how to transform the organizational culture of a service institution to create

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How to Transform the Organizational Culture of a Service Institution to Create an Environment of Commitment, Cooperation and Learning?

A Dissertation Submitted To The University of Manchester

for the Degree of Master of Science

2014

Francisco W. Hagó Celi

Manchester Business School

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TABLE OF CONTENTS

ACKNOWLEDGEMENTS

ABSTRACT

LIST OF TABLES

CHAPTER ONE: INTRODUCTION 9

1.1 Introduction to the Research 9

1.2 Research Context 11

1.3 Structure of the Thesis 12

1.4 Chapter Summary 14

CHAPTER TWO: THE SYSTEMATIC LITERATURE REVIEW 15

2.1 Introduction 15

2.2 Protocol Used in the Systematic Literature Review 15

2.2.1 Review Protocol 15

2.2.2 The Research Questions Addressed by the Study 16

2.3 The Search Strategy for Identification of Relevant Studies 17

2.3.1 Use of Keywords 17

2.3.2 The Criteria for Inclusion and Exclusion in the

Systematic Review 17

2.4 Systematic Literature Review for Relevant Information

for the Research Questions. 18

2.4.1 Antecedents in the Organization to Implement Change 19

2.4.2 The Organizational Culture 20

2.4.3 The Collaborative Culture 21

2.4.4 The Commitment to the Organization 22

2.4.5 Learning Organizations 24

2.5 Academic Literature Gap 25

2.6 Summary of the Systematic Literature Review 26

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CHAPTER THREE: METHODOLOGY 27

3.1 Introduction to Chapter 27

3.2 Research Philosophy and Approach 27

3.3 Research Strategy 28

3.4 Case Study Design 29

3.4.1 Case Selection and Sample Population 30

3.4.2 Data Units of Analysis and Data Analysis 31

3.5 Data Collection 32

3.6 Research Credibility, Reliability and Validity 33

3.7 Data Analysis and Interpretation 34


CHAPTER FOUR: CASE FINDINGS 36


4.2 Findings From The Interviews to Management 36

4.2.1 Managers’ Feelings Towards Their Work Environment 36

4.2.2 Managers’ Perspectives and Perceptions Toward the

Organizational Communication 40

4.2.3 Managers Perspectives and Perceptions Toward the

Organization’s Objectives 43


Organization 44

4.2.5 Managers’ Perspectives and Perceptions Toward Control 45

4.3 Findings From Interviews to Doctors 46

4.3.1 Doctors’ Feelings Towards Their Work Environment 46

4.3.2 Doctors’ Perspectives and Perceptions Toward the



Organization’s Objectives 48


Organization 48

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4.3.5 Doctors’ Perspectives and Perceptions Toward Control 49

4.4 Findings from Interviews to Nurses 50

4.4.1 Nurses’ Feelings Towards Their Work Environment 51

4.4.2 Nurses’ Perspectives and Perceptions Toward the


4.4.3 Nurses’ Perspectives and Perceptions Toward the

Organization 53

4.4.4 Nurses’ Perspectives and Perceptions Toward Control 54

4.5 Findings from Interviews to Administrative Staff 55

4.5.1 Administrative Staff Feelings Towards Their Work

Environment 55

4.5.2 Administrative Staff Perspectives and Perceptions

Toward the Organizational Communication 56

4.5.3 Administrative Staff Perspectives and Perceptions

Toward the Organizational Objectives 57


CHAPTER FIVE: DISCUSSION 58


5.2 Antecedents in the Organization to Implement Change 58

5.3 The Organizational Culture 60

5.4 The Collaborative Culture 61

5.5 The Commitment to the Organization 63

5.6 The Learning Organizations 64


CHAPTER SIX: CONCLUSIONS AND REFLECTIONS 66


6.2 Theoretical Contributions 66

6.3 Practical Implications 68

6.4 Reflections on the Research Limitations 69

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6.5 Further Research 70

REFERENCES 72

APPENDICES

Appendix A Research Report Table 80

Appendix B Interview Guide 81

Appendix C Interview Guide: Doctor A 84

Appendix D Interview Guide: Manager A 89

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ACKNOWLEDGEMENTS

I would like to recognize the support provided to the Ministry of Public Health of

Ecuador and its Ministry, Carina Vance for granting access to the valuable data

collected for this academic research. I would also offer my gratitude to the members

of the Francisco Icaza Bustamante Children Hospital for sharing their views and more

important, to share their feelings and desires to serve the population by providing

care.

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ABSTRACT

The research explores the relationships between organizational changes and the

perception of individuals that prevent them to support initiates to foster efficiency in

the institution. The research proposes an approach to manage the emotional barriers

that members create as a collective. The approach aims to motivate the members in

the organization to commit to the organizational goals and objectives by creating

cooperation. Furthermore, the research discusses the mechanism to create an

environment of a learning organization.

Keywords: Organizational Change, Organizational Culture, Learning Organization,

Commitment, and Cooperation.

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LIST OF TABLES

Table 1: Key Academic References

Table 2: Research Keywords

Table 3: Sample Population and Demographics of the Francisco Icaza

Bustamante Children Hospital

Table 4: Data Unit of Analysis

Table 5: Areas of Perception

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Chapter One: Introduction

1.1 Introduction to the Research

Due to external and internal factors (economic resections, national resources assigned

to other priorities in country or the coercion of the foreign debt of a country1),

societies have not being able to assign enough resources to maintain a continuous

development of their national healthcare systems. Ecuador is a country that has been

investing 6.9% of its GDP (World Bank Database)2 for the past seven years in its

healthcare system. The current government took the political decision to assign the

economic resources to develop the public healthcare system as never before. It is a

very ambitious program of improvements and expansion that includes the

preparation of the personnel, development of new infrastructure, and the renewal and

acquisition of medical equipment. Still, the increase of the established capacity has

also affected the demand. The notorious continuous improvement has made the

demand to increase in an exponential rate. Social sectors that before could no

consider the use of the public healthcare system, they are now demanding services.

The growth of the demand for healthcare services is greater that the increase in

capacity.

The capacity of the healthcare system is being developed, but the demand must be

met with the existing resources. There are plenty of techniques that can provide the

desired improvement of service in a hospital. Among the numerous methods used to

improve processes in institutions, Lean is one that offers widely recognized benefits in

hospitals. However, the benefits that these methodologies can offer, can only reach its

maximum benefits as long as they are fully supported by the personnel such as

doctors, nurses and the administrative staff in a hospital. 1 A complete analysis of the influence of foreign debt in the Ecuadorian case could be appreciated in the research provided by the Internal Auditing Commission for Public Credit of Ecuador. The document examined the stakeholders involved in the foreign debt, the use and badly used of the funds and the influence exercised by multilateral organizations such as the IMF with their Intention Agreements. The audit covered all the public debt since 1976 until 2008. For the source, please see the reference 2 World Bank data from 2009 to 2012. For the source, please see the reference

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The question established by this research explores the current academic literature

and presents a practical approach to reach the desired culture in the organization.

The present research explores the values and feelings that motivate individuals in an

organization to guide their actions in any given structure. This understanding of

values allows managers to transform the current organizational culture in the

institution to create an environment in which the members of the institution will

further commitment, cooperation and learning. The research objectives are to

understand those factors of influence people as individuals and as groups in the

organization. An approach would be proposed for managers to replicate and to

motivate the transformation of the organization into a dynamic entity that is

constantly improving. The key references for the research are presented in the

following table that group then around the axes of the academic discussion:

Table 1

Axes Key Academic References

Antecedents in the Organization to

Implement Change

Allen and Meyer, 1990, 1996

Argyris, 2008

Avolio, Zhu, Koh and Bhatia , 2004

Eby, Freeman, Rush, and Lance, 1999

Holt et al. 2007

Meyer and Allen, 1997

Mowday, Porter, and Steers, 1982

Van de Ven and Poole, 1995

The Organizational Culture

Argyris, 2008

Cooke and Szumal, 2000

Cooke, and Potter, 2006

Holt and Armenakis, 2007

Miles et al. , 1996

The Collaborative Culture Sanchez and Cralle, 2012

The Commitment to the Organization

Armenakis and Bedeian, 1999

Martin et al., 2006

Parker et al., 2003

Pettigrew, 2000

Vakola and Nikolaou, 2005

Learning Organizations Argyris, 2008

Argyris and Schön, 1974

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Key Academic References 1.2 Research Context

The design of the case is based on the interviews at the Francisco Icaza Bustamante

Children Hospital. The approach would be used by any kind of organizations from

private or public nature; however, a hospital would provide the most reach scenarios

for the complexity of the members in the organization. The Francisco Icaza

Bustamante Children Hospital is a public institution that has administrative

independence from the central government in Ecuador, but is under the rectory of the

Ministry of Public Healthcare in Ecuador. For the past years the development plan

(Development Plans and Territorial Ordering, 2014) had included many changes

about policies, structures, services and much more. In addition, new ERP systems

(Enterprise Resource Planning) have been continuously implemented, new services

have being created, new administrative and medical technologies have being

introduce and professional and non-‐professional personnel had being required

(Integral Service Model Of the National Health System of Ecuador, 2012).

Furthermore, some personnel in the hospital have being working there for over four

decades. Their experiences, perceptions, feelings could be analysed across the years;

the different central government periods can provide a unique perspective for the

research. In addition, due to the requirements of the new systems, different

professional profiles had been added to the institutions. The possible matrix of

principles, views, and feelings made of the Francisco Icaza Bustamante Children

Hospital a unique source of data. In addition, a hospital offers a distinctive complexity

of hierarchy that creates very multifaceted relationships. Because the hospital is a

public institution, the Ministry of Public Health is responsible to determine the

national healthcare policy that regulates the institution. In addition, the general

director and upper managers in the institution have the administrative authority to

regulate the actions of the members in this kind of organization, but the medical

personnel may be responsible to regulate the daily operational activities. It could be

found large discrepancies in the general profiles of these groups. For example, a

manager in a given hospital in Ecuador may have a MBA, two decades of work

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experience and other attributes, the medical personnel may have many more years of

postgraduate education, and four decades of work experience in the healthcare

system. Argyris (2008) argues how the most well educated professionals are

especially susceptible to justify the avoidance of changing their theories of action.

Although the research does not focus on those correlations of variables, the research

does look for the values, views and feelings developed from those discrepancies in

profiles in the organization.

1.3 Structure of the Thesis

The dissertation is structured in 6 distinctive chapters that provide the development

of the research. The development is synthesized as follow:

Chapter 1: Introduction

• Provides a general analysis of the social needs and opportunities that Ecuador

faces in this time period.

• The research plans to develop applicable solutions to the middle and long-‐term

national needs that institutions have in Ecuador.

• An explanation of the case context is provided.

Chapter 2: The Systematic Literature Review

• The systematic literature review is presented and explained.

• The research strategy is established with the objective to identify the relevant

studies in need for this academic work.

• A criterion for inclusion, exclusion and historical background is presented.

• The description and analyse of theoretical models, frameworks and

perspectives that can contribute to the development of the research is

presented.

• The justification of how the theoretical establishment for the dissertation

applies to the problem.

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Chapter 3: Methodology

• The methodology chapter provides detailed information of the conceptual

vision and academic meticulousness of methods to implement the research.

• Itemized description of properties of the methods is presented: Research

philosophy, approach, and strategy.

• The characteristics of the case design are developed. A justification of selecting

the Francisco Icaza Bustamante Children Hospital are also prepared and

developed.

• A thoughtful argument is presented for the data analysis and interpretation are

also given.

Chapter 4: Case Findings

• The chapter describes and list the findings collected from the 12 interviews

that were performed in the Francisco Icaza Bustamante Children’s Hospital in

Guayaquil, Ecuador.

• The 12 transcripts were analysed by the use of 5 Units of Analysis: Feelings of

the Subjects towards the Organization, Characteristics of the Communication,

Objectives, Aspects of the Organization, and Control.

• Additionally, the units of analysis or categories of coding were further sub-‐

coded according to findings.

• The outcomes were segmented according to the sample groups and at the end

of each section, a table is provided that listed the statements provided from the

interviewed according to the outcomes and questions made.

Chapter 5: Discussion

• The chapter presents the arguments that emerge from the contraposition

between the synthesis of the systematic literature review, the literature gap

and the findings from the research.

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• The chapter is organized according to the five conceptual pillars that resulted

from the systematic literature review.

Chapter 6: Conclusions and Reflections

• The chapter presents the some reflections about the theoretical contributions

that the research had found.

• The chapter focus on some of the aspects that the proposed approach was

characterized for.

• In addition, some practical applications were presented for the methodology

suggested, as well as the explanation of some of the limitations for the

development of the research.

• Finally, further research possibilities were also presented.

1.4 Chapter Summary

The chapter presented the conceptual and social reasons that motivated the academic

work based the needs in Ecuador. In addition, a detailed explanation of the research

context was also developed to provide a better understanding of the internal and

external factors that influenced the case design. Finally, a summary of the thesis

structure was presented.

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CHAPTER TWO: THE SYSTEMATIC LITERATURE REVIEW

2.1 Introduction

The chapter provides a general description of the organization and perspective used

for the research and methodology used for the systematic review. The protocol

section describes the parameters used to conduct the systematic review of the

existing academic literature available between the selected theoretical framework and

the selected subject of the study. The chapter establishes the perspective and the

evolution in the development of the academic views and theoretical frameworks of

how societies and academics have position the role of the workforce.

The systematic literature review stipulates an analytical summary y description of the

academic discussion upon the topic of the research as well as the discussion of the

findings. Finally, the chapter provides an argument the literature gap found from the

systematic review.

2.2 Protocol Used in the Systematic Literature Review

The section presents the review protocol for the systematic review according to the

research question for the research. The research strategy is developed by the

presentation of parameters for the literature review. The literature review is also

presented according to the areas of analysis.

2.2.1 Review Protocol

For the development of the literature review, a systematic approach is required to

benefit of a highest quality possible of academic works that fits the research question.

In addition, to provide a wider view of perspective to foster the research, an

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interdisciplinary perspective in selected. The fields to frame the review were from the

areas of Service Operation Management in Healthcare and from Organizational

Behaviour. To optimize the richness of investigations that would be produce, the

systematic review provides an efficient methodology to manage such findings. The

aim of the literature review is to analyse current theoretical frameworks, theoretical

approaches and management methodologies that can be implemented for healthcare

institutions in a developing country that will allow improving the engagement of

personnel in the institutions to support lean methodologies. To achieve this aim, the

literature review looked for data from different researches and papers in the fields.

The presented scheme of structure was adapted from Tranfield, Denyer and Smart

(2003).

2.2.2 The Research Questions Addressed by the Study

The specific question that the research presents is: “How to Transform the

Organizational Culture of a Service Institution to Create an Environment of

Commitment, Cooperation and Learning?”. From a general perspective, the research

looks to understand the motivations that influence the individuals to make decisions.

At the same time, the sum of the choices that individuals make, are part of a collective

called organization. The research aims to propose an approach that can stimulate the

organization at the individual level and as a collective to develop commitment to the

institution. In addition, the approach would propose to encourage the cooperation

among the members in independence of the hierarchy to which they belong.

Furthermore, the research looks into the conditions to learn from the experiences,

positive or negative, that the organization encounters.

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2.3 The Search Strategy for Identification of Relevant Studies

The strategy for the systematic literature review includes the use of keywords, and

the criteria for inclusion and exclusion of academic data.

2.3.1 Use of Keywords

The use of Natural Language Keywords allows maximizing the use of electronic

databases that looked into titles, abstracts and similar or related context in the text

body (Jesson et al. 2011). It facilitates the review and identification of possible useful

papers that may contribute to the research. The chosen keywords reflected the

interdisciplinary views for the systematic review. The identified keywords are as

follow:

Table 2 Research Keywords

2.3.2 The Criteria for Inclusion and Exclusion in the Systematic Review

Research Keywords

Behaviour Institutional Behaviour

Conduct Motivation

Control System Organizational Behaviour

Customer Satisfaction Organizational Change

Design Public Healthcare

Employee Behaviour Public Hospitals

Employee Engagement Quality

Facilities Satisfaction

Hospital

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The systematic literature review researched for papers that addressed direct issues

from the last 10 years to ensure the access to updated researches. As Saunders et al.

(2012) suggests, consideration is taken to admit academic recognized sources and to

ensure maximum coverage in the research. Official documents from the Ministry of

Public Health of Ecuador were accepted if they were emitted from the current

government period (from the year 2007 until now) and documents that are aligned

with the current development strategy3 in the sector. Criteria for exclusion were

included for papers that proposed practices that are not in aliment with the current

legal system.

2.4 Systematic Literature Review for Relevant Information for the

Research Questions.

The role of the healthcare system in a country is an undeniable factor of importance

for the development of such country (National Plan of the Good Living, 2013). It is

recognized that the delivery of health care service is considered as intuitive,

interpersonal and a complex realm (Bush, 2007). The performance of the personnel

in the healthcare institutions or the effectiveness to implement lead-‐time reduction

techniques to reach efficiency would depend on the motivation that the workforce

has. Coomber and Barriball (2007) consider that the work environment can affect the

motivation of personnel in the workplace. Furthermore, according to Laschinger

(2004), the organizational environment can increase increases the perception of

respect, resulting in positive outcomes for both the staff and the organization. The

following sections result from the perspective developed in the systematic review and

aims to explain the possible perspective for institutions to motivate their personnel to

make positive choices (Section 2.8 Academic Literature Gap). The systematic review

reveals five perspectives for motivating personnel to be the actors of change in the

institution. The perspectives look for the transformation of the culture in the

3 Under the leadership of President Rafael Correa Delgado, the Ministry of Public Health has implemented a national capacity development plan.

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organization. The result would motivate the members in the organization to drive

their efforts to achieve commitment, cooperation and learning. The five perspectives

are analysed from section 2.4.1 to section 2.4.5:

2.4.1 Antecedents in the Organization to Implement Change

In order to obtain a positive response from the personnel while the institution looks

for improvements in their operations or implementing quality development

programs, the organization need to create commitment from its personnel. The

literature review finds different views to define the organizational commitment from

the personnel. A recognized definition considers it as the existing strength of an

individual’s identification with an association in a particular organization (Mowday et

al. 1982; Avolio et al. 2004). In addition, it is also necessary to consider the

antecedents that influence such association. Some researchers identified as factors

that originate organizational commitment are the work experience, personal and

organizational aspects (Allen and Meyer, 1990, 1996; Eby et al. 1999; Meyer and

Allen, 1997; Avolio et al. 2004).

In order to manage and modify the factors that provoke commitment in an

organization, several changes need to take place. Furthermore, change and

improvement are the necessary constant that organizations must pursuit. Some

consider changes as inevitable features of the organizational life (Cummings and

Worley, 1997). In addition, researchers conceptualize organizational change as a

political event with employees of different status of power and playing different roles

(Schein, 1985). Holt and Armenakis (2007) sustain that for changes to be

implemented in the organization, a state of readiness should be created before such

initiatives are implemented. Executing changes in the form of a new processes or

introducing new technology, create the ground among the personnel of conflict in the

organization. For change to occur in the direction that leadership desires, conflicts

must be resolved in the first place to achieve the objective that organizational

members’ beliefs, perceptions and goals align with those of the leader (Van de Ven

and Poole, 1995; Holt et al. 2007).

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2.4.2 The Organizational Culture

As the service institution understands the factors that influence the association of

individuals, the collective perspective influences the organizational culture.

Researchers consider that organizational culture is not a monolithic structure. The

literature suggests that organizational culture is in constant change and is shaped by

many different factors. Moreover, researchers argue that some of those factors can be

changed, and some factors may be intractable (Cooke and Szumal, 2000; Balthazard,

et al. 2006). Furthermore, Cooke and Szumal, 2000; Balthazard, et al. 2006 consider

that organizations adapt to their external environments by designing responsive

structures and systems, adopting technologies and developing member’s skills and

qualities. Creating a culture of collaboration, with good communication capacity and

willing to adopt the changes that are needed to reduce the lead-‐time strategies would

depend on the existing organizational culture. Because of this situation, the

organizational culture can make the difference between success or failure of any

initiative introduce in the institution (Weber et al., 1996; Javidan, 2001).

Schein (1983) and Sathe (1985) discuss and describe how organizations define their

cultures. They propose that organizations consistently make a series of choices and as

a collective, those choices define the organization culture. They suggest that the

choices that are made by the individuals, are influenced by the philosophy of the

organization, the values of top management, the assumptions of founding principals,

and succeeding generations of organizational leaders. Holt and Armenakis (2007)

discus how the collective in an organization by making a series of wrong decisions can

create the concept of Dysfunctional Organizations. Holt and Armenakis examine and

state that this kind of organizations act in the same way as dysfunctional individuals

and such organizations are characterized because they exhibits markedly lower

effectiveness, inefficiency, and low performance that its peers or in comparison to

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societal standards.

2.4.3 The Collaborative Culture

The previous sections describe the antecedents that influence the association of

individual and the factors that model the organizational culture. A positive

organizational culture can be created by different strategies that aim the collaboration

to achieve the organizational objectives. One of these strategies is the empowering of

the staff members in the healthcare institution. According to Sanchez and Cralle

(2012) and Lavoie-‐Tremblay et al. (2010), employee empowerment could be

considered an essential component in achieving excellent patient care outcomes.

Healthcare institutions should develop conditions under which the diverse staff

members can feel the empowerment. In addition, the empowerment of the staff

members in a hospitals should be need to recognize the difference in personnel which

influence in their culture: administrators, medical doctors, nurses and administrative

staff. Sanchez and Cralle (2012) advocate that employee empowerment can be

achieved through shared governance, engagement, education, leadership at the

bedside, and retention. The greater the extent of participation (none, participation by

representation, and total participation) the more satisfied employees were and the

quicker they met new production goals (Coch and French, 1948; Holt and Armenakis,

2007).

Lowe (2012) indicates that additional positive outcomes are generated based of the

results from the research of Gibbsons and Schutt (2010) that suggests that

engagement influences other important human resources objectives, such as

retention, job performance, absenteeism and recruitment since a positive reputation

of the institution rise the interest of future professionals. In addition, the academic

work of Seijts and Crim (2006) describes that an engaged employee in an organization

is a person who is fully involved in, and feels enthusiastic about, his or her work. The

same study manifests the work of Tim Rutledge (2005) that states that committed

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employees feel attracted to, inspired, committed and fascinated by their work in the

organizations. Seijts and Crim (2006) consider that engaged employees believe that

they can make a difference in their organizations. The study proposes that confidence

in the knowledge, skills, and abilities that people possess is a powerful predictor of

behaviour and subsequent performance. The study also proposes that the leadership

in the organization has the responsibility that to create a climate with the required

conditions that enables employees to unleash and develop their potential.

The adequate leadership may influence peoples' organizational commitment by

encouraging them to consider and to support the implementation of management

approaches by involving employees in the decision-‐making processes, inspiring

loyalty, as well as recognizing and appreciating the different needs of each employee

to develop capabilities (Avolio, 1999; Bass and Avolio, 1994; Yammarino et al. 1993;

Avolio et al. 2004). In addition, the transformational leadership theory proposes that

the commitment of personnel to reach organizational goals and intentions can be

developed by the use of the empowerment of the personnel (Avolio, 1999; Bass, 1999;

Yukl, 1998; Avolio et al. 2004). According to Avolio et al. 2004, empowerment is

defined as a task motivation manifested in a set of four cognitions reflecting an

individual’s orientation to his or her work role: Competence, Impact, Meaning, and

Self-‐Determination or Choice. Their research argues that transformational leaders

guide their employee’s aspirations, identities need, preferences so that personnel are

able to develop their full potential (Lowe et al. 1996; Avolio et al. 2004).

2.4.4 The Commitment to the Organization

As a culture of collaboration is created (section 2.4.3), the efforts need to be

permanent. Personnel that perform with commitment in the organization would

achieve continues improvement. An employee that is highly committed to its

organization is more enthusiastic to consent to changes in the workplace as long as

such employee perceives those changes to be beneficial (Lau and Woodman, 1995).

Moreover, according to Vakola and Nikolaou (2005), an employee that is highly

committed to its organization may also resist to changes in the workplace if he-‐she

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perceives it as a treat for his/her own benefit. Consequently, Vakola and Nikolaou

(2005) conclude that a positive relationship can be recognized between commitment

to an organization and the attitudes that individuals may have towards those changes.

The commitment to an organization is defined by Porter et al. (1976) as the

relationship of an individual's identification and involvement in a particular

organization. Therefore, organizations should look into the perception that changes

have to the personnel in the organization. According to Armenakis et al. (2007), when

changes are introduced into the organization, those changes can generate reactions

among the personnel of the organization. Such reactions can be negative for some

personnel because they confront the feeling of losing the comfort they have developed

by performing a task with the given skills they have.

Organizational culture has been categorized and described as the glue that holds

organizations together (Goffee and Jones, 1996; Holt et al. 2007). The organizational

culture has a distinctive aspect defined as the Psychological Climate which is the

individual’s psychologically meaningful representations of proximal organizational

structures, processes and events (Armenakis and Bedeian, 1999; Parker et al., 2003;

and Pettigrew, 2000; Martin et al., 2006). In addition, Schein (2000) and Martin et al.

(2006) argue that the elements that conform the psychological climate have different

weights in the way they influence the employee behaviour. Furthermore, Martin,

Jones, and Callan (2006) establish in their research that organizational change

theory’s literature does not make difference between the diversity of personnel in

change programmes because they are considered as a monolithic entity (Armstrong-‐

Stassen, 1998; Larkin and Larkin, 1994; Lewis, 1999). A distinctive characteristic of

the psychological climate is the communication and support through the organization.

Martin et al. (2006) study shows that higher levels of supervisor support with upper

levels employees and it decreases with the lower hierarchy. The study argues that

lower level employees sense less support from supervisor and this situation is

explained by Miles et al. (1996) since lower level employees may have more mistakes

in the implementation of changes that upper level employees. Moreover, Haugh and

Laschinger (1996) reports in contrast that managers and supervisors have been

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shown to report high levels of supervisory support.

2.4.5 Learning Organizations

The understanding of the antecedents that influence an organization, recognising the

culture, creating collaboration and commitment would provide guide to the

institution, but the fuel required to transform organizations is its capacity for learning.

Administrative projects with the objective to deal with the lead-‐time reduction cannot

be fulfilling until the most important component is aliened. The personnel’s

commitment to the initiative is the keystone for any successful initiative to be a failure

or a success. The work of Chris Argyris argues that an employee in any given function

may react to situations according to his or her mental maps. Furthermore,

individuals’ mental maps implicate the way they plan, review and implement their

actions (Argyris and Schön, 1974). The theories of actions, double-‐loop learning and

organizational learning may contribute to the development of an effective and

efficient strategy to develop an organizational and experiential process (Smith, 2013).

Argyris and Schön (1974) argue that people may be not aware of the values that

influence their behaviours in the organization. They proposed that two theories of

actions explain the inner motivations that guide people’s behaviours: espoused

theory and theory-‐in-‐use. According to Argyris and Schön (1974), Espoused Theory

represents their believes and values that a person think that guide his or her actions.

The Theory-‐in-‐Use represents their believes and values that a person has and guide

his or her actions in reality. Because people are not aware of their believes and values

(considered as theories of actions) that guide their actions, such individuals cannot

manage with efficiency their behaviour and it may result in unintended and undesired

consequences (Argyris and Schön, 1974; Savaya and Gardner, 2012). Therefore, the

capacity for individuals to make informed decisions would depend in the level of

understanding and capacity for the individual to change his or her governing values

(Argyris, 1974; Savaya and Gardner, 2012).

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The understanding of the individual’s action theories can allow the individuals to

make changes in the organization. Still, to foster continuous improvements in the

organization, the personnel, as a collective should learn from the experiences that the

organization gathers in their activities. According to Kraleva, N. (2011),

organizations can achieve continuous learning which means the developing capacity

on one’s own experience and experience of others and more important, it is a

permanent process of creating and improving the organization’s competences. The

main characteristic of a learning organization is the capacity of the institution to

expand its capacity to create its future (Senge, 1990). King (2001) identifies at least

six different strategic options for organizations to become a learning organization.

Those are: Information Systems Infrastructure Strategy, Intellectual Property

Management Strategy, Individual Learning Strategy, Organizational Learning Strategy,

Knowledge Management Strategy, and Innovation Strategy. In addition, Yeo (2005)

describes three different levels for organizations to become learning: individuals,

groups and the overall organization at large.

2.5 Academic Literature Gap

The literature review shows the current frameworks upon which the Behavioural

Approach in management had developed. It clearly states the influence of the

organizational environment may have over the personnel. It also describes the

importance and the conditions that are needed in the institutions to introduce

changes to achieve the objective to reach continue improvement. Furthermore,

scholars such as Schein (1983) and Sathe (1985) discuss that organizations are

continuously making individual choices and as collective, those choices create the

culture. There is not clear evidence of a mechanism to understand the nature of fears

in the personnel. In addition, such feelings are dynamic because they are constantly

changing (because personnel may change or because as one fear is overcome, a new

feeling replace it). In addition, values can also be found in the organization as

opportunities to generate commitment, collaboration and making a learning

26

organization. Research can be developed to understand what influence those choices

in the individuals in the service organizations and the management of those fears and

values can be use to transform the organization. More important, academic studies

can de developed to understand how institutions may motivate personnel to make

positive choices.

2.6 Summary of the Systematic Literature Review

The chapter presents the steps taken to implement a systematic literature review to

view and analyse the different academic perspective to generate transformation in the

service institutions such as a hospital. The systematic literature review aims to

explore the root factors that influence the people at the individual level and as a

collective to commit to the goals of institutions, to generate cooperation among

members to ac as a community that can learn from the experiences that are generated

in the organization and by others. Section 2.2 details the strategy of the protocol used

to generate information and how the systematic literature review used boundaries in

the process. The strategy is complemented with the used of keywords and a criteria

for inclusion or exclusion of studies.

The systematic review is developed in five perspectives. Section 2.4.1 explores the

antecedents that can be found in the organization before a change is implemented. It

also provides a standpoint for the conditions that influence the organization culture.

Section 2.4.2 also explains the dynamic stimuli that influence the culture in the

institution. Furthermore, section 2.4.3 establish the elements of importance to

provoke collaboration in the organization as the effects in the personnel. In addition,

section 2.4.4 analyses the benefits and causes of commitment for an organization to

achieve transformation. The need for learning capabilities is also recognised in

section 2.4.5 with the aim to understand the conscious and unconscious mechanism

by which people make choices in an organization. Finally, the chapter points the need

for further research about the need of a mechanism to manage the dynamic change of

factors that influence the choices in the personnel.

27

Chapter Three: Methodology

3.1 Introduction to Chapter

The Methodology Chapter would provide a detailed description of the philosophy and

approach applied for the research by defining the theoretical context implemented for

the investigation to interpret inductive reasoning the surrounding reality perceived

by the personnel in the hospital. In addition, the chapter develops the research

strategy to generate data and analyse such reality when changes are introduced into

the organization. The chapter also describes the design of the case study that uses an

embedded single case for the research. The chapter also offers the discussion of the

rational of the case selection, units of analysis and the protocols for the data

collection. Finally, the chapter explains the strategy implemented to obtain the

research credibility, reliability and validity for the data analysis and interpretation.

3.2 Research Philosophy and Approach

The research had the objective to propose a theoretical framework that would provide

guidance to healthcare managers and public policy developers to transform the

organizational culture in a service such as hospitals. The research focuses on the

different ways in which people make sense of their surrounding world in institutions

in the healthcare system. This interpretation of the personnel’s views would be

achieved by the getting the experiences given by the people who work in the hospital

(Berger and Luckman, 1966; Watzlawick, 1984; Shotter, 1993; Easterby-‐Smith et al.,

2008).

It is not only the understanding of the regulations and processes in the entity, but the

personnel who follows those procedures. The research will take an interpretivistic

28

approach, as it will look into the personnel that conform the institutions as they

perform their roles as social actors (Saunders, Lewis and Thornhill, 2012). Qualitative

data will be collected from a diverse group of institutions to explore different

perspectives. As guided by Easterby-‐Smith et al., 2008, under the social

constructionism approach, the research will follow the succeeding aspects. The

observer is neutral and independent to the healthcare institution. The personnel

interest, interpretations and feelings towards efficiency plans would be the main

drivers. The personnel explanations collected from the personnel are expected to

contribute to the general understanding of the individual in relationship to the

institution. The concepts that may be elaborated from the research would consider

and would incorporate the stakeholders’ perspectives.

The research approach will be eminently of inductive reasoning. The research looks

to understand the variables that create a cause-‐effect link (Saunders, Lewis and

Thornhill, 2012) among the personnel in a hospital in the public healthcare system of

Ecuador. To obtain an understanding of the nature of the problem, data were

collected from the social actors that create the healthcare organization.

3.3 Research Strategy

The strategy for this research considers the use of the narrative inquire as part of the

qualitative approach designed for this research. The interviews to the personnel in

the hospital aims to provide data in the form of facts (from the perspective of the

personnel), gaining insights, the opinions, attitudes, experiences, processes,

behaviours, or predictions (Rowley, 2012). The experiences from the subject of the

study which in this case are the doctors, nurses and administrative staff, would be

accesses for analysis through the questions in the interview (Saunders, Lewis and

Thornhill, 2012). From the data collected, the study will develop a framework to

understand the cultural barriers that may prevent institutions to implement programs

or initiatives to reduce the lead-‐time. The findings and the proposed frameworks

would provide ground and guide for further researchers, and managers at

29

government level or at the institution level.

Variables to be evaluated will be related to employees’ behaviours when they are

required to participate in the implementation of programs or involvement at actions

that may change the current patterns in the organization. The subjects would be able

to share their experiences and their assumptions of the contextual aspects and social

relations with the aim to reveal cultural, managerial, and capabilities factors from the

organization (Chase, 2005; Musson2004; and Saunders et al. 2012). Changes that the

subjects will be required to describe (their perceptions about the feelings that they

face o their peers) would be new procedures or new technical equipment that is

related to the processes. Those changes may be from the macro level which refer to

the policies decided by superiors. In the case of Ecuador healthcare system, such

policies may come from the Ministry of Public Health or the Zone Coordination.

Policies at micro level refer to the actions decided in the institution.

The interviews would be developed about several areas to establish parameters that

influence the culture in the hospital. According to Argyris (1991), he identifies 4

tendencies in which individuals designed their actions. Some of the questions given to

the personnel in the hospital in Ecuador are aimed to feed this framework: To remain

in unilateral control; To maximize ‘‘winning’’ and minimize ‘‘losing’’; To suppress

negative feelings; and To be as ‘‘rational’’ as possible.

3.4 Case Study Design

The health care system in Ecuador is under continues and aggressive development.

The National Healthcare Development Plan (Ministry of Public Health of Ecuador)

includes the construction of new units across the country. In addition, the system is

strength with the development of Health Centres at the local neighbourhoods. Since

procedures in the healthcare system are highly standardized, the section of a single

hospital from the system would provide a representation of the whole. For the

purpose of the research a single case was selected for the design where several staff

30

members that represent different hierarchical positions are selected for interview.

The members that create the organization are various.

A case study can be defined as an empirical enquiry that investigates a contemporary

phenomenon within its real-‐life context (Yin, 2009). Furthermore, a case study is an

empirical inquiry that investigates a contemporary phenomenon in depth and within

its real-‐life context, especially when the boundaries between phenomenon and

context are not clearly evident (Saunders et al.2012). The research is developed with

an embedded design in the sense that the study includes the interview of personnel in

the hospital who perform their activities from different departments of areas from the

organization. An embedded design is more appropriate because it allows the research

of a single organization where a number of logical sub-‐units would be explore (Yin,

2009; and Saunders et al. 2012).

3.4.1 Case Selection and Sample Population

The selected hospital is the Francisco Icaza Bustamante Children Hospital and is

located in the city of Guayaquil, Ecuador. The Francisco Icaza Bustamante Children

Hospital serves to the population of the Guayas Province (with 3,650,000 habitants

according to the INEC). The hospital offers Outpatient Services, Emergency,

Hospitalization, Clinical Lab, X rays, surgery and obstetrics (Ministry of Public Health).

The sample selected represented the population that conforms this organization: Two

Middle Level Managers, Four Medical Doctors, Three Nurses and Three members of

the Administrative Personnel. The sample population that was interviewed had an

average of work experience in this hospital of 13 years each. The sample population

takes for the analysis personnel who have from 1 year of experience in the institution

to 30 years of experience in the same institution. The sample provides a timeline

perspective of experiences working in the hospital that covers the last 10

democratically elected central governments periods. This is particularly important

31

because the selected hospital is a public institution that depends from the central

government.

Interviewee Function Gender Area of work Age Time Working in the Institution

Doctor A Doctor Male Pediatrics 55 24

Doctor B Doctor Female Emergency 54 7

Doctor C Doctor Male Emergency 60 20 Doctor D Doctor Female Physiatrists Area 55 20

Manager A Manager Female Customer Service Direction 30 8

Manager B Manager Female Admissions Department 35 1

Nurse A Nurse Female Emergency Area 54 29 Nurse B Nurse Female Intensive care Unit 31 5

Nurse C Nurse Female Neonates Area 49 30

Worker A Administrative Personnel Male Admission Area 54 4

Worker B Administrative Personnel

Male Stretcher bearer in Emergency Area

28 3

Worker C Administrative Personnel

Female Physiatrists Area 37 7

Table 3 Sample Population and Demographics

of the Francisco Icaza Bustamante Children Hospital

3.4.2 Data Units of Analysis and Data Analysis

As defined by Easterby-‐Smith et al. (2008), the unit of analysis is the entity that forms

the basics of any sample. The data units of analysis (See Table 4) provide the axes to

develop the scrutiny of the data. The research would consider the number of words,

lines of transcripts from the interviews, a sentence, a number of sentences, a

paragraph of any other form of data that is accepted (Saunders, Lewis and Thornhill,

2012). The units of analysis are the selected members of the organization used for the

case design (See Table 3). As the collected data is analysed, categories would be

created for the report of findings and discussion.

32

Data Units of Analysis Unit Unit Description

Feelings Words that reflects positive or negative feelings. Communication Words or expressions that refers to

communication or the elements of communication (message, sender, recipient, transmission medium response, noise and context.

Objectives It refers to the objectives internal or external to the interviewee (such as aspirations or institutional goals).

Organization It refers to the institution that shows importance to the interviewee.

Control It refers to expressions, described actions in which the interviewee has the perception to be subject of control or when the interviewee desire to exercise control over others.

Table 4 Data Unit of Analysis

3.5 Data Collection

The interview is developed to gather information from the personnel from the

Francisco Icaza Bustamante Children Hospital in Ecuador. The sample population

(Table 3) were asked 16 questions that were organized in three different areas of the

interviewee’s perceptions (Table 5). Appendix B shows the Interview Guide with

explanations and questions for the interviewed. The interviews were conducted in

Ecuador in Spanish language and recorded in a digital file. The interviews were

transcribed in Spanish for the data analysis process. A sample English transcription of

the interview can be appreciated in the Appendix C, and an Spanish translation and

transcription can be seen in Appendix D.

Since the interviews are developed in Ecuador, a team of two assistants were gathered and

prepared to conduct the interviews. An interview protocol was developed to reproduce the

exact conditions for each interview. The protocol provided information of material

33

necessaries, the objectives of the interviews, the conditions necessaries to implement the

interviews, and a glossary of terms. In addition, several online meetings took place to

prepare the team to do the interviews. The research was conducted in one of the

meetings rooms available in the hospital to provide complete confidentiality to the

subjects and to avoid interruptions from the workplace. Some possible candidates

refused to participate to the interview since they were recorded. However, as soon as

the first subject accepted, the subject recommended peers to collaborate to the

research.

Perceptions Questions Description

Before Implementation

From 1 to 8 Questions are related to the perception by staff during the implementation of any initiative or change in the hospital

During Implementation

From 9 to 12 Questions are related to the perceptions of the personnel after the implementation of projects

Positive Experience

From 13 to 15 Questions are related to the general experiences of the personnel in the hospital

Table 5 Areas of Perception

3.6 Research Credibility, Reliability and Validity

The research presents the rationale of the case study selection, and the characteristics

of the structuring of the context for review (Cook and Campbell, 1979; and Gibbert,

Ruigrok and Wicki, 2008). As Easterby-‐Smith et al. (2008), the identification of

general relationships and other variables can be established by the use of cross-‐

sectional design. The reliability of the research is established by the use of a rigorous

methodology implemented. One of the approaches to reach the reliability is the

Content Validity that would provide suitable exposure of the research questioners

(Gibbert et al. 2008. In addition, the findings would be correlated with the results of

similar researchers to establish of the positive correlations. The correlations would

be established with other researchers that that were realized at different times and

under different conditions.

34

A clear and detail protocol is presented in the design of the research. The case study

protocol would provide of clear documentation and clarification of the procedures

chosen in the research and providing transparency and replication (Gibbert et al.

2008). The research validity refers to the selection of procedures that lead to an

accurate observation of reality (Gibbert, et al. 2008; Denzin and Lincoln, 1994) and

the quality of the conceptualization or operationalization of the relevant concept. The

appropriate selection of procedures would result in the accurate reflections of reality

and the elimination of alternative explanations for any differences of observed

between groups (Easterby-‐Smith et al., 2008).

3.7 Data Analysis and Interpretation

Qualitative data collected from the interview guide conducted to the personnel at the

Francisco Icaza Bustamante Children Hospital would be analysed by inductive

reasoning. As explained by Saunders et al. (2012), selected variables will be chosen as

they show a positive or negative correlation in the behaviour of the personnel

towards the implementation of initiatives that represent a change in the organization.

As the literature review take place, it will reveal frameworks of analysis and a

dynamic structure of coding can be drafted. The literature review provided the

theoretical sensibility (Strauss and Corbin, 1990) to establish the categories for

analysis and the selection of the variables for the coding. As pointed by Strauss, the

data will be broken down, conceptualized and put back together in new ways. The

qualitative analysis will allow this decomposition and re-‐composition of the data. The

collected data is categorized as a coding list that represent the themes revealed from

the data that has been collected according to the units of analysis in Table 4 (Saunders

et al. 2012).

3.8 Chapter Summary

The Methodology Chapter provided with the description of the philosophy, approach

and strategy for the research. Section 3.3 describes the scheme of the single case

35

design where the Francisco Icaza Bustamante Children Hospital is the selected case

for investigation. Twelve interviews were selected as the sample population from the

hospital composed of four doctors, two managers, three nurses and three staff

members from the institution. This section also discussed the data unit of analysis for

the investigation and the data collection process. The section specifies the areas of

perception that the study aims through the interview guide presented. A discussion to

achieve research credibility, reliability and validity for the study is presented in

section 3.5. Finally, the chapter presented the data analysis and interpretation

mechanism to guide the investigation.

36

Chapter Four: Case Findings


The chapter describes and list the findings collected from the twelve interviews that

were performed at the Francisco Icaza Bustamante Children Hospital in Guayaquil,

Ecuador. The twelve transcripts were analysed by the use of the five distinctive Data

Units of Analysis (Table 4) towards the subjects’ Areas of Perceptions (Table 5).

Additionally, the data units of analysis or categories of coding were further sub-‐coded

according to the findings. The outcomes were segmented according to the Sample

Population Groups (Table 3). The chapter is classified according to the four sample

population groups.

4.2 Findings From The Interviews to Management

The findings from the interviews to the middle level managers at the Francisco Icaza

Bustamante Children Hospital are classified according to the Managers’ Feelings

Toward the Work Environment, Managers’ Perspectives and Perceptions Toward the

Organizational Communication, Managers Perspectives and Perceptions Toward the

Organization’s Objectives, Managers’ Perspectives and Perceptions Toward the

Organization, and Managers’ Perspectives and Perceptions Toward Control.

4.2.1 Managers’ Feelings Towards Their Work Environment

The implementation of initiatives and changes in the hospital created a positive effect

to some of the members in the organization. The effects encountered from the

37

interviews to the middle level managers in the hospital showed that the positive

relationship can be classified to the effects to the Institution, Inclusion, and View of

the Personnel.

A dynamic institution creates an image of prestige that attracts professionals and

stimulates them as well. As stated by Manager B: “There is something that I like from

this hospital and it was the reason I looked for working here…”. The interviewed

manager showed positive feelings in regard to the job's duties and to the organization

as well. Manager A indicated that: “This is an hospital so dynamic, so dynamic…”. The

manager expressed satisfaction to this particular aspect that is part of the culture that

the interviewed perceived in the institution. Management affirmed that innovation

was another characteristic implemented in the institution that raced the admiration

from the members. Manager B expressed the admiration for the improvements

implemented in the institution: “The novel of the institution. Definitely, the novel

because, this management is an innovator management, there is no discussion about

it…”. Moreover, Manager A articulated how proud they can feel because of the

dynamism of the institution and its prestige:

“One feels, one always feels proud to work in this hospital

because of the category of the hospital and its level and for

the name of the hospital: Children's Hospital Francisco

Icaza Bustamante, but because one comes to a new and

beautiful infrastructure. One comes to work to an office

that is beautiful. Before, it was where wholes were...”

Manager B expressed the compromise with the institution to collaborate with the

improvements as well: “As I tell you, with compromise to work for the institution, we

make things to happen”.

Manager A stated that the subject enjoyed when they received information and were

considered in the decision-‐making process: “I like when I am included, for the changes.

I do not like what I told you. That we are imposed the decisions”. The Manager B

38

affirmed the capacity the subject had to propose to upper management ideas and

suggestions, but with limitations according to the hierarchy position they had: “… and

we all have a voice, it is obvious that those of higher hierarchy level have vote… but we

all have voice, and we have the opportunity to express ourselves…".

Manager A expressed that some personnel adapted to the new position held in

customer service: “… But they are others that they like those changes. In the way of

implementing the changes, personnel started to like those…”. Manager B described the

subject perception of acceptance and integration of personnel in the change of

organization: “then, generally, now is a little difficult that any reluctance or any

inconformity because now projects have been polished and now they have passed a

period, a process”. Manager A expressed that personnel was surprised by the

continuous changes in the organization: “… That is, that people think that, as we are

used to that changes were slow to take place, and sometimes not”. Manager A also

detailed that people liked inquiring by departments about initiatives: “I like when we

are asked by areas…”.

Due to the changes implemented in the hospital like the digitalization of documents,

creation of several databases that simplified some processes such as the doctors

prescribing to the patients by the use of ERP systems4, personnel was reallocated into

other areas of the hospital. Those changes have created conflicts among the staff.

Manager A stated about organizational conflicts between new and old personnel:

“They are people who have here like 20, 25 years and now they are working in customer

service. They have never provided customer service directly. They are just attending

them. It is a shock to them because there are people who complain to them, asked them

for solutions and they get upset. At least to my personnel, the 50%, but the 60% that are

they, they reject the change”.

4 ERP system means Enterprise Resource Planning

39

The inconformity and rejection to the changes were expressed as conflicts between

the personnel that were working in the hospital before the changes and the newly

integrated staff. According to subject Manager A, this generated a conflict between

new and old personnel: “As I told you, new personnel, old personnel that are happy with

the new function and old personnel that is not happy”. Manager A expressed the lack of

commitment from the personnel to the changes in the hospital: “What I would

comment is that the people here, the personnel are not taking things seriously”.

Furthermore, according to subject Manager A, the lower level management also

expressed their rejection to the establishment of standards in the organization:

“I have many fellows that I hear, that speak about their nonconformities with the

authorities, with the authority from here from this hospital. Not only from the President

[of the republic], but the authority of this hospital because the manager came to put a

strong hand”

The interviews to the middle level managers or supervisors provided data in

reference to the fears that personnel may have while the organization implements

changes. Question 3 from the interview asked the subjects to share the expectation

that staff members may face. Manager stated that personnel face fears and positive

expectations as well. Subject Manager B stated that “Fine, this always depends on the

departments because in general, there are fears that get mix with the expectations...”.

Managers indicated the initial resistance of the personnel to change in the

organization. Manager B indicated that personnel fears to lose their jobs because the

integration of technology: “However, there are some fears in reference to it

[expectations to change], for example, if we are automating processes, the person that is

in that job position fears to lose his/her job and function”. Manager A suggested that

expectations from the personnel were negatives. There was resistance to the changes

or improvements in the organization: “… Negative!!! It is always negative for a period

of time. After a period of time. We are people of customs. Then, it is a time that we are

negatives, everything is bad, everything bad, we all se bad”.

40

People who resisted change may create barriers in the organization. As manager A

described barriers that personnel had upon the changes:

“Sometimes el computer system fails, sometimes it is slow. Then people say: you see, this

is the reason for which we should not be digitalized. I could give my prescription faster,

I could ask someone to do it fast. There are positives and negatives. There are personnel

that agrees and there are personnel who is not in agreement”.

Manager A explained the struggle that personnel showed after the reallocation of

personnel: “Because for them is like humiliating, is like coming from an office, to come

to work with customer service, for them is like a punishment”. Manager A described the

initial resistance of the personnel to change in the organization: “At the beginning it

was chaotic, people said no!: "the old way was much better", "with that, nothing was

lost", "I do not have to be behind the patient". Members in an organization expressed

their unpleasant feelings to change in various ways. Manager A also complained

about the lack of inclusion in the decision-‐making process: “I do not like when we are

imposed certain established things and that sometimes those things are not according to

who we are working in reality”. According to Manager A the disagreement for the food

amendments was described as follow: “What in reality made people feel demotivated

was the issue of the food”.


Organizational Communication

Manager A indicated that some information was given to the personnel, but there was

a need to improve those communication channels: “Many times instructions are given.

On other occasions instructions are given, but there is not a flow or there is not an

scheme to follow”. Manager A also indicated that upper management provided

information to middle level management to be replicated to the member in the

organization: “The majority of times yes, they say it, at least to me as responsible of an

area, I am given information and I am told that this has been changed and you have to

inform your personnel”. In addition, Manager B provided a detail description of the

41

channel of communication in the organization: “First, it stars with ah situational

diagnostic, which is required by the management to each one of the heads of services

units”. Furthermore, Manager B indicated that socialization was part of process in the

information sharing in the organization: “Within this chronogram of implementation

the socialization of the initiative is involved with the rest of the team”.

Manager expressed satisfaction when they were requested feedback from the upper

management. Subject Manager A stated that: “I like when we are asked by areas”. As

collected in the response from the interview, subject Manager A indicated that: “I like

when a change will take place and the department is asked before the implementation”.

Manager affirmed that communication and integration took place in the department

in regular basis. Interviewee Manager B said that: “Suggestions are always asked to the

personnel. There is a feedback, feedback exists”. As mentioned by subject Manager A,

management detailed the benefits of being included in the decision-‐making: “Then, I

like when they come and we are asked about it before the implementation because we

know what is going on down here. If they come to ask what we think, how we would like

it. I like it”. On the other hand, middle management or supervisors also expressed

their dislikes about the organization. Manager A mentioned in the interview: “I do not

like when we are imposed certain established things and that sometimes those things are

not according to who we are working in reality”. The Manager A also stated that:

“Because I do not like when I am told: ‘because you have this and not to another’….".

According to interviewee Manager A, the communication channels existed in the

organization. The Manager A affirmed that as a manager, the subject socialized the

information about the projects from the hospital and integrated personnel from the

department: “En reality yes. In the way I conduct myself, the boys, the ladies and

gentlemen express their ideas to me as well as their unconformities”. Subject Manager A

also explained how the pass of information took place in the organization: “I go and I

expose them to my bosses and he would say in what we can change and what we cannot

change. But this is the opening than the boss would give to the person”. Interviewed

manager also explained that communication process is not standardized in the

42

organization. Manager A stated that: “In other areas there are departments that do not

offer openness o they do not speak the unconformities from their personnel, the truth is

that I do not know. But I do speak with my boss”.

Manager B also described the proses of communication channels in the organization:

“We have meetings to work every single day”. In addition the same subject expressed

that: “We have a meeting agenda that includes from meetings with the general

management, meetings with the medical direction, with the sub-‐directors of services,

between head departments and its departments and internal meetings as a department”.

In addition Manager B expressed that conditions existed in the organization to

provide feedback: “And obviously everyone has a voice, but vote is for the upper

managers”. Managers detailed that socialization of projects was present in their units

as well as the integration of personnel in the department. Subject Manager A further

explained that: “En reality yes. In the way I conduct myself, the boys, the ladies and

gentlemen express their ideas to me as well as their unconformities”. Subject Manager B

also explained how their participation took place: “But, we all have a voice and we

have the opportunity to express ourselves”.

The organization seemed to follow a standardize channels or a regular

communication structure with all the departments or levels in the organization.

Manager A claimed that: “… in reality the personnel in my department, the one that

takes care of the patients, we have had meetings and we had looked for solutions and

improved the activities and how to coordinate them”. In addition, Manager A described

how the personnel articulated solutions for improvement: “we do have those meetings

to make those kind of projects to make changes. They also want to participate. In this

department they can tell me in what areas they can help”. On the other hand, Manager

B recognized the need to improve the communication channels by integrating other

areas with the staff: “I think involving a bit more the operative personnel because we

work well together in the administrative part”.

43

4.2.3 Managers Perspectives and Perceptions Toward the Organization’s

Objectives

The interviewed managers expressed their motivation for the importance of the

organization’s objectives. Subject Manager B stated: “The novel of the institution.

Definitely, the novel because, this management is an innovator management, there is no

discussion about it…”. The interviewees recognized the achievements of

organizational objectives. Manager B described this satisfaction: “Among those

projects, for example, it is the appointments reminder by text messages. And we are

pioneers in this subject as well”. Manager B also pointed out the recognition of

objectives: “But look, we have seen big changes…”. Manager B also mentioned some

barriers created from the personnel: “and also the laboratory that I mention. The steps

are being taking, but the people are first negative, negative”.

The interviews to the middle level managers showed disagreements about the

knowledge of measurable goals to achieve organizational objectives. Manager B

indicated about measurable goals: “Correct, yes. They are measurable. And they are

explained with the indicators of procedures. Yes, absolutely”. On the other hand,

Manager A detailed that: “We do not have for example a measurable way to see if one

thing had lowered or raised, no parameter”. Still, lower level managers explained how

they look for successful ways to achieve objectives. On this regard, Manager B

indicated that: “This depends on how much the personnel is involved. Because I may

really have all planned, but I must have a compromised work team to achieve it”.

Manager A explained how collaboration helps to reach objectives: “… in reality the

personnel in my department, the one that takes care of the patients, we have had

meetings and we had looked for solutions and improved the activities and how to

coordinate them”. In addition, subject Manager A stated that improvement could be

44

achieved in the organization by: “There are ways to improve. I believe that there would

be for example, to implement a day in which all coordinators should get together with

the personnel and then among us”.

4.2.4 Managers’ Perspectives and Perceptions Toward the Organization

Manager indicated that team effort was part of the organizational culture in the

hospital. The statement was presented by Manager B: “There is something that I like

from this hospital and it was the reason I looked for working here…”. Managers also

discussed their perception of the hospital’s culture for changes and improvements.

Manager B indicated in the interview: “Here the hospital is implementing the

organizational culture by processes and obviously for products”. Furthermore, Manager

A explained how they created an environment of information sharing, but such

environment was not extended to other departments: “…for example, that, does not

exist. We meet between ourselves and we look how we can change/improve, but I do not

meet other departments, unless I need it for my new process to talk to another

department”. In addition, Manager A further insisted in the lack of relationship with

other departments: “There is interrelation among departments”.

The subjects in the interview described a generalized resistance to certain events in

the organization. Middle level managers felt mistreated by the administrative

decisions adopted for the upper-‐management as the result of following by the national

laws of the country. Still, Manager A provided detail statements: “

“Right here, we had a lunchroom and here lunch was given to us. Then, the people said it

was ok. We receive our half a hour for lunch, we receive the lunch and we had to return

the half hour. But when they came, we lost the lunch since December or January, I do not

remember. We have to stay the extra 30 minutes. They took away the lunch, and it is

not pay nor give us anything”.

Furthermore, the food and change of work schedule regulation affected the morale in

the organization. As Manager A stated: “What in reality made people feel demotivated

was the issue of the food”. In addition, the organization also encountered the

45

confrontation between the personnel hired to fulfil the needs established in the new

strategy for the national health care plan and the personnel who had been working for

long time in the institution. The conflict was mentioned by Manager A: “Nevertheless,

there are a 30% that because of the age situation, for being older, they still present some

resistance to some changes that in reality are positive”.

4.2.5 Managers’ Perspectives and Perceptions Toward Control

Most dictionaries consider control as the exercise to direct, to dominate or to

command. Managers who were interviewed indicated that control in the organization

was implemented from top-‐down. Manager B stated that: “Fine, here this is the way

how these issues managed…”. On the other hand, across the interviews to all the

sample groups, the desire to exercise control from bottom-‐top was also present.

When Manager A was asked about what practices upper management could do for

improvement, the subject expressed their desire to influence the decision-‐making

process: “I like when I am included, for the changes. I do not like what I told you. That

we are imposed the decisions”. Manager A also expressed the desire to be included as

a decision maker: “I like to be considered for the changes in the organization. I do not

like what I said, to be imposed…”. Manager A also mention the rejection to impositions

from upper management: “I do not like when I am told: ‘because you have this and not

to the other’”. Furthermore, Manager B also recognized the need to integrate the

operative personnel in the decision-‐making process: “… Involving a litter more to the

operative personnel because we have a lot of compromised administrative staff”.

46

4.3 Findings From Interviews to Doctors

The findings from the interviews to the doctors at the Francisco Icaza Bustamante

Children Hospital are classified according to the Doctors’ Feelings Toward the Work

Environment, Doctors’ Perspectives and Perceptions Toward the Organizational

Communication, Doctors’ Perspectives and Perceptions Toward the Organization’s

Objectives, Doctors’ Perspectives and Perceptions Toward the Organization, and

Doctors’ Perspectives and Perceptions Toward Control.

4.3.1 Doctors’ Feelings Towards Their Work Environment

The effects encountered from the interviews to the middle level managers in hospital

showed their perceptions toward the hospital in relationship to the institution. A

dynamic institution created an image of prestige that attracted professionals and stimulates

them as well. Once doctors were asked about the capacity of the organization to implement

changes, and Doctor B that: “Yes, yes, they are prepared because this is the personnel that

work in the hospital that I know for so many years, it is a qualify personnel”. The

interviewee argued that they supported all the changes implemented in the organization.

The doctor described the agreement with change and new processes implemented. As

described by Doctor D: “I am in favour of all the changes in the institution. I am not in

disagreement”. Furthermore, Doctor D indicated that: “… from the changes I have seen

since 2008 to 2014, there have been many positive changes to the hospital in the physical

aspect, scientific and structural to the hospital…”.

The findings from the interviews showed litter declarations of positive statements.

Data shows that only subject Doctor D had declared positive statements in reference

to the institution. There was not evidence of positive declarations from other subjects

participating in the study or positive reclamations regarding the areas of View of the

Personnel or Inclusion.

Doctors also expressed feelings of exclusion during the interviews. This was the case

of Doctor C who stated that: “I would say, not in general, I do not mean this hospital, I

would say it for the public sector in general, the personnel do not feel fine, I would say

47

considered, the personnel is not supported”. The feeling of exclusion was noticed in

statements that revealed the doctors’ need to be part of the decision-‐making process

in the hospital. This feeling was observed in the declaration made by Doctor A that

stated: “… when we are impose without previous consultation, without previous

justification, that means, what changes would take place, where is it going...”.

Resistance from the doctors were found in several statements. That resistance was

motivated for the policies adopted by the institution5. When doctors were asked

about their expectations while implementing initiatives in the hospital, their

responses showed that doctors feel uncertainty, rejection for the changes and then

they finally accept the changes. On this regard, Doctor A stated that: “Well, there are 2

aspects, first there is uncertainty and second, any change generates a reaction and then

it is accepted”. Doctor C also expresses the same feeling. Doctors indicated that

people in the organization felt uncertainty about new initiatives: “The people feel

uncertainty, don't know how would it be, if they would see it fine or wrong, if we can do

it as they want it. Do you get it?”.

4.3.2 Doctors’ Perspectives and Perceptions Toward the Organizational

Communication

Communication took place in the organization in various ways. Doctor A stated that

information did not flow officially by the institutional channels. Doctor A affirmed

that: “Well, it varies because sometimes the needed information is given and other times

the change takes place and then the information is given”. The second subject also

mentioned that information was not given to the personnel. They learned about

changes as they faced the implementation. Doctor B indicated: “I would tell you in this

aspect that instructions are not given to us, we learn for what we can see as we go along,

but there is not socialization”. Doctor C also had a similar response: “… but, there is

not much information, here still, the information is vertical, no horizontal”. 5 Detail discussion of the policies adopted by the institution would be provided in more detail in the discussion section.

48

Doctor A recognizes that the leaders are the channel for communication, but they also

want to reach upper management: “Well, each area has a leader and they are the

ones that go to the meetings, but sometimes is also good to listening as you are

making an interview to the personnel that are next to the patents…”. Doctor B

indicated in the interview that there was not socialization of projects and there was

not information sharing in the organization: “I think, as I mentioned that the lack of

socialization and that we are given all the information to the personnel. If you

implement something from one moment to the other without people knowing the

project, then, I do not think it will have the success, as it is wished”.

4.3.3 Doctors’ Perspectives and Perceptions Toward the Organization’s

Objectives

Interviewed doctors showed disagreement regarding the knowledge of institutional

objectives and goals. According to Doctor B, doctors were not aware of the objectives

or measurable goals in the hospital: “I have not seen that [objectives], I mean that there

are objectives right, immediate and mediate and we are not communicated if we are

meeting the goals...”. On the other hand, Doctor D also argued that doctors were aware

of the objectives and goals planned by the organization. Furthermore, Doctor D stated

that meetings were arranged for the purpose of evaluation: “well… we have a methods

of measurement and we manage it basically with those institutional goals, we manage it

that way and we meet and we are told that we have to improve, implement new things

although there is resistance”.

4.3.4 Doctors’ Perspectives and Perceptions Toward the Organization

The evidence collected from the interviews showed established characteristics in the

organization towards changes and learning. Doctor D clearly indicated such views.

According to Doctor D, the personnel did not like changes or the learning of new

processes: “… people did not accept the change that they had to learn the use of those

equipment that they did not like, they oppose, there is resistance…”. In reference to

49

resistance, Doctor D also specified that: “…then, the resistance is the fundamental part

for things to go wrong… there are people who has taken root to the old customs. That

made it difficult and brings failure in all...”.

Evidence suggested that as an organization, the personnel had developed a generalize

rejection to certain management decisions taken for the administration. Doctor A

clearly indicated that loosing the free lunch was a decision that was not consulted to

the personnel: “For example, taken away the lunch, that before it was paid [for the

institution], now we have to paid for it and go out with that risk, because out there have

been attempts of murder, there have been robberies around all this place...”. The

statement revealed a complaint that was present in many interviews from different

interviewed groups.

4.3.5 Doctors’ Perspectives and Perceptions Toward Control

Doctors during the interviews had made several statements in relationship to the

established control system in the organization. In the interview, Doctor C stated

opinions about the control implied by the institution:

“Unfortunately, there are situations, a public example is the issue of the teachers,

practically they were impose such a thing, we are talking about school teachers. We can

also include the university professors who have been mistreated. I think that one person

who has spent for good or badly their time and their lives to work in an institution. At

the end that person deserves consideration. It is not like that here, they are practically

fired and they have to leave because they have to leave”.

Doctor A also made reference to the administrative control exercise by the hospital:

“For example, taken away the nourishment, which was paid before [by the institution]

now we have to pay it…”. Doctor A also described that the consequences for the upper

management position generated pessimism, resistance, and therefore, no motivation

was created in the personnel: “…and a predisposition from everyone, there are a lot of

pessimism, a lot of resistance, it is because of the breach from all the unfulfilled things,

then when one is motivated by something…”.

50

4.4 Findings From The Interviews to Nurses

The findings from the interviews to the nurses at the Francisco Icaza Bustamante

Children Hospital are classified according to the Nurses’ Feelings Toward the Work

Environment, Nurses’ Perspectives and Perceptions Toward the Organizational

Communication, Nurses’ Perspectives and Perceptions Toward the Organization, and

Nurses’ Perspectives and Perceptions Toward Control.

4.4.1 Nurses’ Feelings Towards Their Work Environment

The nurses while they were interviewed showed positive responded to the various

topics that were asked for. The nurse expressed some positivism to the changes

implemented in the organization. Furthermore, nurses considered that changes were

positive to the organization. Nurse C stated that: “Expectation… We are all expecting

that those changes, those projects to be positive and good for the institution, for the

hospital in special because this is the place we are working”. In addition, Nurse C felt

confidence that the nurses had the adequate skills: “Well, here all the personnel, as

much as medical, paramedic, at all level, we are prepared for any kind of work, this

according to our specialty”.

The evidence found in the interviews showed that nurses recognized the

improvements of the institution. Nurse A indicated: “Of course I like it because the

institution improves, then we can see, then sure, because it is for improvement…”. The

nurses recognized the positive changes implemented by the organization. The nurses

also detailed the benefits for the patients and their family members as well as for the

staff members. Nurse C identified that: “The area of pharmacy is a magnificent new

change that has been implemented. The patients are better served, there is more space,

it is faster”. Nurse B also expressed the desire to participate in the improvement

processes in the organization and more important, they expressed the desire of being

informed of such programs: “I like to be considered to look into the project that would

take place and to be motivated to learn, get engaged and know more of the institution's

plans”.

51

During the interview, the nurses suggested situations that could show conflicts in the

personnel. Such is the case for Nurse A where the nurse stated the existence of two

groups. Those two groups were considered by the interviewees as the Old Personnel

(the personnel previously working in the institutions) and the New Personnel (the

personnel who have been hired during the new administration which started in

2008): “We are always marginalized in everything, anyone of us of those who work in

health. These personnel that we have because here we have personnel who have 30

years, these personal who is old, but the new one is considered for everything”.

Furthermore, Nurse A felt that the new management had come to the hospital with a

pre-‐disposition against the previously hired personnel:

“I do not know why, there is a rejection to us and we have not damage to no one. We

welcome the person who came to the management, the person is welcome, but we have

not blame for the frustrations that the person brings from another place. That made the

management to take it with the workers here that have many years. It is not only with

the nurses, it is with the doctors too, it is general...”.

Finally, Nurse C suggested lack of hope for a change of behaviour of the management.

Nurse C showed her failed expectation that mangers should change their behaviour

according to their convenience: “Speaking of the change in management. I believe that

the person already has the aptitudes fixed in their minds, I believe it is not easy to be

changed”.

Nurse A stated that changes were imposed upon the personnel. The nurse also

expressed her feeling of social exclusion in the organization. Nurse A detailed: “Here,

impositions are to all the personnel and we have to do it because it is imposed. They

could be prepared for changes, but we are rather we are excluded”. Nurse C also

mentioned during the interview that the nurse felt inconformity in the organization:

“There is not comfort”. In addition, Nurse A indicated fears to the structure in the

hospital: “I feel a bit of fear”.

52

The nurses complained for the numerous changes in the organization. The Nurse A

specifically pointed out the frustration felt with the arrival of a new head department.

The unpleasant feeling was for the lack of personal contact to the nurse: “For example,

we received a memo indicating us that a new boss came for the department of external

services and we do not know her, she just sent a memo telling us her arrival”.

4.4.2 Nurses’ Perspectives and Perceptions Toward the Organizational

Communication

The review of the interviews of the three nurses showed similar findings in reference

to the existence of the communication channels that delivered information to them.

Nurses A, B, and C stated that no mechanisms of communication existed to inform the

personnel. Nurse C indicated that: “To the personnel of the hospital, to the workers, to

the personnel no information is given of any kind”. On the same hand, Nurse A also

affirmed that: “To us, no instruction is given”. In addition, Nurse B also mentioned that

nurses did not participate in any king of socialization o feedback process: “Sincerely,

any instruction. Here we work on the projects and the pacification is made at the upper

management level”.

Nursed claimed the need of participation in the decision-‐making process. Nurse B

mentioned the satisfaction and desired to participate: “I like it more when they are

taking us into account to see the project that will be implemented as well as being

motivated to participate in the project and learn more of what the institution will do”.

In addition, Nurse B affirmed that the information they received was in the form of

final orders for implementation: “That we are not considered in the projects, we do not

have any motivation, that is all, the project is ready and we have to do as the regulations

are made”.

The nurses also claimed for the need of a feedback mechanisms in which the

personnel could provide their views. In this regard, Nurse B detailed: “We are never

asked for suggestions to every person that forms part of the area where we are working.

53

It is simply like that, we have to do it that way”. The nurse indicated that notorious

projects could be observed in the workplace that was taking place, but the personnel

were not informed of them. Nurse B denoted: “we are not part in any of the projects,

because all of that, the plans, they passes by our faces. The engineers, all of the

architects all of them possess by, but we are not informed of what is going on”.

4.4.3 Nurses’ Perspectives and Perceptions Toward the Organization

The interviews revealed the perception of the nurses about structures and values in

the organization. Nurse A described the characteristic of the organization were very

hierarchical: “Here, impositions are to all the personnel and we have to do it because it

is imposed. They could be prepared for changes, but we are rather we are excluded”.

Nurses also expressed their perception about their place in the organization. Nurse A

expressed exclusion in the organization: “We are always marginalized in everything,

anyone of us of those who work in health. These personnel that we have because here we

have personnel who have 30 years, these personal who is old, but the new one is

considered for everything”.

Nurses have shown resistance to the organization in various forms. Nurse B

commented about the rejection to the new system: “The file is digital now, but if the

doctor needs la clinical history of a child that came when he was 1 year old, and now is

14 o 15 years old, we have to look for the physical file because it is not updated, ten we

loos time looking for the file”. Nurse C also used the same example by which expressed

her rejection to the change. Since the institution decided to digitalize the patient’s

information, they do not longer used paper files. Nurse C stated: “… when, we have to

request the file, while it comes. Then it takes time. It creates disadvantages for the

patient and the doctor who wants to admit the person in the hospital…”.

54

4.4.4 Nurses’ Perspectives and Perceptions Toward Control

Nurses had expressed in the interviews their views about the structure of power in

the organization. Nurse A described that the organization was hierarchical and

authority was exercised from the top-‐down: “Here, impositions are to all the personnel

and we have to do it because it is imposed. They could be prepared for changes, but we

are rather we are excluded”. The ways nurses faced the authority scheme was to

accept the changes for the organization. Nurse C indicated that: “We have to act

according to the indications given, as is requested in the new change. But, from there,

nothing else, we have to do it”. Nurse statement showed that decision-‐making was

made from the top of the organization and they showed the feeling of exclusion in the

establishments of the objective or the regulation. The need to participate in the

decision-‐making was described by Nurse B: “That we are not considered in the

projects, we do not have any motivation, that is all, the project is ready and we have to

do as the regulations are made”.

Nurse showed the desire to exercise control in the organization as well. The need to

be heard to express their aspirations in the organization was expressed by Nurse C:

“But, from a time ago until, with the new administration, we had not they had

opportunity to express our nonconformities”. However, Nurse C alleged that

communication existed to the immediate boss and that such feeling was general

among nurses: “we complain among co-‐workers and our boss and nothing else. We can

only do that, nothing else”. In addition, Nurse C recognized that the organization did

not consider their input into the execution of initiatives. Furthermore, Nurse C clearly

stated that their role as members of the organization was the condition for success:

“For [the projects] to be successful, I think that they should communicate them to us. We

should be participants”.

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4.5 Findings From The Interviews to Administrative Staff

The findings from the interviews to the administrative staff at the Francisco Icaza

Bustamante Children Hospital are classified according to the Administrative Staff

Feelings Toward the Work Environment, Administrative Staff Perspectives and

Perceptions Toward the Organizational Communication, Administrative Staff

Perspectives and Perceptions Toward the Organizational Objectives, and Nurses’

Perspectives and Perceptions Toward the Organization.

4.5.1 Administrative Staff Feelings Towards Their Work Environment

Administrative staff member from the hospital recognized the positive changes

implemented in the organization. The interviewee Worker B affirmed the positive

view that existed about the hospitals’ projects: “Well, if the institution keeps this as we

are now, it would continue the success”.

The interviewee also claimed fear of change because the subject thought that

transformations in the workplace might affect the worker negatively. Workers argued

to be in constant fear because of the possibility of losing their jobs because of their

age. The interviewee Worker A affirmed that:

“Well, we have many concerns and worries about what's

going to happened in the future with us because of these

changes. It is always latent, afraid the future because of the

changes, we are told that with the changes the old

personnel will be fired and we are in a stage of

nervousness”

The staff member accepted the changes in the organizations formulated by the

administration and declared that the personnel were willing to follow the instruction

given. The interviewee Worker B detailed the attitude to accept management

strategies: “It seems to me that there are not inconvenient for the administration to

make changes. I do my work and I do not get complicated by them. Every person is a

56

different world, but we have to follow to what is here, to understand that this is the

schedule”. However, the personnel declared that the organization did not consider the

personnel’s needs. Staff member Worker A affirmed: “Our expectations are not

considered…”. Furthermore, Worker A asserted that they were excluded: “we are

excluded in the organization…”.

4.5.2 Administrative Staff Perspectives and Perceptions Toward the

Organizational Communication

The interviewees stated that information was not given to them by regular channels

or constantly. Subject Worker A mentioned during the interview that: “We do not

receive much information, but rather we are told that we change to this position and

that is all”. The staff member expressed the existence of informal communication

channels where info was transmitted in the way of rumours. Furthermore, subjects

argued that there were no meetings with management where they could get official

information from the institution. Subject Worker A explained the way members in the

administrative supporting personnel learned of the initiatives: “We get comments that

we listened that this will get improvements, that this is for this. However, no authority

had gathered us to tell us that management would di this for that, to implement that

thing”.

Staff members stated that meetings with the management of the hospital were highly

unusual. Subject Worker A indicated that: “Only one time, I believe in so long that we

had a meeting with the manager”. Likewise, staff member expressed that they did not

participated in the decision-‐making process in the hospital. The staff declared that

they were not considered to contribute in the design of any project. Staff member

Worker A affirmed that: “It is because we are not informed by the processes to generate

our opinions. They do not ask for our opinion. Because we are not knowing those

processes…”. According to Worker A, the subject stated that they were "restricted" to

give opinions: “I cannot give an opinion, we are practically restricted”. However, staff

57

member Worker B indicated that information regarding to project's objectives were

given to the personnel: “Of course, we are explained all…”.

4.5.3 Administrative Staff Perspectives and Perceptions Toward the

Organizational Objectives

Staff member recognized that organization’s goals have been achieved by the hospital.

Subject Worker B indicated: “We can see something different here not seen since many

years ago…”. Staff member claimed that measurable goals were given, but they did not

get feedback from the organization or if goal has been achieved. Interviewee Worker

A stated that: “We are told for example that we have a goal and we have to fulfil, but we

do not know if we reached the goal or not”.

Staff member recognized that the changes implemented by the organization have

reached the perception of the general public in the city. As augmented by subject

Worker B, the personnel received complements for changes by the public:

“Well, now all the people who come to the hospital are saying that it is different from

before, that patients had to wait and wait, now people from the door are asking how to

help the children [patients]? And we served then right away where they correspond...”

4.6 Chapter Summary

The chapter provided detail information about the outcomes from the interviews

made to members of one of the most important hospitals in Guayaquil, Ecuador. The

outcomes were listed and categorized according to the different data units of analysis

designed for the research. The chapter list the perspective and perceptions of the

personnel in the organization. The complete analysis and relationships from the four

population groups are present in the Discussion Chapter.

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CHAPTER FIVE: DISCUSSION


The chapter presents the arguments that emerge from the contraposition between the

synthesis of the systematic literature review, the literature gap (section 2.6 from

chapter 2) and the findings described from the interviews in chapter 4 (from sections

4.2 to section 4.5). The chapter is organized according to the five conceptual pillars

that resulted from the systematic review from sections 2.4.1 to section 2.4.5.

5.2 Antecedents in the Organization to Implement Change

The transformation of an organizational culture to create an environment of

commitment, cooperation and learning requires an understanding of the institution

before changes are implemented. Introducing changes in the organization could be a

stressful process (Bush, 2007; King, 2001). Introduction of new processes, changes of

any kind or even the insertion of new technologies that would provide support to the

users can be perceived by the members in the organization as a treat to the comfort

zone. The understanding of the perceptions of the organization is considered the

initial stage to achieve a culture of continuous learning and improvement. The

research finds that the hospital can be characterized and recognized for the positive

improvements that have been developed. Manager B talks about the innovations

implemented, Doctor D described in detail the changes achieved since 2008 with the

new public healthcare plan proposed by the central government, Nurse C provides

examples of the radical changes taken by the administration, and staff members such

as Worker B mention how the plans in the hospital were successful for patients and

personnel.

The negative feelings developed from the work experience, personal and

organizational aspects (Allen and Meyer, 1990, 1996; Eby et al 1999; Meyer and Allen,

1997; Avolio et al. 2004) prevent the creation of the commitment from the members

in the organization. Such negative feelings could be the consequence of previous

59

unsolved conflicts in the institution. The research presented a conflict in the hospital

that had not be solved or overcome. Such feelings could be generalized as possible

scenarios from other organizations when the faced changes. In the research, the

negative feelings are subcategorized as Fear of the consequences to the change,

conflict among the personnel who embrace the change and those who do not by

expressing resistance and rejection.

The fears to the changes were reported by all subjects as the possibility of the

personnel to lose their jobs, not being prepared to the challenge that represent to

realized a different task in the organization, and fear to the unknown. There are also

particularities or differences about the nature of the subjects fears. Such is the case of

the medical doctors who although has special characteristics and preparation to make

them more suitable to manage change (doctors are highly trained, prepared to search

for new knowledge, capacity to manage extremely complex concepts) and explained

by Argyris (2008) and explained in the Action and Espouse Theory from section 2.4.5.

Since fears are provoked by the possibility of negative occurrences, the stage of

readiness can be achieved by solving such conflicts (Van de Ven and Poole, 1995; Holt

et al. 2007). Therefore, an auditory of organizational conflicts should be developed to

better understand the nature of the fears.

The research proves that the members in the organization for the previously

mentioned reasons and fears reject the changes. However, after the changes are

implemented, they provide doubtless improvement for the performance of the tasks,

but the rejections continued. If the fear to lose their jobs was the reason to avoid the

change, after not loosing their jobs the logic conclusion was to accept the change.

Therefore, it can be argued that negative feelings that prevented the organizational

commitment are constantly replaced for new negative feelings. For example, the

interviewed expressed resistance to the digitalization of prescriptions. The subjects

express the benefits that such system brings to them and to patients, but they subjects

pay attention to the minimum detail used to resist the use. Furthermore, the replace

the negative feeling for the lack of brand names for medicines that should be use in

60

the hospital. It is observed in the research that a new ERP system is implemented, and

personnel are no longer needed in some areas of the hospital. Upper management

did not fire personnel; the workers were reallocated in the customer service area. A

new set of negative feelings replaced the old scheme of perceptions from the members

in the organization.

5.3 The Organizational Culture

To achieve the goal of creating an environment of commitment, cooperation and

learning which is the aim of the research, key aspects of the existing culture in the

organization most be attended. Based on the work of Cooke and Szumal, 2000 as well

as the research of Balthazard et al. (2006), that indicates that organizational culture is

in constant change and is shaped by many different factors. The cultural audit would

provide the required data to understand what are also the values or fears that

influence members in the organization to drive their actions. The research suggested

that information was one of the variables that influence the members in the

organization to make choices or to develop fears and rejection. The communication

phenomenon described by Miles et al. (1996)6 is found in the research. The top of the

hierarchy in the hospital subject of the study proves to benefit from having more

information and support than the lower levels of the structure. As the subjects are

interviewed from the top of the organizational structure to the bottom, formal

communication channels are decreasing, and less information about the

administrative decisions are given to the subjects in the interviews. The outcomes

from the research also suggested that some member in the organization declared not

receiving information from the upper management, but argued that they did

communicated with the supervised.

6 The study argues that lower level employees sense less support from supervisor since lower level employees may have more mistakes in the implementation of changes that upper level employees.

61

The research showed that all the subjects interviewed declared the lack of

information given to them as members of the organization. Furthermore, the research

suggested that informal communication channels were presented in the organization

and the informal information impacted negatively to the organization in various

aspects. First, the erroneous information served to fed and increase the feelings of

rejection and fear to the changes in the organization. For example, Worker A claimed

that the lack of information made them worry and this generates resistance to the

initiatives. Second, fears seemed to be the catalyst to create the collective believes for

what Holt and Armenakis (2007) defined as dysfunctional organizations. Third, the

erroneous information could become the elements for the development of reasons to

the defensive reasoning described by Argyris (2008). The erroneous information

should be contrasted with official and correct information. For example, staff

members are reallocated in the customer service area. The subjects interpreted the

actions as a punishment because they their relocation was given as an administrative

order.

5.4 The Collaborative Culture

After conducting the auditory of organizational values and understanding the

communication issues in an organization, more could be needed to reach a culture of

collaboration where strategies such as lean can reach its potential. The organization

would be required to overcome the negative feelings that prevent its member to reach

organizational commitment to the objectives established by the upper management.

The following segment discuses the proposed strategy to manage this commitment.

As was expected from a society, a micro society or organization, their members

expected rights and duties. A proposed aspect of collaborative culture is the

empowerment of the member in the organization. As advocated by Sanchez and

Cralle (2012) that employee empowerment can be achieved through shared

governance.

62

The shared governance should be understood as the participation of the members of

the organization to be par of the processes that make decisions and actions for the

achievement of the organizational objectives. The internal and external history in the

organization could influence such process. In the case of Ecuador, in the past, the

governing entities prevented the participation of the members in the organizations

(or in society) to take advantages of them. With the time, the member in the

organization or the institutions themselves used their leverage to take advantages

from the governing entities. There were also cases in which temporal solutions in the

past became distortions that were carried in time. Such anomalies had created bigger

problems today. The major disagreement from the personnel in the researched

hospital were related to a change in the schedule of work for doctors and the free

lunch for all members in the organization. The reason of resistance and complains

where reported by Manager A and Doctor A.

The conflict was originated many years ago when workers negotiated salaries

increases. The government of the time decided that rather than reaching a consensus

by paying a fair salary, they reduced the full-‐time week from 40 hours to only 20

hours a week. Along the time, other grants were given with the public funds

(contradicting national laws), where personnel received paid lunch in the institution

and leaving the institution before the exit time. The point here was that shared

governance could be established as a way to achieve continues improvement. The

establishment of boundaries, regulations and progressing use of participation could

be considered in the development of sharing governance in the organization. Every

single right in a social group should be accompanied with the responsibilities and

sanctions for unrespecting them.

63

5.5 The Commitment to the Organization

As indicated by Vakola and Nikolaou (2005) a positive relationship can be recognized

between commitment to an organization and the attitudes that individuals may have

towards those changes. Armenakis and Bedeian, 1999; Parker et al., 2003; Pettigrew,

2000; Martin et al., 2006 understood the loops between the individuals in a group and

the commitment to such a group as a psychological climate. This psychological

climate was characterized as the psychologically meaningful representations of the

organizational structures, processes and events by the individuals. The commitment

would have a positive relationship between the values the individual posses (or

believe the individual posses) and those values perceived in the organization.

The research showed that the values from the subjects from the interview were

clearly mentioned across the interviews. The subjects demonstrated a desired to

reach the upper layers in the hierarchy to express complaints, suggestions, to be

recognized, to contribute to the initiatives, to be informed and to also exercise control

to the management. Upper management should have a clear understanding of those

values and desires to formulate their strategies of development. In diverse ways, the

subjects mentioned the desire and need to make suggestions to upper management

and to participate in the initiatives of the projects. This could be considered as an

opportunity to improve the design of the initiative with the support of the personnel

who would participate in such initiative. In addition, upper management can also

benefit with the opportunity to provide information about their vision. A

methodology for this exercised could be always needed. The socializations of ideas,

concepts and visions generate reactions from the members of the organization. The

fact that socialization existed might create the expectative for amendment according

to each group in the organization.

Socialization process could be perceived by the different groups as the opportunity to

exercise control. This is a basic need among humans and emerges as an unconscious

mechanism of self-‐protection as well. In every example given by each subject, their

64

titles, the years working in the institution and so on, were used to express their

rejection to the changes and as a way rationalize their decisions.

5.6 The Learning Organizations

According to Argyris and Schön (1974), espoused theory represents their believes and

values that a person think that guide his or her actions. Therefore, members in the

organization (from supervisee to upper management) might think that their personal

or group performance could be appreciated and considered the most appropriated.

As the theory-‐in-‐use represents their believes and values that a person had and

guided his or her actions in reality. The organization should develop mechanisms to

deal with the possible resistance from personnel and to create opportunities for self-‐

awareness of the personnel actions in the organization. The standard proposal from

academia was to develop measurable outcomes from for all levels in the organization.

This meant to incorporate the desired outcomes for the group (a department or area)

and the expectations from their superiors. The same scheme should be developed for

the individuals in the group.

Argyris, 2008, proposed that individuals could use a defensive reasoning as a reaction

to certain challenges such as the understanding of underperformance in an institution.

Such mechanism was more frequent among individuals characterized to be high

achievers, well educated (such as doctors and consultants). Argyris, 2008 proposed

that by understanding of the individuals’ resistances and dialogue, a person could

transform his/her defensive reasoning to constructive reasoning. Continuous

learning which means the developing capacity on one’s own experience and

experience of others and more important, it is a permanent process of creating and

improving the organization’s competences. Therefore, the organization should

develop system of sharing learn lessons.

65

5.7 Chapter Summary

The chapter discussed the antecedents needed in an organization to implement

changes and initiatives. The section 5.2 argues that an organization is influence by

the pre-‐existing feelings of fears or dislikes that create barriers to the acceptance or

support to new initiatives for the institution. The chapter also argues the requirement

for an institution to develop an auditory of organizational conflicts to understand the

nature of the feelings that influence individuals and groups in the organization. In

addition, the reasons for the creation and management of the organizational culture

are presented in section 5.3. The chapter indicates that values and conflicts that

influence the members of the organization are in a dynamic movement. Therefore, as

one barrier is overcome, a new rejection may emerge in the institution. Moreover, the

discussion of the need to understand values to manage the creation of a collaborative

culture is developed. Section 5.4 proposed that a collaborative culture can be

establish by the empowerment of its members. The chapter also present the

discussion of the aspects that influence the process of empowering the members in

the institution. Furthermore, a discussion for the creation of psychological climate is

presented in section 5.5 with the aim to cause the commitment from the member to

their organization. The section discusses the creation of the values of the entire

organization. Finally, section 5.5 proposes a mechanism to made individuals and

groups participant of a learning organization. It also present the barrier that explain

the reason for individuals to create a defensive reasoning mechanism.

66

Chapter Six: Conclusions And Reflections


The present chapter presents the reflections about the theoretical contributions that

the research had found. The chapter focus on some of the aspects that the proposed

approach was characterized for. The chapter presents the seeks to understand the

root motivations that influence people as individuals and as a group. In addition,

some practical applications were presented for the methodology suggested, as well as

the explanation of some of the limitations for the development of the research.

Finally, further research was also presented.

6.2 Theoretical Contributions

The research discusses and empirically explores the emotional perceptions that

influenced individuals to guide and motivate their actions in an organization. As

individuals and together as groups their emotions such as recognition, fears, need for

recognition and to be heard create the organization culture in the organization. Such

emotions react as they faced other internal and external variables in the organization.

In the case of a hospital for example, the fulfilment of national regulations such like

the recognition of full-‐time workweek of 40 hours for all members in the institution

created a general rejection to any other initiative at the hospital. In contrast,

personnel are highly committed with their compromise to do their best to provide

care to patients. Other feelings influenced individuals that sharing the same rejection

had created a general feeling that characterized the institution provoking realities

between newly integrated personnel and the experienced member in the

organization.

To reach such understanding of emotions, the research proposed the development of

an auditory of organizational values. The aim of the auditory would be to understand

the root motivations that the group has in the institution. It was argued that the

management could be able to make decision for the management of the values or fears

67

in the organization. The proposed aim could be to take advantage and maximized the

values and satisfactions from the personnel and decreased negative values and fears.

In the case of values, policies could be developed to make of those values

characteristics of the organization that could influence the new members in the

organization for them to adopt such values. The communication of those values could

be required. Moreover, those values should be publicised to the stakeholders of the

organization. On the other hand, fears would require a different strategy. Some of the

fears could be the result of lack of information or need for exercising control in the

organization. If the fear was provoked as the reaction to the unknown, with training

and support it could be managed. If the fear was provoked for the need to control

others, a communication process could be necessary.

In addition, the following step after the understanding of the organizational values by

the use of the auditory of organizational conflicts or values would be the

empowerment of the members of the organization. The empowerment is proposed to

be achieved by the shared governance. The shared governance was proposed as a

way to develop goals and objectives with the participation of the upper management

as an official governing entity and the members of the organization. The participation

of employees was suggested to be an on-‐going process that would allow the

individuals to learn the responsibility of participating in guidance of the institution. It

was also proposed that participation required clear boundaries to participate as well

as restrictions. The research also proposed to understand the unaware desire from

the supervisees to exercise control to the superior members in the hierarchy of the

organization. The research also discussed the implementation of socializations

mechanisms to achieve the adequate psychological climate among the members of the

organization to create a commitment to the institution.

In addition, the culture in an organization is constantly exposed to the influence of

positive and negative variables. Such variables can be internal or external. Therefore,

the proposed approach should be considered and view as a dynamic constant process

of continues implementation. As values and fears can change in the organization, such

68

emotions can also change in the individuals or as a group. The research keywords

(Table 2) guided the systematic literature review generated key academic

perspectives that guide the research. Studies such as Armenakis et al. (2007) on

organizational change and Allen and Meyer (1990) on commitment to the

organization contributed to understand the antecedents needed to overcome in an

institution. Cooke and Szumal (2000) and Holt and Armenakis (2007) also present a

variety of views on organizational culture that create a perspective in the study. The

investigations of Sanchez and Cralle (2012) on collaborative culture contributed to

understand the social requirements needed in an institution to achieve collaboration

among members. Furthermore, the investigations of Armenakis and Bedeian (1999)

and Parker et al., (2003) contributed with a framework of analysis to create an

approach to provoke commitment to the institution. Finally, Argyris (2008) and

Argyris and Schön (1974) on Learning Organizations contribute with the framework

to understand the decision making of individual.

6.3 Practical Implications

The practical implications of the framework can be oriented to motivate the members

of an organization that is structured with a mixture of professional profiles. Public or

private institutions, manufacturing or service organizations are equally exposed to the

influence of people’s values and fears upon the institution. Because there are

organizations that due to their nature or for external reasons posses a constant

turnover of personnel, the approach recognize the dynamic changes that institution

may have over its personnel values or fears.

Another opportunity of the approach is that its application can be implemented in

institutions of different sizes. The approach can be suitable for a national system such

as the case of the Healthcare System in Ecuador that is compose by many different

hospitals. On the same hand, the approach can also be used in or smaller units such as

health centres in the local neighbourhoods.

69

Since fears can be identified and eliminated, the personnel can reduced or eradicate

the resistance of administrative initiatives implemented in the institution. The

personnel can contribute to reach efficiency and efficacy by obtaining the full

potential that a Lean methodology or ERP systems can provide to the organization.

Furthermore, management and members in the organization can develop a

commitment to the objectives that mutually establish. In addition, institutions can

overcome challenges and benefit of opportunities if its members work in

collaboration.

The learning process involves the capacity to recognise the rejection that individuals

presents unconsciously to any initiative or event in the organization. The awareness

of the decisions that individuals adopt as a decision making process allow the

members in the institution to accept and to collaborate to create collective goals.

Once the organization stabilized the approach, the organization can gain the value of

prestige among professionals that can appreciate and motivate them to be part of the

organization that foster collaboration and professional development.

6.4 Reflections on the Research Limitations

The research finds several limitations. One limitation was the sample population

selected for the research. Although, the 12 interviews might represent the major

groups present in the cased studied (Doctors, Managers, Nurses and Administrative

Personnel), there are many more subgroups that are part of the organization. Even

though four doctors were interviewed, subgroups were not considered such as

surgeons, obstetricians, between other not explored sub-‐groups. In addition, since

institutions such as the Francisco Icaza Bustamante Children Hospital are highly

hierarchized, data were not collected to reflect such structure.

Another limitation of the proposed approach is its theoretical and empirical nature.

The research proposes a theoretical contribution and the approach had not been

contrasted in practice to observe its implementation. An implementation model

70

should be necessary to realize effectiveness of the five pillars or areas of the approach

since the research cannot fully address the need for fewer or additional perspectives.

Since the cased designed for the research was an Ecuadorian hospital, the researcher

was not able to conduct the interviews directly to the subjects. A trained team was

conformed to conduct the interviews and record them for transcription and analysis.

The proper preparation and training was given and boundaries to limit the interaction

of the interviewers with the subjects. Therefore, relevant information regarding to

their non-‐verbal communication was not considered. In addition, a interview guide

was used, and the instrument has 16 open questions that were presented to all the

subjects. No follow up questions were presented to explore other pertinent

comments or perceptions presented by the subjects of the interview.

6.5 Further Research

Further research could be conducted in reference to the management of control issues

that people could tray to implement in the organization. It should be considered as a

natural reaction and desire from the individuals to consciously or unconsciously to

exercise some sort of control in the organization as a mechanism of defence and

security. The understanding and management of the desire of exercise control could

contribute to better guide the culture in the organization.

In addition, further research is needed to develop a model to conduct the

Organizational Audit of Conflicts and Values. The model should contemplate the

resistance from the personnel to share their views and feelings in reference to the

organization and its systems. Individuals in the organization could also feel the need

to agree with their immediate supervisors. Additional research need to develop a

model that can be maintain in time in the organization. At the same time, the model

should be able to adopt to the changes that are normal in any institution due to

internal o external variables.

71

Another aspect for further research are the need to link all parts of the hierarchy in

the process to create the environment of collaboration, cooperation and learning. Due

to the nature of hierarchies, further research is needed to relate the authorities and

the lower layers of the institution.

72

References

Allen, N. J. and Meyer, J. P. 1990. “The Measurement and Antecedents of Affective,

Continuance and Normative Commitment to the Organization”. Journal of

Occupational Psychology.

Allen, N. J. and Meyer, J. P. 1996. “Affective, Continuance and Normative Commitment

to the Organization: An Examination of Construct Validity”. Journal of Vocational

Behaviour.

ANDES Agency, 2013. “The Past 7 Years’ Investment in Health Consolidates Services,

Quality of Equipment and Professionals in Ecuador”. Available at:

http://www.andes.info.ec/es/noticias/ultimos-‐siete-‐anos-‐inversion-‐salud-‐consolida-‐

atencion-‐equipamiento-‐profesionales-‐calidad. (Accessed: 25 April 2014).

Argyris, C. 1974. “Behind the Front Page”. Jossey-‐Bass, San Francisco.

Argyris, C. 2008. “Teaching Smart People How to Learn”. McGraw-‐Hill, London.

Argyris, C. and Schön, D., 1974. “Theory in Practice: Increasing Professional

Effectiveness”. San Francisco: Jossey-‐Bass.

Armenakis, A. A. ; Bernerth, J. B. ; Pitts, J. P. and Walker, H. J. 2007. “Organizational

Change Recipients' Beliefs Scale: Development of An Assessment Instrument”.

Journal of Applied Behavioural Science.

Armenakis, A. A. and Bedeian, A. G. 1999. “Organizational Change: A Review of

Theory and Research in the 1990s”. Journal of Management.

Armenakis, A. A., Bernerth, J. B., Pitts, J. P. and Walker, H. J. 2007. “Organizational

Change Recipients’ Beliefs Scale Development of an Assessment Instrument”. Journal

of Applied Behavioural Science.

Armstrong-‐Stassen, M. 1998. “The Effect of Gender and Organizational Level on How

Survivors Appraise and Cope with Organizational Downsizing”. Journal of Applied

Behavioural Science.

Avolio, B. J. 1999. “Full Leadership Development: Building the Vital Forces in

Organizations”. Thousand Oaks, Sage, California.

Avolio, B. J., Zhu, W. C., Koh, W. and Bhatia, P. 2004. “Transformational Leadership

and Organizational Commitment: Mediating Role of Psychological Empowerment and

73

Moderating Role of Structural Distance”. Journal of Organizational Behaviour.

Baker, M. J. 2000. “Writing a Literature Review”. The Marketing Review.

Balthazard, P. A., Cooke, R. A. and Potter, R. E. 2006. “Dysfunctional Culture,

Dysfunctional Organization Capturing the Behavioural Norms that Form

Organizational Culture and Drive Performance”. Journal of Managerial Psychology.

Bass, B. M. 1999. “On the Taming of Charisma: A Reply to Janice Beyer”. Leadership

Quarterly.

Bass, B. M., and Avolio, B. J. 1994. “Improving Organizational Effectiveness Through

Transformational Leadership”. Thousand Oaks, Sage, California.

Berger, P. L. and Luckman, T. 1966. “The Social Construction of Reality”. Penguin,

London.

Bounds, G. M., Dobbins, G. H. and Fowler, O. S. 1995. “Management: A Total Quality

Perspective”. South-‐Western Publishing, USA.

Bush, R. W. 2007. “Reducing Waste in US Health Care Systems”. Journal of the

American Medical Association.

Butler, R. 1991. “Designing Organizations. A Decision-‐Making Perspective”.

Rutledge, London.

Chase, S. E. 2005. “Narrative Inquiry: Multiple Lenses, Approaches, Voices”. In The

Sage Handbook of Qualitative Research, , 3rd ed., Edited by: Denzin, N. K. and Lincoln,

Y. S. 651–680. Thousand Oaks, CA: Sage.

Coch, L. and French, J. R. P. 1948. “Overcoming Resistance to Change”. Human

Relations.

Cook, T. D. and Campbell, D. T. 1979. “Quasi-‐Experimentation: Design and Analysis

Issues for Field Settings”. Houghton Mifflin, London.

Cooke, R. A. and Szurnal, J. L. 2000. “Using the Organizational Culture Inventory to

Understand the Operating Cultures of Organizations”. Handbook of Organizational

Culture and Climate.

Coomber, B. and Barriball, L. 2007. “Impact of Job Satisfaction Components on Intent

to Leave and Turnover for Hospital-‐Based Nurses: A Review of the Research

Literature”. International Journal of Nursing Studies.

74

Cummings, T. G. and Worley, C. G. 1997. “Organization Development and Change”.

6th ed., South Western College Publishing, Cincinnati, OH.

Daft, R. L. 1989. “Organization Theory and Design”. 2nd Ed., St Paul, MN: West

Publishing.

Daft, R. L. 2003. “Management”. 6th Ed. Thomson South-‐Western, UK.

Denzin, N. K. and Lincoln, Y. S. (editors), 1994. “Handbook of Qualitative Research”.

Sage: Thousand Oaks, London.

Druker, P. 1954. “The Practice of Management”. Harper and Bros, New York.

Easterby-‐Smith, M., Graca, M., Antonacopoulou, A. and Ferdinand, J. 2008.

“Absorptive Capacity: A Process Perspective”. Management Learning.

Easterby-‐Smith, M., Thorpe, R. and Jackson, P. R. 2008. “Management Research”. 3rd

Ed. SAGE Publications Inc., London.

Eby, L. T., Freeman, D. M., Rush, M. C. and Lance, C. E. 1999. “Motivational Bases of

Affective Commitment: A Partial Test of an Integrative Theoretical Model”. Journal of

Occupational and Organizational Psychology, 72, 463-‐483.

Gerstner, L. V. Jr. 2002. “Who Says Elephants Can’t Dance?”. Harper Collins

Publishers, New York, NY.

Gibbert, M., Ruigrok, W. and Wicki, B. 2008. “What Passes as a Rigorous Case Study?”.

Strategic Management Journal.

Gibbons, J. and Schutt, R. 2009. “A Global Barometer for Measuring Employee

Engagement”. Conference Board.

Goffee, R. and Jones, G. 1996. “What Holds the Modern Company Together?”. Harvard

Business Review.

Griffin, R. W. 2008. “Fundamentals of Management”. Houghton Mifflin Company,

USA.

Haugh, E. B. and Laschinger, H. S. 1996. “Power and Opportunity in Public Health

Nursing Work Environments”. Public Health Nursing.

Holt, D. T., Armenakis, A. A., Field, H. S. and Harris, S. G. 2007. “Readiness for

Organizational Change: The Systematic Development of a Scale”. Journal of Applied

Behavioural Science.

75

INEC/Instituto Nacional de Estadistica y Censo. “2010 Census Outcomes”. Available

at: http://www.ecuadorencifras.gob.ec/wp-‐content/descargas/Manu-‐

lateral/Resultados-‐provinciales/guayas.pdf. (Accessed: 30 August 2014).

Internal Auditing Commission for Public Credit of Ecuador. “Final Report of the

Integral Auditing of the Ecuadorian Debt”. Available at:

http://www.auditoriadeuda.org.ec/index.php?option=com_content&view=article&id

=89&Itemid=55 (Accessed: 28 August 2014).

Javidan, M. 2001. “The Impact of National Culture on Cross-‐Border Mergers: The

Lessons from GLOBE”. Paper presented at the 5th International Management

Conference of The Carnegie Bosch Institute for Applied Studies, Berlin, Germany.

Jesson, J., Matheson, L. and Lacey, F. 2011. “Doing your Literature Review:

Traditional and Systematic Techniques”. SAGE Publications Ltd, London.

King, W. R. 2001. “Strategies for Creating Learning Organizations”. Information

Systems Management.

Kraleva, N. 2011. “Learning Organizations: Prerequisite for Successful Tourism

Organizations”. UTMS Journal of Economics // University of Tourism and

Management: International, Multidisciplinary Journal for the Area of South and

Southeastern Europe.

Larkin, T. J. and Larkin, S. 1994. “Communicating Change: How to Win Employee

Support for New Business Directions”. McGraw Hill, New York.

Laschinger, H. K. S. 2004. “Hospital Nurses’ Perceptions of Respect and Organizational

Justice”. Journal Of Nursing Administration.

Lau, C. and Woodman, R. C. 1995. "Understanding Organizational Change: A

Schematic Perspective". Academy of Management Journal.

Lavoie-‐Tremblay, M., Paquet, M., Duchesne, M. A., Santo, A., Gavrancic, A., Courcy, F.,

and Gagnon, S. 2010. “Retaining Nurses and Other Hospital Workers: An

Intergenerational Perspective of the Work Climate”. Journal of Nursing Scholarship.

Lewis, L. K. 1999. “Disseminating Information and Soliciting Input During Planned

Organizational Change: Implementers’ Targets, Sources and Channels for

Communicating”. Management Communication Quarterly.

76

Lewis, L. K. 1999. “Disseminating Information and Soliciting Input During Planned

Organizational Change: Implementers’ Targets, Sources and Channels for

Communicating”. Management Communication Quarterly.

Lowe, G. 2012. “How Employee Engagement Matters for Hospital Performance”.

Healthcare Quarterly.

Lowe, K. B., Kroeck, K. G., and Sivasubramaniam, N. 1996. “Effectiveness Correlates of

Transformational and Transactional Leadership: A Meta-‐Analytical Review of the

Literature”. Leadership Quarterly.

Martin, A. J., Jones, E. S. and Callan, V. J. 2006. “Status Differences in Employee

Adjustment During Organizational Change”. Journal of Managerial Psychology.

Meyer, J. and Allen, N. J. 1997. “Commitment in the Workplace: Theory, Research and

Application”. Thousand Oaks, CA: Sage.

Miles, E. W., Patrick, S. L. and King, W. C. Jr. 1996. “Job Level as a Systematic Variable

in Predicting the Relationship Between Supervisory Communication and Job

Satisfaction”. Journal of Occupational and Organizational Psychology.

Ministry of Information of Ecuador. “Development Plans and Territorial Ordering,

2014”. Government of Ecuador. Available at:

http://sni.gob.ec/web/inicio/descargapdyot (Accessed: 20 July 2014).

Ministry of Public Health of Ecuador. “Integral Service Model Of the National Health

System of Ecuador, 2012”. Government of Ecuador.

Mowday, R. T., Porter, L. W. and Steers, R. M. 1982. “Employee-‐Organization Linkages:

The Psychology of Commitment, Absenteeism and Turnover”. Academic Press,

London.

Musson, G. 2004. “Life Histories”, in: C. Cassell and G. Symon (Editors) Essential Guide

to Qualitative Methods in Organizational Research. Sage, London.

Musson, G. 2004. “Life Histories”, in: C. Cassell and G. Symon (Editors) Essential Guide

to Qualitative Methods in Organizational Research. Sage, London.

National Secretary of Planning Ecuador. “National Development Plan / National Plan

for Good Living, 2013-‐2017”. Available at http://www.buenvivir.gob.ec. (Accessed:

20 July 2014).

Parker, C. P., Baltes, B. B., Young, S. A., Huff, J. W., Altmann, R. A., Lacost, H. A. and

77

Roberts, J. E. 2003. “Relationships Between Psychological Climate Perceptions and

Work Outcomes: A Meta-‐Analytic Review”. Journal of Organizational Behaviour.

Pettigrew, A. 2000. “Foreword”, in Ashkanasy, N. M., Wilderom, C. P. M. and Peterson,

M. F. (Eds). Handbook of Organisational Culture and Climate. Sage, Thousand Oaks,

CA.

Porter, L., Crampon, W. and Smith, F. 1976. "Organizational Commitment and

Managerial Turnover: A Longitudinal Study". Organizational Behaviour and Human

Performance.

Rowley, J. 2012. “Conducting Research Interviews”. Management Research Review.

Rutledge, T. 2005. “Getting Engaged: The New Workplace Loyalty”. Mattanie Press,

Toronto.

Sanchez, L. and Cralle, L. 2012. “Attaining Employee Empowerment”. Nurse Leader.

Sathe, V. 1985. “Culture and Related Organizational Realities”. Irwin, Homewood, IL.

Saunders, M., Lewis, P. and Thornhill, A. 2012. “Research Methods for Business

Students”. Sixth edition. Pearson Education Limited, London.

Savaya, R. and Gardner, F. 2012. “Critical Reflection to Identify Gaps between

Espoused Theory and Theory-‐in-‐Use”. Social Work.

Schein, E. H. 2000. “Sense and Nonsense About Culture and Climate”. In Ashkanasy,

N., Widerom, C.P. M. and Peterson, M. F. (Eds). Handbook of Organizational Culture

and Climate, Sage, Thousand Oaks, CA.

Schein, E. H. 1983. “The Role of the Founder in Creating Organizational Culture”.

Organizational Dynamics.

Schein, E. H. 1985. “Organizational Culture and Leadership”. Jossey-‐Bass, San

Francisco, CA.

Schutt, R. 2012. “Investigating the Social World: The Process and Practice of

Research”. Seventh Edition. SAGE Publications, Inc.

Seijts, G. H. and Crim, D. 2006. “What Engages Employees the Most or, The Ten C’s of

Employee Engagement”. Ivey Business Journal.

Senge, P. M. 1990. “The Leader’s New Work: Building Learning Organizations”. Sloan

Management Review.

Senior, B. and Fleming, J. 2006. “Organizational Change”. 3rd Ed. Pearson Education

78

Limited, England.

Shotter, J. 1993. “Conversational Realities: Constructing Life Through Language”.

SAGE Publications Inc., London.

Smith, M., 2013. “Chris Argyris: Theories of Action, Double-‐Loop Learning and

Organizational learning”. Available at: http://infed.org/mobi/chris-‐argyris-‐theories-‐

of-‐action-‐double-‐loop-‐learning-‐and-‐organizational-‐learning/. (Accessed: August 05,

2014).

Spreitzer, G. M. 1995. “Psychological Empowerment in the Workplace: Dimensions,

Measurement and Validation”. Academy of Management Journal.

Strauss, A. and Corbin, J. 1990. “Basics of Qualitative Research: Grounded Theory

Procedures and Techniques”. Sage Publications Inc., London.

Tranfield, D., Denyer, D. and Smart, P. 2003. “Towards a Methodology for Developing

Evidence-‐Informed Management Knowledge by Means of Systematic Review. British

Journal of Management.

Vakola, M. and Nikolaou, I. 2005. “Attitudes Towards Organizational Change: What is

the Role of Employees’ Stress and Commitment?” Employee Relations.

Van de Ven, A. H. and Poole, M. S. 1995. “Explaining Development and Change in

Organizations”. Academy of Management Review.

Watzlawick, P. (Editor) 1984. “The Invented Reality”. Norton, London.

Weber, Y., Shenkar, O. and Raveh, A. 1996. “National and Corporate Cultural Fit in

Mergers/Acquisitions: An Exploratory Study”. Management Science.

World Bank, 2014. “Data: Expenditure in Healthcare, Total Percentile of GDP”.

Available at: http://datos.bancomundial.org/indicador/SH.XPD.TOTL.ZS (Accessed:

25 April 2014).

Wren, D. A. 1994. “The Evolution of Management Thought”. John Wiley & Sons, Inc.

Canada.

Yammarino, F. J., Spangler, W. D. and Bass, B. M. 1993. “Transformational Leadership

and Performance: A Longitudinal Investigation”. Leadership Quarterly.

Yeo, R. 2005. “Implementing Organizational Learning Initiatives: Insights from

Singapore Organizations -‐ Part I”. Development and Learning in Organisations.

79

Yeo, R. 2006. “Implementing Organizational Learning Initiatives: Insights from

Singapore Organizations – Part II”. Development and Learning in Organizations.

Yin, R. K. 2009. “Case Study Research: Design and Methods”. 4th ed. Sage

Publications, Los Angeles.

Yin, R. K. 2012. “Application of Case Study Research”. 3th ed. Sage Publications, Los

Angeles.

Yukl, G. 1998. “Leadership in Organizations”. 4th edn. Englewood Cliffs, Prentice-‐

Hall, New Jersey.

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Appendix A Research Report Table

Search Report Table

Source: University of Manchester's search database, Google Scholar

Time period

of publication

From 2004 to 2014

Search

Categories

Employee

Engagement in

Hospitals

Implementing

Organization

Change

Implementing

Organization

Change in

Hospitals

Organizational

Behaviour in

Hospitals

Organizational

Change in

Hospitals

Reducing

Waiting

Time in

Hospitals

Language

Considered

English English English English English English

Number of

Hits

15,600 18,000 17,000 17,600 83,000 17,600

Core Selected

Papers

11 4 6 15 30 22

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Appendix B Interview Guide

General Info Position Held: Manager Doctor Nurse Administrative Staff Gender: Male Female Subject A B C D E Time working In the Institution: __________ Age: __________ Area of Work: __________ Presentation Hi. Thank you very much for taking time from your busy schedule to allow me to do this interview. The information that is collected is totally confidential and is part of an academic research for a master degree at the University of Manchester in England. The masters is in Operations, Projects and Supply Chain and the topic of the research is: How to Transform the Organizational Culture of a Service Institution to Create an Environment of Commitment, Cooperation and Learning? Institutions use a variety of techniques to achieve improvements, but sometimes, those strategies do not consider personnel perception. The following questions are open. The interviewee is expected to provide short answers from the their own experience, but more important, from what is observed in the work place among peers. The observations can be from managers, doctors, nurses, or administrative staff. To provide answers from your observations, please think of any initiative, plan, or action implemented in the hospital to make it more efficient. Think of any introduction of new equipment, procedures, or initiatives that worked or not.

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Questions for Interview The following questions are related to the perception by staff during the implementation of any initiative or change in the hospital 1. Once a change (project or initiative) is introduced in the hospital what

instructions are given to the personnel? 2. How do you see the preparation of the personnel (doctors, nurses, and

administrative staff) to implement projects or initiatives in the hospital? 3. Can you explain your peers’ expectations when changes are placed in the

hospital? 4. What do you (or your peers) like when management implements new programs

in the hospital? 5. What do you (or your peers) dislike when management implements new

programs in the hospital? 6. If projects or initiatives are not working as they were planned. How do the

personnel express their concern with those procedures? 7. Can you please explain how is the participation of the personnel in the

implementation of changes (projects or initiatives) in the hospital? How do you think that project be improved?

8. Can you please tell me what are your expectations when a project is executed? The following questions are related to the perceptions of the personnel after the implementation of projects 9. Can you please tell me if any follow up is given to the initiatives implemented in

the hospital? Do you or your peers were requested suggestions from the management?

10. Can you explain me what are your expectations (or from your peers) after a

project or initiative is completed? 11. In your opinion, what are the reasons that explain the failure or success of

initiatives implemented at the hospital? 12. After project is implemented, can you explain if the objectives of the project are

clear and measurable?

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The following questions are related to the general experiences of the personnel in the hospital? 13. Can you please mention successfully implemented projects in the hospital? 14. Can you please tell me about projects that gained the support and collaboration of

the personnel in the hospital? 15. Can you please comment of projects in which people felt unmotivated to

participate and why? 16. Do you have any additional comments to add to this conversation? Thank you very much for your support and time.

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Appendix C. Interview Guide Doctor A Questions for Interview The following questions are related to the perception by staff during the implementation of any initiative or change in the hospital 1. Once a change (project or initiative) is introduced in the hospital what

instructions are given to the personnel? Well, it is variable because sometimes the necessary information is given and sometimes first the change occurs and then the information is given.

2. How do you see the preparation of the personnel (doctors, nurses, and

administrative staff) to implement projects or initiatives in the hospital? Certainly, the staff is highly trained and capable. 3. Can you explain your peers’ expectations when changes are placed in the

hospital? There are two aspects, uncertainty first and second every change generates reaction then it is accepted.

4. What do you (or your peers) like when management implements new programs in the hospital?

All changes are generally positive for the welfare not only internal but also for the external user, then that is fine but sometimes certain things don’t occur, for example the free lunch, clothing, that we don’t have at the moment.

5. What do you (or your peers) dislike when management implements new

programs in the hospital? When projects are imposed without previous consultation without first getting justification of what it is going to happen.

6. If projects or initiatives are not working as they were planned. How do the

personnel express their concern with those procedures? We only talk to the leaders, because we cannot go to the uppermanagement, and we usually can provide our suggestions, the correct way is to talk to the leader, the leader is who talk to the hierarchy, and the leader is encharged to talk for us in any meeting.

7. Can you please explain how is the participation of the personnel in the

implementation of changes (projects or initiatives) in the hospital? How do you think that project is improved? Well, each area has a leader, they are the ones who go to the meetings, but sometimes it is also good to hear from us, as you are doing, doing an interview with

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those who are working with the patient, for example there are some medicines that we use, and others that we do not use, we should get those according to the pathology and provide an excellent patient care.

8. Can you please tell me what are your expectations when a project is

executed? The changes that have been made, some are good, and all changes they always bring expectations, until one adapts to them and then they work. The following questions are related to the perception of staff after the implementation of a project.

The following questions are related to the perceptions of the personnel after the implementation of projects 9. Can you please tell me if any follow up is given to the initiatives

implemented in the hospital? Do you or your peers were requested suggestions from the management? Yes, they are done by the leaders, the leader is responsible for the socialization with the staff and the leader presents the results.

Leaders are presently responsible for certain areas, as they are called now, they are also responsible for the processes from all areas, now we also have expectations, the leader is responsible to meet us and socialize and to take the suggestions to upper management to see the improvements.

10. Can you explain me what are your expectations (or from your peers) after a

project or initiative is completed? Expectations are are always present, as I say, they are sometimes uncertainties but then they generate changes, some of them are positive changes, sometimes there are people who work in a function for several years, suddenly they are change, and it is good too, because then others learn.

11. In your opinion, what are the reasons that explain the failure or success of

initiatives implemented at the hospital? When they believe that they are only the people who knows, they not let others to participate, or don’t coordinate or socialize with other, they think that that is what must exist or to be done. It is very rigid. I wouldn’t say failure because they realized the change needed and they modify it.

12. After project is implemented, can you explain if the objectives of the project

are clear and measurable? Yes, sometimes, but when a project will be implement, the leader call for a meetings, but not always with the staff, but the leader has a meeting with the upper managers and they are who in turn transmit the changes to be made.

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Well it's like getting information to know that they are going to make this change, you are going to go to such a place, you are going to work this time and that's what is done. Sometimes we are not considered for the issues of schedule for example, suddenly you are going to work in the afternoon when you've done an agenda, this should be taken into account, for the new staff that are coming, they should be the most appropriate to start the new trial on this ground.

The following questions are related to the general experiences of the personnel in the hospital? 13. Can you please mention successfully implemented projects in the hospital?

Well this hospital have done several things, for example, before we had the outpatient services, in a place that was near to here, to the hospital. A process that was closing and we were able to close it, at least until this, this was equipped, fully built and it was done. There was also a project of the tents, we had a tent which was closed, but they are currently building. It became a process to gradually close it, and the success that was achieved was quite difficult. But what is at the moment successful, it is in primary care service. Patients are coming because this is a referral hospital. There is a lot to talk, because the project is is not what we want, it needs to be improve it. Patients continues to come, they want to reach our people, because patients rely on the staff of this hospital, and by the policies that are being developed. They closed by certain areas, like paediatric care and everything and everyone comes here because it will become the only hospital. Then, they want to take patients by reference. It will be problems, and then, this… I think that should be reviewed and see the best solution.

14. Can you please tell me about projects that gained the support and

collaboration of the personnel in the hospital? There have been many activities such as the staff training, as well as in human resources, computer courses, and all you have learned. Of course, they motivate, all these types of courses have been given. This change occurs in construction, in some places with better implementation, better infrastructure and all this motivates, we are waiting for new projects, such as parking because we do not have it. We saw a demo of that, of what will be done, and I think it will give long-‐term solution, to motivate, to be proud to be in that hospital. I think we need that kind of motivation, because I consider that this should be the first hospital in the country, that is my view, that should be done, we can do it, but I think many things are missing to achieve that success.

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15. Can you please comment of projects in which people felt unmotivated to participate and why? Of the projects that exist, almost not all personnel are involved, but they are at a higher level, but the motivation comes from the breach. For example, they don’t pay for lunch any more, which was previously paid up, now we have to pay for it and leave at the lunch time at our risk because there have been assassination attempts; there have been robberies in this sector. We are exposed because there is no security, there are reports of stolen vehicles and one has to park there, schedule changes that make the work of half an hour, they do not have food, we have clothes, we have aprons, and haven’t paid us, we retroactively issues by increases in fees that one has played or because they have some experience and climbing categorization, which is not paid to date, only a small part and the rest must be totally begging, called reserve funds that have more than 3-‐4 years are waiting and we are paid by here, and begins with the authorities and says "our finances, than here, and that the from here, "and we have every month and there is no concrete, no serious and require us to work, compliance and accountability, the authorities should also meet for one also feel satisfaction, that's the incentive, which one manifests, and good treatment to be given to internal staff as well.

16. Do you have any additional comments to add to this conversation?

There has not been much, I think it has been said that much has been established, should improve in some aspects to take into account not only the changes that come from sectors, but that models of other countries copied to where there is, I speak from experience I have been to several countries, and can fully enhance a predisposition of all, there is much pessimism, too much resistance, by defaults for things that do not exist, then that motivates one in something, one gives the same, but instead in the care of patients, that is excellent, one gives the best he can for their benefit and improve; there are models in Chile, in Miami, in administration, coverage, care must be implemented many other things, like we are here in a living room that is to interview, in other countries there recreation room for patients, there places where parents can eat. Because there are people who come from other places and do not have to eat, we sometimes have to make her something to collect. Yesterday I had the opportunity to present him $ 10 a lady, she was here, she had nowhere to go, she was with the same clothes, then gave her so she can eat. Here there is an established place, being built logically, but should be implemented in specific rooms for children to recreate, but not only this play, but audio-‐visual. In Miami there is that, there are the places where the breasts may also be prepared to bathe, are suitable places that should give better care. There isn’t a church or chapel suitable we are forgetting the main thing is God, in other countries, you find a list of doctors who are in hospital departments, when you ask for a doctor sometimes the guard did not know or know if you come to work, there is no information required and occur many times the user goes.

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We need more coverage, greater participation, that is a lot to do, not just infrastructure, could make a hospital of first, must be the best hospital in the country. It is possible, i think little miss, there is much to do but you can make change and can give reputation, the hospital must have a name, then there are private hospitals that have well put your name, they are very well positioned, all everyone says I'd rather go there, then here organize better and I think you can achieve success.

Thank you very much for your support and time.

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Appendix D Interview Spanish Version Manager A Las siguientes preguntas están relacionadas a la percepción del personal durante la implementación de cualquier iniciativa o cambio en el hospital. 1. Una vez que un cambio (proyecto o iniciativa) es introducida en el hospital.

¿Qué instrucciones se les da al personal en el hospital? Muchas veces se las da con instrucciones. Otras ocasiones se las da, pero no hay un flujo o no hay un esquema que seguir. La mayoría de las veces si, se dice, por lo menos para mi como responsable de un área me dan una información y me dicen esto se ha cambiado y usted tiene que avisarle a su personal. Que es luego lo que yo hago con ellos. Entonces si de da. Del 100% digamos que el 80% se da un procedimiento y el otro restante, 20% se va aprendiendo en el camino.

2. Como ve usted al personal (administradores, doctores, enfermeras y

personal administrativo) ser organizado y preparado para la implementación de alguna iniciativa en el hospital? Así mismo, a unos si, y a otros no. Hay personas que por ejemplo doctores que por ejemplo ahora estamos en las digitalizaciones. Ahora tienen que hacerlo todo con computadoras y no como era antes con recetas. Ya, manual, ellos. Hay algunos que si, están contentos. Dicen que es mas rápido. Que el proceso es mucho mas ágil. Que se puede hacer cosas mas ágilmente. Y su tiempo se optimiza mejor. Pero en cambio hay otros doctores que ellos no. Ellos dicen que la maquina nunca va a superar al medico. Que a veces. Y en parte tienen razón. A veces se cae el sistema, a veces esta lento. Entonces ellos dicen, si ven, por eso es que no deberíamos estar bien digitalizados. Yo hubiera dado mi receta mas rápido, hubiera mandado a hacer todo mas rápido. Tiene sus pros y contras. Si hay personal que esta de acuerdo y hay personal que no esta de acuerdo.

3. Cuales cree usted son las expectativas de sus compañeros cuando algún

cambio es presentado en el hospital? Negativa! Siempre es negativa. De hecho, yo puedo decir con mi persona. Mi personal atiende al publico. Y como es atención al usuario, por lo general son quejas. Siempre tenemos que resolver problemas. Entonces como no se pueden hacer contrataciones nuevas de personal, se han re-‐ubicados personas de otras áreas para este departamento. Son personas que ya tienen aquí como 20, 25 anos y ahora están trabajando en atención al usuario. Nunca han atendido al publico directamente. Recién lo están atendiendo y se encuentran con este choque de hay gente que les reclama, de que les tiene que solucionar y ellos no estaban preparados para esto y se molestan. Por lo menos mi personal el 50 % sino el 60 que son ellos, se encuentran reacios al cambio. Y hay unos que le va gustando en el camino y me doy cuenta que bueno, no es tan difícil. Porque para ellos es como humillante, es como de haber estado en oficina, venir a trabajar con el publico, para ellos es como un castigo. Pero hay otros que en cambio les gusta. En el camino les fue gustando. Que mas les toca. Pero hay otros que pueden estar dos meses y no cambian y siguen

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molestos por el cambio que les ocurrió. Si, se les nota al atender, se esconden. No quieren atender. Entonces, pero por lo general es negativo.

4. Que le gusta a usted o a sus compañeros cuando la administración

implementa algún nuevo programa en el hospital? Que me gusta! Me gusta cuando nos preguntan por áreas. Me gusta cuando van a hacer un cambio y preguntan al departamento antes de implementarlo. Porque nosotros estamos, como dicen mis compañeras, mis compañeros antiguos, donde las papas queman. Donde estamos con el usuario todos los días. Entonces me gusta cuando vienen y nos preguntan antes de implementar porque nosotros sabemos que esta sucediendo aquí abajo. Si vienen y nos preguntan, como nos parecería, como les gustaría. Eso me gusta. No me gusta cuando nos punen ya ciertas cosas establecidas y que a veces no van acorde con lo que nosotros trabajamos en realidad.

5. Que es aquello q a usted o a sus compañeros no le gusta cuando la

administración implementa algún nuevo programa en el hospital? Lo contado pues. Si me gusta que me tomen en cuenta, para los cambios. No me gusta lo que le decía. Que nos lo impongan. O que por ejemplo, a mi me dan persona, yo manejo personal. Como le dije, personal nuevo, personal antiguo que sí esta contento con la función nueva y personal antiguo que no esta contento. Entonces me dicen, pero si tu tienes tanto personal. Pero cuando uno maneja personal y tan, no es homogéneo, tengo de todo tipo de carácter. Si soy responsable y me delegaron la jefatura, por algo ha de ser, verdad. Entonces yo digo, bueno, a esta señora. Le doy un ejemplo, tengo una señora que ella se queja de que tiene unas varices porque ella tiene 50, 55 anos y que ya no puede caminar tanto. Entonces yo digo, bueno, si yo tengo un personal que atienda bien al usuario, que no vaya a estar con su mala cara todo el día, como voy a poner a una persona que no esta conforme en un lugar donde yo le estoy… que camine tanto tanto. Entonces para poderla hacer proactiva, que hago? La mando a un área de atención al usuario donde es mas pequeño el flujo y donde ella tendrá lapsos de tiempo para sentarse. Y también de pararse y ubicar a la personas. Yo veo a donde pongo a cada uno de mi personal. Por ejemplo, me dicen a donde, pero me dicen que tengo que rotarlas. Tengo el área de consulta externa donde es mas grande el área y yo tengo que decirle, mire, no hay cama para un paciente. Vaya a buscarme cama en todos los pisos. Yo no la voy a hacer caminar 5 pisos cuando tengo gente joven de este lado que yo le puedo decir, “vaya sáqueme una copia”, “necesito esto”, “vaya con el paciente a tal lugar”, “hábleme con este doctor para que me ayude con una consulta”. Entonces yo necesito gente que me camine rápido, que no me ponga mala cara ni que me diga todas esas cosas. Pero no me gusta cuando me dicen “porque tienes a esto no o lo otro?”. Deberían en lugar, de primero de decir sus ideas, de preguntar porque? Porque yo no lo hago de loca, sino porque yo analizo la situación mi personal. Se supone que esa es mi función cuando se habla del departamento. Ver a donde me conviene a tener a cada uno de ellos.

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6. Si los proyectos o iniciativas no van como se planeaba, como puede el personal expresar sus opiniones sobre dichos procedimientos o iniciativas? Si los proyecto o iniciativas en realidad yo creo que es con cada jefe, y el jefe que exponga sus ideas directamente a las autoridades. En realidad si. La manera en que me manejo yo, los chicos, las señoras y señores me expresan a mi sus ideas y sus inconformidades. Yo voy y las expongo ante mis jefes y el me dirá en que podemos cambiar y en que no podemos cambiar. Pero esto es de la apertura que el jefe le de a la persona. Otras áreas hay departamentos que no dan quizás apertura o ellos no dan las inconformidades de su personal, la verdad no los se. Pero yo si hablo con mi jefe.

7. Podría explicar como es la participación del personal en la implementación

de cambios (en proyectos o iniciativas) en el hospital? Como cree usted que el proceso podría ser mejorado? Bien, en realidad el personal ya en mi departamento, el que atiende al usuario, hemos tenido reuniones y hemos visto que podemos hacer entre nosotros y coordinar mejor las actividades y como coordinar. Si alguien va a faltar, a quien tenemos para cubrir. Y participamos, de hecho hasta para hacer los horarios entre todos. Para que no se vea que hay favoritismos para unos y hay una conversación para también atender. Cuando se tienen nuevos proyectos también a ellos se les llama o se les participa. Si ellos tienen alguna nueva idea y podemos hacer eso, también, también tenemos esa apertura. Si hacemos esas reuniones para hacer ese tipo de proyectos que queremos cambiar. Ellos también quieren participar. En este departamento si me pueden decir en que podemos colaborar. Si hay maneras de mejorar. Yo creo que debería de haber por ejemplo, implementado un día que todos los coordinadores deberían de reunirse con su personal y luego entre nosotros. Eso por ejemplo no existe. Nosotros nos reunimos entre nosotros y vemos como podemos cambiar, pero yo no me reúno con otros departamentos, a menos que necesite dentro de mi proceso nuevo hablar con el otro departamento. Como ayer me sucedió con emergencias que tuvimos un desfase con un paciente entonces en una reunión y entre nosotros coordinamos para coordinar para otra vez no nos ocurra lo mismo. Ahí si hay interrelación entre departamentos.

8. Cuando un proyecto es desarrollado o implementado, cuales son sus

expectativas o la del personal consideradas? Siempre las expectativas es de que funciones en el tiempo. Por ejemplo se cambio un proceso de laboratorio que las muestras de laboratorio ya no tenían que el resultado ya no tenia que llevarlo el paciente que antes lo cogía. El paciente iba: “hey aquí va el resultado” y era. Se implemento el proceso de que el paciente ya no tenia que ir con el resultado. Si no que ahora va un señor que se entrega los resultados de laboratorio donde este, en emergencia u hospitalización. Al principio fue caótico, la gente decía no: “la forma anterior estaba mucho mejor “, “ahí no se perdían” “no tengo que andar atrás del paciente”. La gente siempre ve primero lo negativo, y luego en el camino se da cuenta que hay mejoras. De hecho ahora ni siquiera es que lo ve el paciente en papel. Si no que ya lo tenemos en el computador o en el celular q ahora ya viene el resultado del examen. Si usted lo manda a su

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correo electrónico, le llega a su correo electrónico el resultado del examen. Este servicio se esta implementando. Al inicio todo lo consideran negativo, en el camino ven que las cosas si se están mejorando

Las siguientes preguntas están relacionadas a la percepción del personal después de la implementación de algún proyecto. 9. Se les da algún tipo de seguimiento en el hospital a las iniciativas

implementadas en el hospital? Se le pide a usted o el personal sugerencias de la administración después de la implementación? El seguimiento, yo creo que lo hacemos cada departamento. Por ejemplo yo estoy a cargo el traslado de cadáveres, la autorización para trasladar un cadáver fuera de la ciudad. Mi departamento esta a cargo de vigilar que el protocolo se cumpla. Ahora, si bien el proceso esta a cargo de otro departamento. Mi departamento como es 24horas el personal esta a cargo de vigilar que ese proceso se lleve a cargo. Cuando hay que hacer correcciones entre departamentos, por ejemplo. Justo tuve uno con trabajo social estábamos haciéndolo de una manera cuando vimos que la forma de mejorarlo, nos reunimos las dos áreas y coordinamos la corrección. Si coordinamos.

10. Podría indicar cuales son sus expectativas o la del personal después de que

un proyecto o iniciativa es implementada en el hospital? Negativas!!! Siempre es negativo por un lapso de tiempo. Hasta después de un lapso de tiempo. Somos personas de costumbres. Entonces es un tiempo que estamos negativos, todo mal, todo mal, todo vemos malo. Por ejemplo cuando dijeron: “vamos a poner computadoras para atender al usuario y dar las citas”. Yo recuerdo, yo he estado en todo el proceso de cambio. Yo trabajaba en estadística en ese momento y nuestra respuesta fue: “huy cuando se hará eso!”. Cuantos años faltaran para que traigan las computadoras para que todo lo bonito que nos dicen y fue rápido. Fue inmediato. O sea, la gente piensa, como estamos acostumbrados que los cambios se den lentos y se dan, a veces no se dan. Solo nos lo dicen y no lo hacen. Pero mire, hemos visto cambios inmensos. Como el que le digo, ahora ya tenemos estos livianos en los cuales estamos todos en red. Y también lo del laboratorio que le digo, mire. Se están dando los pasos, pero la gente es primero negativa, negativa.

11. En su opinión, cuales son las razones para que proyectos o iniciativas

fracasen o sean exitosas cuando se implementan en el hospital? La verdad que no. No tenemos por ejemplo una encuesta para ver si ha bajado X cosa o ha subido X cosa, parámetro no son medibles por ejemplo ciertos. Por ejemplo cuando se implemento el proyecto este de que nosotros somos un hospital de tercer nivel. Nosotros no podemos ver pacientes de primer nivel. Es decir, una gripe no puede ser atendida aquí. Estamos dejando de atender a un niño que si tiene una enfermedad una neumonía o algo mas grande. Antes se venia aquí por una gripe. Entonces esa implementación de que tiene q ir a su lugar de primer nivel y ya venir acá cuando ya es un caso que necesite, ahí. Primero fue negativo. Porque

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antes habían tantos consultorios de atención primaria que fueron quedándose, sacándolos, retirándolos de poco a poco hasta que hubo un momento en el que ya no hubo mas. Todavía tenemos a personas que vienen en emergencia por la atención primaria, pero tenemos un filtro que es el “triaje” que dice: “No mi amor, usted esta con gripe y tiene que ir a su centro de salud mas cercano a su casa”. Se le explica. Si es necesario darle la atención de emergencia, se le tiene que dar. Pero por ejemplo, ese proceso es medible. Porque estadística nos puede decir cuanto, tantas personas fueron atendidas de emergencia y se ve que bajo mucho la cantidad relacionada al ano pasado a este año. Ese tipo de proceso si es medible. Hay procesos que son medibles hay otros procesos que no.

12. Después que un proyecto se implementa, los objetivos que se esperan

obtener son debidamente explicados y medibles? El de laboratorio. Fue muy exitoso porque la persona, imagínese que me llegue el mensaje y que me digan que ya esta el resultado de mi examen y que lo pueda ver en mi casa. Si yo digo, no creo, si uno como madre quiere segundas opiniones. Ese, se que ahora lo van a implementar en imágenes. Imagino que como ahora estamos tan rápidos, eso ha de ser también pronto. Me parece exitoso esta área de consulta externa. A uno le da, siempre le da a uno gusto trabajar en este hospital por la categoría y el nivel del hospital y por el nombre del hospital. Hospital del Nino Francisco Icaza Bustamante, sino también porque uno viene a una infraestructura bonita. Uno viene a trabajar a una oficina que bonita. Antes era donde gavia un huequito. Entonces si, si me gusta. Como le dije, el que creo que es exitoso, uno es el de emergencia que deriva a sus pacientes a sus respectivas áreas cercanas a sus casas y el de laboratorio que me parece fabuloso.

Las siguientes preguntas están relacionadas a la experiencia en general del personal en el hospital. 13. Seria tan amable de mencionar proyectos que hayan sido implementados

exitosamente en el hospital? En el de donación de sangre. La campana de donación de sangre. Nosotros motivamos al personal para que haga sus donaciones. Aquí se hacen campanas trimestrales y el personal dona. Nosotros hacemos aquí en las afueras de consultas externas. Un DJ, se hace como un día de fiesta y es agradable. Porque las personas participan, vienen, cantan. O sea es un día bonito. Esa implementación fue muy buena. Es muy buena porque todavía las seguimos haciendo.

14. Podría por favor mencionar proyectos en que particularmente la gente se

sintió motivada en participar en el hospital? Bueno, en realidad por proyecto no. En lo que en realidad la gente se sintió desmotivada es por lo de la comida. Porque yo recuerdo que hace como 5 años, mas o menos, a nosotros .. yo trabajaba de 8 a 4 de la tarde. Pero como nos dijeron, bueno como a ustedes se les da el almuerzo, ustedes no trabajan de 8 a 4, pero de 8 a 4:30. Porque estamos pagando, estamos dando el almuerzo. Aquí mismo, teníamos

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un comedor y aquí nos daban de comer. Entonces bueno, la genta, dijo esta bien. Me dan mi media hora de almuerzo, me dan la comida y tenemos que devolver la media hora. Pero cuando ya vino, ya nos quitaron el almuerzo, desde diciembre o Enero, no recuerdo. Seguimos con la media hora de que tenemos que quedarnos. Nos quitaron el almuerzo, no es que nos lo pagan ni que me dan nada. Si me dan la media hora para ir a comer. Pero yo preferiría irme a las 4 de la tarde que tener que salir a comer.

15. Podría por favor mencionar proyectos en que particularmente la gente se

sintió desmotivada en participar en el hospital y que motivo el descontento? N/A 16. Tiene usted comentarios adicionales a esta entrevista?

Lo que yo podría comentar es que las personas aquí, el personal no toma las cosas seriamente. Tengo muchos compañeros que yo escucho, que hablan de sus inconformidades con las autoridades, con la autoridad de aquí, de este hospital. No solamente del presidente, sino de la autoridad de este hospital porque vino a poner mano fuerte. Quiso hacernos trabajar mas y hay personas que están acostumbradas a un ritmo de trabajo mucho mas suave. Entonces como que les costo. Pero solo hablan. Pero ahora que hay la oportunidad que pueden decir algo que no les parece la verdad que. No entiendo porque… porque tienen que expresarlo si cuando llega un momento en el que tienen toda la oportunidad de expresarse para que una autoridad superior escuchen sus ideas, escuchen sus inconformidades no lo hacen. En eso no estoy de acuerdo. Deberían que los que no están de acuerdo explicar y porque. Esa es mi interrogante. La idea de una persona que no esta de acuerdo no tiene valor. Porque en el momento que no la puede plasmar en una entrevista me parece entonces, como que ni ella misma se siente segura de decirlo.

how to transform the organizational culture of a service institution to create

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