational experience that contribute to quality, such as nursing care, job satisfaction, and patient safety [1]. The notion of organizational culture is clearly an attempt to capture the basic feel or sense of the organization, but it brings with it conceptual complexity and confusion. No intact definition of culture from anthropology or sociology readily lends itself for use as an organizational construct [2]. Understandably, there are a variety of definitions of the term [3–6]. Although differences exist in conceptions, there is common ground for defining culture. Organizational culture is a system of shared orientations that hold the unit together and give it a distinctive identity [2]. It denotes a wide range of social phenomena, including an organization's customary dress, language, behavior, beliefs, values, assumptions, symbols of status and authority, myths, ceremonies and rituals, and modes of deference and subversion; all of which help to define an organization's character and norms. Unsurprisingly in view of this diverse array of phenomena, little agreement exists over a precise definition of organizational culture, how it should be observed or measured, or how different methodologies can be used to inform routine administration or organizational change [7]. Some academics and many policymakers are showing renewed interest in the quantitative measurement of organizational culture in order to determine its relationship with performance and quality of care [6, 8, 9]. A range of tools designed to measure organizational culture have been developed and applied in industrial, educational, and health care settings over the last two decades. Although there is increasing interest in the relationship between organizational constructs and health services outcomes, information on the reliability and validity of the instruments measuring these constructs is sparse [10]. Since they believed the main shortcoming of existing tools was the inability to surface unanticipated findings, Mallak et al. [11] designed and applied a methodology to surface cultural information in a health care organization using critical incidents via a pencil and paper format. Some Turkish researchers also designed and applied a measurement of organizational culture as published by Erdem and Işbaşı [12]. As they indicated culture is produced by interaction of faculty, administrators, and students subcultures at academic settings and examina-
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tion of cultural characteristics of these organizations is important due to the role of culture in development of research and student education. The aim of this study has been determine the perceptions of Turkish military medical graduates—a subculture of the academic organization—about the organizational life, and to reveal weakness and strengths of organizational culture components at Gulhane Military medical School. This study would be first to emphasize the importance of organizational culture that comprises assumptions, beliefs, values, norms, symbols and practices in the educational institutions.
Method and participants Measurement tool A measurement of organizational culture perception, which was developed and applied by the researchers from Akdeniz University, the School of Economic and Administrative Sciences, has been used in the study in order to make comparisons between participants who had the same cultural background. This measurement is 31 item rating scale. The items were scored on a five-point scale anchored by 1: strongly agree and 5: strongly disagree. Originally the items of the measurement were designed to represent five main dimensions in their study. These dimensions are “communication and relation with faculty,” “symbols,” “power range,” “cohesion,” “organizational structure and efficiency.” Those items, which receive high scores, tend to be perceived negatively, while the items, which were scored low, tend to be perceived positively. The total scale score and the subtotal scores of dimensions are also estimated and all of these scores are calculated again in a range of 1 to 5. Participants This measurement with some additional socio-demographic questions has been applied to all of the military medical graduates from Gulhane Military Medical School in a selfreported form during their clerkship period of Military Medicine in 2004. This clerkship is compulsory for all military medical graduates in their first year of graduation before assignment any field service. Of the total 137 graduates, 106 were reached for applying measurement. All graduates included in the study were the students a very short time ago and they were still studying to complete the military clerkship program at the same academic setting. This helps to exclude recall limitation. They were also a homogenous group; all have just one year work experience and male, almost all of them were single. Some other characteristics of the students’ were documented elsewhere [13, 14]. The only remarkable difference among
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students the city in which their families lived during their school life. Since the school is a military boarding school, the social environment is limited to the students, faculty, administrators and other workers at the campus but those whose families lived in Ankara had a chance of staying at their family homes on weekends regularly that gave them opportunity to build social relations with different people.
ment tool. The mean scores of entire scale and subdimensions have been estimated. T-test has been used to compare the mean scores of groups based on living city. Factor analysis has been done for validity.
School environment
According to study all participants were in the age group of ‘20–29’. The average age of participants was 25.2±1.1. At the time of study only 8 (7.5%) graduates were married. While the percentage of those graduates whose families lived in Ankara was 22.6%, it was 77.4% for graduates whose families lived in a city other than Ankara. Cronbach’s alpha Value for the scores of items in the measurement tool used in the study has been found as (0.91) that was higher than the recommended value (0.70). This finding was also consistent with the results of the first study using this measurement carried by Erdem and Işbaşı [12]. Corrected Item-total correlation of items varied 0.29 to 0.64 with the exceptions of items 5 and 17 with itemtotal correlations of 0.12 and 0.14. After removing these two items from measurement tool, the Cronbach’s alpha value has been raised up to 0.92 and Corrected item-total correlation of items have varied 0.28 to 0.65. This indicates the scale with 29 items has a sufficient level of reliability. The percentages of participants’ choices for each individual item have been presented in Table 1, which listed the items according to the five main dimensions. While the item “There is competition among departments of the Medical school” has been agreed with a highest proportion 47.1% (12.3% strongly agree and 34.9% agree) among items of organizational structure and efficiency, the item of “School management protects the faculty from outside influence and pressures” has been disagreed with the highest rate of 51.9% (24.5 strongly disagree and 27.4 disagree; Table 1). While the items of “communication and relations” have been mostly agreed, the item “Communication is strong between different year students” has been strongly agreed at highest rate of 25.5%. The item of “I will see myself as a member of this school even after I graduate” has been got the highest score of agreement at a rate of 70.7% among not only cohesion items but all items of measurement tool. “The members of the faculty are caring in their relations with the students” and “Memories, stories and events are transmitted to new students by the old ones” have been agreed higher respectively among items of power distance and symbols dimensions. The mean scores given to the each item have been estimated and presented in Table 2 as an ascending order. Two items from symbol dimension have been ranked as 1 and 3 while one item from identification dimension has been ranked in second order (Table 2). On the contrary 1
While more than 50 civilian medical school serve to support health services in Turkey, Gulhane Military Medical School (GMMS) is the only military medical school attached to Gülhane Military Medical Academy (GMMA), which is the highest consultative organ of Turkish General Staff on Health issues. GMMA, which served Turkish Medicine over a century, was founded as Gülhane Military Application School and Hospital on 30 December 1898 in Istanbul as the first modern Turkish medical school. GMMA was the initiator to develop Medicine in Turkey and contributed to found Istanbul Medical School in 1909 by transferring the faculty and specialists in order to create a civilian medical school. After foundation of Istanbul medical school GMMA had stopped to educate undergraduate medical students until 1980 but continued to give post graduate education particularly residency programs. GMMA was founded again 1980 to meet the physician needs of all Turkish Armed Forces. GMMA moved to current modern building in Etlik/Ankara in 1971. Today, GMMA educates and trains more than 3,000 people including graduate and postgraduate levels. The military medical students of GMMS interact with two different main groups of trainers during their school life. The first group consists of faculty members, who are considered as idols by students. The second group is administrative officers who train medical students on military issues and are authorized to conduct the rules and principles. Particularly in the early years of medical school the second group is more effective on the school life. These two groups have a very different educational background and orientation. Addition to this, While the faculty members work at the academy for a quiet long time sometimes several decades, Administrative personnel work comparatively for shorter time span, such as 2 to 6 years. Data analyses Data obtained from the study was analyzed with SPSS package version 15.0. Statistical methods were chosen as recommend in literature [15]. Descriptive analyses have been done to demonstrate the distribution of participants according certain variables. The Cronbach’s alpha value has been estimated to evaluate internal consistency of measure-
Results
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Table 1 The distribution of participants’ choices according to options for each item of measurement tool with 31 items have been presented (n=106) Q. No Items
Organizational structure and efficiency 1 There is strong coherence between major science and science branches in the school in means of activities 3 Medical School Student Group Command is successful in solving problems 4 School management protects the faculty from outside influence and pressures 5 There is competition among departments of the Medical school 10 The courses are taught in a manner that develops reasoning and skills rather than mere information transfer 12 Members of the faculty are in coordination with each other and in solidarity 13 School management duly and correctly informs the students about the code. regulations and their applications 23 Managerial staff has positive attitudes in handling demands from the students 24 There is coordination and solidarity among students–faculty–staff 26 School meets the expectations in the family, society and business Communication and relations 2 Students are well informed about the administration and operation of the major science and science branches 6 The faculty is always open for communication 7 We are well informed about the educational objectives of the school 8 Communication is strong between different year students 15 Students see the faculty close enough to share their different problems 16 Students can communicate their problems and thoughts concerning school regulations with the management 20 New students easily blend with the existing students 22 Residents and research assistants heartily help the students Cohesion 11 The school is known to be prestigious (in the campus, in the city) 21 It is a privilege to be a med student in the faculty of medicine of this academy/university 25 I recommend college candidates around me to choose this school 27 I will see myself as a member of this school even after I graduate 31 I see myself lucky in competition with the medical schools of other universities Power distance 9 The members of the faculty are caring in their relations with the students 14 The members of the faculty are tolerant in means of mistakes 17 The members of the faculty are authoritarian in means of relations between professors and students 18 All the members of the faculty treat students similarly Symbols 19 The faculty is identical with the school 28 The physical places of your school are unique and distinct comparing with the places of other schools or colleges 29 Ceremonies such as opening and closing ceremonies are taken seriously in the school 30 Memories, stories and events are transmitted to new students by the old ones
Strongly agree (%)
Agree (%)
Indifferent (%)
Disagree (%)
Strongly disagree (%)
3.8
42.5
22.6
22.6
8.5
1.9
15.1
33.0
35.8
14.2
1.9
21.7
24.5
27.4
24.5
12.3 1.9
34.9 23.6
31.1 26.4
16.0 40.6
5.7 7.5
2.8
22.6
33.0
30.2
11.3
2.8
29.2
35.8
28.3
3.8
2.8
20.8
36.8
26.4
13.2
2.8 3.8
34.0 26.4
34.0 21.7
24.5 30.2
4.7 17.9
3.8
30.2
27.4
33.0
5.7
12.3 4.7 25.5 6.6 3.8
34.9 30.2 38.7 34.0 24.5
27.4 38.7 23.6 34.9 37.7
19.8 17.0 12.3 17.9 27.4
5.7 9.4 – 6.6 6.6
17.0 5.7
43.4 42.5
20.8 28.3
17.0 18.9
1.9 4.7
13.2 24.5
35.8 22.6
21.7 18.9
16.0 20.8
13.2 13.2
3.8 37.7 18.9
18.9 33.0 30.2
23.6 16.0 23.6
28.3 8.5 14.2
25.5 4.7 13.2
10.4
47.2
31.1
9.4
1.9
4.7 7.5
45.3 34.9
31.1 29.2
9.4 21.7
9.4 6.6
4.7
23.6
25.5
39.6
6.6
5.7 10.4
26.4 31.1
23.6 29.2
32.1 16.0
12.3 13.2
26.4
40.0
16.0
5.7
1.9
29.2
43.4
14.2
10.4
2.8
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Table 2 The mean scores of the items included in the organizational culture measurement tool with 31 items used in the study have been presented (n=106) Question No
Items
Mean
SD
29 27 30 8 12 23 10 20 9 5 6 31 14 21 22 11 15 17 1 28 24 7 13 2 16 19 18 26 3 4 25
Ceremonies such as opening and closing ceremonies are taken seriously in the school I will see myself as a member of this school even after I graduate Memories. stories and events are transmitted to new students by the old ones Communication is strong between different year students Members of the faculty are in coordination with each other and in solidarity Managerial staff has positive attitudes in handling demands from the students The courses are taught in a manner that develops reasoning and skills rather than mere information transfer New students easily blend with the existing students The members of the faculty are caring in their relations with the students There is competition among departments of the Medical school The faculty is always open for communication I see myself lucky in competition with the medical schools of other universities The members of the faculty are tolerant in means of mistakes It is a privilege to be a med student in the faculty of medicine of this academy/university Residents and research assistants heartily help the students The school is known to be prestigious (in the campus, in the city) Students see the faculty close enough to share their different problems The members of the faculty are authoritarian in means of relations between professors and students There is strong coherence between major science and science branches in the school in means of activities The physical places of your school are unique and distinct comparing with the places of other schools or colleges There is coordination and solidarity among students–faculty–staff We are well informed about the educational objectives of the school School management duly and correctly informs the students about the code, regulations and their applications Students are well informed about the administration and operation of the major science and science branches Students can communicate their problems and thoughts concerning school regulations with the management The faculty is identical with the school All the members of the faculty treat students similarly School meets the expectations in the family, society and business Medical School Student Group Command is successful in solving problems School management protects the faculty from outside influence and pressures I recommend college candidates around me to choose this school
2.07 2.09 2.14 2.23 2.25 2.26 2.28 2.43 2.45 2.68 2.72 2.73 2.74 2.75 2.75 2.80 2.84 2.85 2.89 2.91 2.94 2.96 3.01 3.07 3.08 3.19 3.20 3.33 3.45 3.51 3.53
0.9 1.1 1.1 1.0 1.0 1.0 1.0 1.0 0.9 1.1 1.1 1.3 1.0 1.4 1.0 1.2 1.0 1.1 1.1 1.2 0.9 1.0 0.9 1.0 1.0 1.1 1.0 1.2 1.0 1.1 1.2
cohesion item has been ranked at the highest point which made it last item and two items of organizational structure and efficiency have been ranked as 30 and 29 just before the last one. The dimension of symbol has received the highest mean score while the Organizational structure and efficiency dimension has received the lowest one (Table 3).
Table 3 The mean scores rated for the dimensions of the organizational culture measurement tool with 31 items used in the study have been presented Dimensions
Mean
SD
Symbols Communication and relations, Cohesion Power distance Organizational structure and efficiency Total
2.58 2.76 2.78 2.81 3.16 2.88
0.7 0.6 0.8 0.6 0.6 0.6
The mean scores given to the dimensions of the scale were compared between groups based on the city, which participants’ families lived during medical school duration. No significant difference was found between these groups for the total mean score and the dimensions’ scores with the exception of communication and relation dimension (Table 4). Those whose families lived in Ankara scored this dimension significantly higher than those whose families did not live in Ankara. The mean scores given to the dimensions of the scale were also compared between unmarried and married groups. Married Graduates got significantly higher scores on both the communication and relation dimension and symbol dimension but not on the total scale and the other dimensions (Table 5). A factor analysis was done for validity of the scale. Kaiser–Meyer–Olkin (KMO) test result has been 0.794 just below the limit of “meritorious” according to Kaiser criteria [16]. The significance level of Bartlett’s test of sphericity (1,654.9) for 29 item correlation matrix has been highly
322 Table 4 The comparisons of the mean scores rated by the groups based on the living city for the dimensions of measurement tool with 31 items used in the study have been presented
J Med Syst (2008) 32:317–325 Dimensions
Families’ living city
n values
Mean
SD
P values
Cohesion
Ankara Out of Ankara Ankara Out of Ankara Ankara Out of Ankara Ankara Out of Ankara Ankara Out of Ankara Ankara Out of Ankara
24 82 24 82 24 82 24 82 24 82 24 82
3.03 2.71 3.23 3.14 3.03 2.68 2.55 2.58 2.89 2.79 3.02 2.83
0.8 0.9 0.5 0.7 0.5 0.7 0.6 0.7 0.6 0.6 0.4 0.6
0.095
Organizational structure and efficiency Communication and relations Symbols Power distance Total
significant (p
