Despite its capacity to arouse vigorous debate, the concept of organizational culture (OC) has grown in popularity since it was introduced in the 1980s by Edward Schein, a professor at the Massachusetts Institute of Technology Sloan School of Management. OC is often seen as a fundamental determinant of company performance,1 and although discussions around OC originated in the general business management sphere, research and anecdotal evidence suggest it also plays a crucial role in the performance of healthcare.2 If management literature considers OC to be part of the fabric of an organization’s daily operations, it would seem logical to suggest that EMS is also influenced by OC.
Although this article introduces some key components of OC and applies them to ambulance companies in New Zealand (N.Z.), many of the principles are applicable to international EMS organizations.
What is OC?
Despite much talk about OC and its inextricable links with organizational behavior, it’s hard to find two people able to give the same definition as to what OC actually is. Without a clear idea of what OC is, it’s difficult to truly understand the subject, and to devise ways in which aspects of OC within a company could be improved.3
Just as French, Spanish, Arabic and American cultures each have their own way of doing things, organizations such as Microsoft, McDonald’s or Google each has their own distinct culture. These different cultures embody a certain personality, philosophy, ideology or climate that gives each company their unique identity. A working definition of OC is “the shared values, beliefs, and norms which influence the way employees think, feel, and act towards others inside and outside the organization.”4
OC can be considered as “the way things are done around here,”5 and the link between an organization and its culture is the same as that between an individual and their character.6 Culture comprises a multitude of hidden things that affect employees’ behavior within a company, and, although it may be true that leaders can influence a firm’s culture, it must also be remembered that culture can influence and shape leaders. The leadership of an ambulance service may be the result of a culture, rather than being the cause. Paramedics and their managers are both responsible for the existence, development, and in some cases change, of OC within their own organization. This may then affect OC within other ambulance companies as they try to emulate a culture that is perceived as “good.”
Model of Culture
Schein’s model of culture divides OC into three distinct levels:
1) artifacts; 2) espoused beliefs and values; and 3) basic underlying assumptions.7 A good way to think about it is to visualize an iceberg. (See Figure 1.) Much of the things that comprise OC lie beneath the surface in organizations and are unseen by the casual observer.
Level 1: Artifacts
Also thought of as “surface manifestations,” artifacts are the observable culture of an organization, and can be broken down into four main categories:
1. Organizational stories and legends. Organizational stories increase commitment to the organization, although it’s unclear which stories are best at doing this.8 In N.Z., St. John provides ambulance services for the majority of the country, with Wellington Free Ambulance (WFA) servicing Wellington—the capital—and its immediate surroundings. The fact that the history, stories and legends of the two organizations are different may point to a difference in culture.
The Order of St. John dates back to the Crusades in the 11th Century, and has a history in N.Z. since 1885,9 and its roots still lie firmly in Christianity. However, amid the current political climate, this history may promote mixed feelings among some current ambulance staff, who either have no religious affiliation or who are Muslim—the very people being fought by the Christians during the Crusades. These staff members are unlikely to fully identify with some of the stories and legends that underpin the organization as a whole, which may result in an “us vs. them” culture.
In contrast, WFA started in 1927, and was initiated purely on the grounds of transporting sick and injured patients from one place to another.10 Crudely put, this means there’s no historical baggage like St. John has. This could be seen as either a positive or a negative: Positively, staff may be unfettered by the religious and organizational history that St John has. Negatively, WFA doesn’t have the grand history that St. John has, meaning there’s no richness of history from which to draw inspiring stories to help unify and motivate staff. Whether or not the differences in history between the two organizations promotes a difference in overall culture is really conjecture that would need to be substantiated by further research.
2. Rituals and ceremonies. Rituals are “the programmed routines of daily organizational life that dramatize the organization’s culture,” whereas ceremonies are more formal, and can be thought of as “planned activities conducted specifically for the benefit of an audience.”11
Meal breaks are a ritual and ceremony within N.Z. paramedicine that continues to draw attention from management, staff and unions. As population density increases, particularly in metropolitan areas, so too does the number of calls for an ambulance. Despite these increases, there hasn’t been a corresponding increase in the number of ambulances and paramedics, which simply means existing staff are having to attend more and more calls during their shift.
Even in parts of Auckland, by far the biggest city in N.Z., paramedics who may have been called out 3–4 times during a night shift 15 years ago, are now busy for the whole night attending incidents. This increase in workload creates a difficulty for management trying to enforce guidelines around regular meal breaks. From their side, communication centers are struggling to meet key performance indicators to keep ambulance response times under a certain threshold; and meeting these targets is a requirement under the contractual terms agreed with the government and district health boards.
If meal breaks are erratic, or not granted at all, research from the nursing sector suggests that ambulance crews are more susceptible to injury, cardiovascular disease and mental health issues.12 The same research also points out that affording staff regular breaks increases social engagement and promotes healthy eating.
Although the issues around regular meal breaks are echoed in ambulance services worldwide, there’s still variability within a single service. For example, the difference in workload between some cities and rural areas will mean that ambulance crews in rural areas tend to get more downtime that their metropolitan colleagues. This then has the potential to create a different work environment and culture depending on the locality that crews operate.
3. Language. Referring to the form and manner in which employees within an organization communicate with each other, language also affects OC and vice versa.4 Not only does language relate to technical aspects of a job, but also to the general manner in which employees converse with each other.
In paramedicine, dark or off-color humor is often used by staff as a coping mechanism for dealing with the stresses of working in a frontline ambulance, and swearing is often a part of that humor. Although the use of profanity in normal conversation is traditionally considered ill-mannered, some authors take a more liberal view by suggesting that it has more to do with the context of use than the actual words spoken.13 Interestingly, studies have found that swearing in the workplace can boost morale and create solidarity among colleagues.14 Because of this, management are advised to be more permissive towards the use of foul language.
4. Physical structures and symbols. Rather than simply being by-products of an organization, physical structures and symbols are visible and physical manifestations of organizational life, and can help shape perception and behavior of staff and clients.15
One very visible symbol of paramedics in N.Z., as with most other countries, is the wearing of uniform when at work. The main uniform of St. John paramedics comprises green utility pants, a green short-sleeved shirt and black leather boots. Paramedic uniforms help members of the public and other emergency services personnel easily identify paramedics. It provides a professional image to the public and can instill pride among those who wear it. Although all frontline paramedics at St. John wear the same uniform, shoulder epaulettes denote clinical qualification level and/or organizational rank. Regardless of whether staff are attending an incident or chatting in the coffee room on station, this creates an obvious hierarchy that may influence OC.
Although the use of profanity in normal conversation is traditionally considered ill-mannered, studies have found that swearing in the workplace can boost morale and create solidarity among colleagues.
Level 2: Values
Being both explicit and implicit, values guide how employees go about their work and respond to situations.16 Values determine how employees behave. However, there’s often a gap between those values that a company formally espouses and the ones that actually pervade an organization. After all, words are simply that—words. It’s the behaviors and actions of the employees that reflect actual values. In the modern world, values are normally found in vision and mission statements and included on company websites. For example, St. John lists their values as:
1. We do the right thing—Whakaaro Tika
We take responsibility. Make the tough calls. Think of others.
2. We stand side by side—Whakakoha
We respect, value and support what others contribute.
3. We make it better—Whakawerohia
We find solutions. Step up, own it, do it.
4. We have open minds—Whakahangahanga
We listen openly. Encourage ideas. Welcome feedback.
5. We are straight up—Whakapono
We act with honesty, courage and kindness.
It’s not the words written, but how they’re written that can convey company values. The fact that the Maori language has been used next to the English phrases reflects St. John’s desire to be seen as culturally sensitive.
Values contained in mission statements provide a point of difference from other companies and can be used to drive competitive advantage. In terms of where values originate, company founders normally inject their own philosophies and senior management teams act as “cultural carriers” that pass values to the next generation of executives.17 However, it can be difficult for a culture to form in companies with a staff retention problem. High staff turnover can breed distrust among employees, have a negative impact upon organizational learning and productivity, and create a distinct culture all of its own. This is especially relevant to ambulance services in modern times that struggle to keep up with the high numbers of staff leaving paramedicine altogether.
Level 3: Basic Assumptions
The third and final level of culture is also the deepest and most difficult to change, and comprises ideas and beliefs that are so ingrained that people tend not to confront or debate them. These basic assumptions might include such things as the basis on which individuals are respected, or who gets to make department/company decisions. When managers try to affect change, it’s this last level of culture that can provide a barrier. For example, a company might espouse and pursue the value of collaboration among its employees, but stumble in its aim if assumptions about status and power within the firm make staff uncomfortable with voicing their ideas.
The way ambulance services are delivered internationally is changing. There’s often a stark contrast between many modern systems and the traditional ambulance role of simply transporting the sick and injured to the hospital as quickly as possible. Increased knowledge and skills of paramedics, combined with financial pressures of international health systems, mean the potential for delivering advanced care and treatment has been greatly enhanced. However, culturally, this requires a thought shift, both from paramedics and patients.
Paramedics who’ve been in the job a long time and have grown used to transporting most of their patients to the hospital have had to get used to the more modern system of ambulance care in which recommendations may be made to the patient that they don’t in fact need to go to the hospital at all. On the patient side, this can seem disconcerting, since many people aren’t aware of the knowledge and skill of many modern paramedics, and presume it’s their right to demand transport to hospital.
Another example of basic assumptions might include the thought within paramedicine that as a 24/7 emergency service, regular breaks during a working shift are considered a luxury. However, ongoing research into the health and wellbeing of health workers reveals that not only are regular breaks a nicety, not having them is a contributing factor in adverse health issues of staff.12
In N.Z. and other countries, legislation around driving hours limits the number of consecutive work hours paramedics can work before the ambulance company is obliged to enforce a mandatory rest break. Although this is to help protect staff and members of the public, managing these enforced breaks creates an added resourcing difficulty for the ambulance dispatchers. Despite these problems, this is an example of how legislation can influence culture, performance and efficiency. This can be positive, in the sense of trying to maintain safety, but also negative, in the sense that there may be fewer ambulances to respond to incidents if a crew is stood down for an enforced rest break.
Paramedicine has evolved greatly over the last several decades. With this evolution has come increased workloads, paramedic stress and burnout, and clinical and operational errors—some leading to the tragic death of patients, paramedics or both. In the United Kingdom, Canada, Australia and New Zealand, paramedic staff morale is low and the number of paramedics leaving the profession is on the rise. Although some sources allude to external contributing pressures such as population growth,18 others highlight internal problems such as workplace bullying.19
Regardless of whether the influences are internal or external, exploration of OC within paramedicine may uncover common themes that, once brought into the wider conscience of ambulance management, hold the key to increasing levels of positivity within paramedicine. In simple terms, paramedics who are happier and more content would surely be more likely to provide optimal patient care than disgruntled, burned-out paramedics.
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