Organizational Culture: Its Impact on Employee Relations and Discipline in Health Care Organizations Organizations need to examine their cultures atthe level ofthe “shop floor”—in health care, the point where health ceare workers deal with patients—to determine ifthe culture is consistent with management po an effective program of reward and discipline. This article describes a case where organiz: ‘major imperative in the outcome of an arbitration jesand will permit jonal culture was a we. Discussed is a shop-floor situation in manufacturing holding implications for healthcare, a setting in which management, by countenancing counterproductive aspects of the culture, made itimpossible to apply discipline as needed. The conclusion is that health care organizations that neglect the detrimental elements of their culture may find themselves not only at risk of poor employee relations, but also unable to apply discipline effectively. Key words: health care management, organizational culture, discipline, arbitration. Stephen M. Crow, BS, MS, PhD Professor and Edward G. Schlieder Endowed Chair of Healthcare Management Department of Management University of New Orleans New Orleans, Louisiana Sandra J. Hartman, BA, MBA, PhD Professor of Management Department of Management University of New Orleans New Orleans, Louisiana ITRODUCTION ‘There has been a great deal of discussion about organizational culture. Organizational culture is said to represent the shared beliefs, values, norms, expectations, and assump- tions that are manifest in behavior and that bind people to the organization." This article reviews relevant literature and presents a case study that should give health care man- agers evidence of the need to understand how organizational culture operates to influence employee activities. Moreover, we show how failure by management to lead in the formation of a positive organizational cul- ture—one consistent with overall organiza- tion goals—can lead to an inability by man- agement to effectively apply discipline when it may be warranted. The specific case we introduce is one from manufacturing, nor health care, and there is a reason for that. To. ourknowledge, there has not been arbitration on this specific issue in health care to this point. Unfortunately, the problem exists just beneath the surface in many settings with which we are familiar and, as was the case in Health Care Manager, 2002, 21(2), 22-28 1002 Lippineots Williams & Wilkins, Ine.the situation we will describe, management is refusing to recognize it. Such failure by man- agement simply perpetuates a negative culture and leaves management open for costly prob- lems. CULTURE In academic circles, the idea of organiza- tional culture was probably recognized as early as 1948, by Selznick. He discussed how the ways of thinking and behaving in organi- zations become institutionalized and “take on lives of their own” in influencing employ- ees’ actions.” Outside of the academic setting and before the introduction of the term cul- ture into the workplace lexicon, most em- ployees knew organizational culture as “the way we are around here.” Employees may, for example, say or think, “Taking a few shortcuts with sterile materials is just the way we do it around here.” One result is that if'a newcomer or, for that matter, any member of the organization, be- haves any other way than “the way we are around here,” that individual's work life may not always be pleasant. Moreover, Weiner points out that the unpleasantness occurs especially in cases where the organization possesses a strong culture, meaning one in which the cultural values are intensely held and widely shared. The individual is sub- jected to pressure because the “rituals” or “ceremonies” signifying the newcomer’s acculturation into the organization are part of ‘a process used to determine if the newcomer fits the culture. We know this ritual as a rite of passage. If the newcomer is too out of syne with the prevailing culture, the alternatives are limited. The newcomer may have to forgo way” for “their way” or face isolation, ment, or possibly even discharge.* Of Organizational Culture — 23 course, over the past 30 years as the work- place has become more diverse with a result- ant wider range of gender- and race-based values and beliefs, organizations have had to become more vigilant in the management of the rites of passage or face the potential for discrimination charges. Most large organiza- tions with competent human resource staff's have had reasonable success in managing the rites of passage.> Others have not done so and have paid dearly. Mitsubishi comes to mind. Mitsubishi Motor Manufacturing of America agreed to pay plaintiffs $34 mil- lion—a record for a sexual harassment case. From an examination of the Mitsubishi case, it seems that the management of Mitsubishi tolerated, perhaps even nurtured, a culture of sexual game playing and aggressive behav- ior toward female employees. Among other sexual games, any new female employee was subjected to a rite of passage that included tests to see if she had a taste or tolerance for “hanky-panky” in the workplace, It is important to recognize, as the above example makes clear, that an organization's culture can be either a strength or a liability. Culture is an obvious benefit to organizations where the cultural values (ornorms, as they are often described in the group literature) are positive and include ideas such as helping coworkers or working to achieve high produc- tivity. But what about cases such as Mitsubishi or Texaco,’ where dysfunctional cultures sup- port activities that are clearly nor in the best interest of the organization? It is important to recognize that an organization’s culture can be either a strength or a liability.24 THE HEALTH CARE MANAGER/DECEMBER 2002 This article considers the impacts of a dysfunctional culture on management's abil- ity to discipline an employee who may well be someone management wishes would eave the organization. Yet, where managers refuse to deal with a dysfunctional culture, they may find themselves lacking appropri- ate ability to enforce discipline. Specifically, this article discusses how organizational cul- ture may impact disciplinary actions at the shop floor—the level, in health care, where patient care is given. ‘The case study that follows involves a grievant who seemed out of step with a num- ber of significant aspects of the company’s culture, but did share the culture’s accep- tance of rough-and-tumble language and macho posturing.’ Moreover, management tolerated these rather negative or dysfunc- tional aspects of the culture. In most other aspects of the culture, however, the em- ployee did not conform to the shared beliefs and expectations of work-related behavior and seemed isolated. The result was a series of “mixed signals” that left management hin- dered in its ability to apply discipline. As noted, upon initial review, many health care managers may be tempted to say, “What's this have to do with my organization?” We hope to show that it may be meaningful, indeed. THE CASE The case was set in a rural manufacturing company in the South. The blue-collar workforce, in keeping with demographics and customs of this geographic area, was rela- tively homogeneous, consisting primarily of white males. At issue was an altercation between coworkers, Aland George (not their real names). There had been a history of “bad blood” between the two. The incident began when George directed foul, provoca- tive language (the type that was consistent with the culture) at Al. Moreover (and again consistent with the culture), George physi- cally attacked Al, who responded by falling to the ground and shielding himself trom George's blows. The company disciplined both employees. ‘Al was suspended for five days and given three reasons for the suspension: the scuttle with George, a recent violation of work rules, and a history of poor work performance and poor work habits. Because of his role in the altercation and his attempt at a cover-up, George was given the opportunity to resign. Although Alwas nota well-liked employee, the union was called uponto represent him in grieving the suspension. It argued that Al's suspension was not based on just cause. Specifically, Al simply acted in response to provocative language by George. Moreover, George's provocative language was not un- common and, in fact, fell within the context of accepted behavior inthe work setting. George initiated the scuttle and Al fell to the ground and covered himself rom George's attack. Al didnotstrike George. What's more, the union pointed out, the company's use of an earlier work rule violation and discussion of Al's history of work-related problems was, in real- ity, an attempt by the company to strengthen an otherwise weak rationale for disciplinary action. Testimony by the company witnesses re- vealed that Al had a troubled history as an employee, a record of poor work perfor- mance, absenteeism, conduct making him difficult to supervise, and, on occasion, in- subordination, He had poor relationships with employees and supervisors and had been cited and disciplined on numerous occa-sions. From the perspective of the organization's culture, Al did not fit in well within the workers’ informal norms, which emphasized the need to “hold up your own end” and not leave problems or undone work forothers, especially those on incoming shifts. Moreover, the norm was to settle problems among workers within the group and to avoid involving management or, most especially, “outsiders.” Management, in effect, supported these norms by letting workers settle their ‘own problems and by tolerating the foul lan- guage, posturing, and minor scuffles that occurred as issues were “worked out.” Man- agement knew their working-class employ- ees’ Southern culture supported physical posturing and macho approaches to conflict, both inside and outside the work environ- ment. Al was known to violate the group's norms fairly regularly and, based on the testimony, was persona non-grata with su- pervisors and coworkers. In short, his atti- tude and behavior did not conform to the prevailing culture of the company. Al and George were shift workers. At the time of the altercation, George was coming ‘on shift, and Al was going off. In accordance with work procedures, Al began communi- cating to his replacement, George, about the production issues from the previous shift that he thought were important. The two workers had a history of not getting along. Instead of listening to Al, George cut him off, stating something to the effect of that he was a“ habitual liar” and that he [George] would take care of any problems that he found on the shift. More to the point, George initiated the confrontation with Al through the use of pro- vocative language. George testified that he initiated the con- frontation with Al because Al could not be trusted to tell the truth when “making relief” Organizational Culture 25 (the term used to communicate during shift changes). For example (and in marked con- trast to the prevailing norms), Al had a ten- dency to leave work for the incoming shift that he should have taken care of beforehand. He also had a habit of leaving “surprises for the incoming shift—problems that he was aware of, but had not communicated to the incom- ing workers. The stories vary after George dropped the gauntlet with his abusive and contemptuous epithet. Al said he walked away and, over his shoulder, said something to the effect of “F... you, George.” In response, George jumped Al from behind and began flailing at him. George did agree that Al said “F... you, George;” however, George stated that Al did not walk away. Instead, George said that Al wheeled around and cameat him, with amenacing look and clinched fists, as if he were about to attack. George admitted that to protect himself, he counter-attacked. Conflicting testimony not- withstanding, it was clear that George initiated the confrontation with provocative language and threw the first punch. During the scuffle, another employee separated the men before either was seriously hurt. Had Al not reported the incident to the police, it may have never been addressed officially by the company. A cover-up by employees who were in the area of the inci- dent—again, in keeping with the norms— had started to protect George and (toalesser extent) Al from disciplinary action. Once again, by involving the police, Al was violating the culture of the shop. Once the altercation was forcibly brought to the company's attention as a result of the police report, an investiga tion ensued and, as mentioned above, man- agement suspended Aland gave George the opportunity to resign. George accepted the offer. Al filed a grievance.26 THe HEALTH CARE MANAGER/DECEMBER 2002 Witness testimony supported the union's allegation that the language in the work set- ting was very rough and the use of the phrase “F... you” was not uncommon among em- ployees and management. One witness tes- tified that the company had tolerated pro- vocative language over the years. More specifically, considerably more explicit ob- scenities were commonplace in the work environment, in communications between coworkers, between managers, and between workers andmanagers. The union suggested that by tolerating this type of language, the company was, in effect, telling employees that such talk was perfectly acceptable. In short, the culture of the work setting at the company, both on the part of management and workers, tolerated provocative language. Moreover, although disputed by the com- pany, hearsay comments from union wit- nesses detailed other fights that occurred within the work setting in which no follow-up disciplinary action was taken against the participating employees. The union sug- gested that the company had tolerated a culture of physical dispute resolution be- tween employees for some time. As stated, the company suspended Al for five days for several reasons: the altercation with George, a recent violation of work rules, and a history of poor work performance and poor work habits. The arbitrator viewed the company’s allegations of Al's recent violation ofworkrulesandhis poor work historyasaway of ‘padding’ the case to justify the suspension. Nevertheless, had the company proven that Al had provoked the altercation, it would have been reason enough to uphold the company’s decision to suspend Al for five days because fighting or provoking a fight is a serious offense in the workplace. Violence is such a threat to morale, productivity, and the safety and welfare of employees that it warrants severity in meting out discipline to those involved. Discharge is usually justified, and anything less than suspension should be out of the ordinary. In short, Al's suspension would be warranted if the company could have proven that he provoked George or that he was a willing participantin the scuffle. The company did not make that case. Al used poor judgment by contributing to a possible hostile situation when he said “F... you, George.” For that, given the culture of abu- sive language and macho posturing, the ar- bitrator ruled that the appropriate penalty for Al's contribution to the altercation was a written reprimand. How does a person provoke aggressive behaviorin the workplace? The answer is: by action, by deeds, or by words. Physical ac- tion involves grabbing, shoving, hitting, or using other direct contact that may cause a person to react physically to the provocateur. ‘The intent of the provocateur may be non- aggressive, as in a case of horseplay, where, on a lark, one employee “gooses” another employee from behind. That employee, then, may overreact to the touch and spontane- ously backhand the first employee. Provocation hy deed is an indirect action taken by an employee that has a detrimental impact onanotheremployee to the extent that the harmed employee feels the need to retali- ate physically. “Rating” on a fellow em- ployee is an example. Provocation by words is often a situation in which one employee says something so vile to another that the insulted employee feels there is only one option to protect his honor. He must respond to his provocateur through verbal or physical aggression. Men in the South, more than men in most other regionsof the world, are likely to take offense to an insult and to think aggression is an appropri- ate response.” This predisposition is nurtured in organi- zations that buy into the cultural imperative that an insult to one’s honor warrants a strong, aggressive response. In their testi- ‘mony, the union employees suggested such an organizational culture existed at the com- pany. The arbitrator concluded that the use of provocative language by managers and em- ployees was commonplace. Also, employees occasionally resorted to verbal and physical aggression to resolve differences. And, in general, the culture called for employees to look the other way and cover for employees who acted or reacted aggressively. It is inter- esting to observe the strength of the company’s norms in this area: workers were willing to cover for Al even though he was “outside” the culture. ‘The testimony and the facts of the arbitra- tion suggest that given George’s mood and the cultural context of the company, Al did not provoke George to any great extent. For whatever reason, George was probably al- ready primed to fight Al. His provocative language came outof the blue. Al was merely “making relief” and his rejoinder to George may have been just the excuse George was looking for to attack him. THIS IS ABOUT HEALTH CARE? We suspect, at this point, that a number of readers are saying to themselves, “That's another world—we in health care never see that sort of thing!” However, we suggest that there may be some disturbing parallels in some health care settings, Recently we have pointed out that many health care organiza- Organizational Culture 27 Organizations need to examine “the way we are around here” and ask whether that way is consistent with good employee relations. tions are at risk because of their failure to discipline—and ultimately remove—what we call the “rogue doctor” from their ranks. Rogues are doctors who exhibit severe ethi- cal and performance problems that expose patients and those around them to various risks. Moreover, the problems are deep- seated, problems that the doctor cannot or will not change, We have contended that health care organizations must develop a “zero tolerance” approach to identifying and removing such doctors."° But what ifthe culture is such that the rogue cannot be removed? While they are typically unwilling to admit it, a number of health care organizations have a culture that tolerates a level of disrespect that is displayed by doc- tors and directed toward other patient care providers—especially nurses and aides. Snide comments, shows of irritation, and even mild forms of name-calling are often tolerated and even accepted within the cul- ture. What happens, then, if a rogue takes ita step further and becomes verbally or perhaps even physically abusive? In a culture in which disrespect is tolerated, can aclear case be made for disciplining just the rogue? Here’ s another possibility that should raise a red flag. Historically, physicians were largely males who enjoyed a substantial power differential over others such as nurses technicians, and aides. These “lower level” individuals, moreover, were traditionally fe- male. (And yes, we are aware that this situa- tion is changing rapidly, but itis important to28 THe HeavTH CARE MANAGER/DECEMBER 2002 recognize that in many organizations the culture was formed prior to the demographic changes in health care, and that organiza- tional culture is notably slow to change.) In situations in which males hold a power dif- ferential over females, there is always poten- tial for behaviors that in our society are labeled sexual harassment to become part of the culture, The range may be from mild sexually oriented joking to overt activities such as fondling or outright abuse. Again, however, consider the prospects for an orga nization whose culture has supported sexual “kidding around” when a rogue who is a sexual predator joins the organization. When the inevitable problems arise, will manage- ment, having tolerated some forms of sexu- ally oriented activity, be able to discipline the rogue without disciplining others as well? CONCLUSIONS Organizations need to examine “the way we are around here” and ask whether that REFERENCES way is consistent with good employee rela- tions. It is beyond comprehension that a large, international company like Mitsubishi could have failed to see the importance of changing its organizational culture at its work setting in Illinois. But fail it did, and failure cost it a significant penalty. Our con- cern is that the health care industry may be just as blind to potential problems arising from culturally supported differences be- tween the physicians and individuals who have more status and power and the other health care workers who are involved in the delivery of care to patients. 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