Relationship between Health Care Organizational Culture and Professional Nurses' Autonomy

Background : In the professional field of health care, organizational culture has been positively associated with elements of organizational performance and professional autonomy of nurses that contribute to the quality of services, such as nursing care, job satisfaction, patient and personnel safety, personnel turnover rate, and change of management process. Aim of the study: Examine the relationship between health care organizational culture and professional nurses' autonomy at Hosh Issa Central hospital, El-Beheira Governorate. Research design : A descriptive correlational research design was used. Setting : all inpatient care units (n=11) at Hosh Issa Central Hospital, El-Beheira Governorate. Subject: All head nurses and their assistants (n=22) and all staff nurses (n=267). Tools: Two tools were utilized Tool I: Organizational Culture Questionnaire. Tool II: Professional Nurses’ Autonomy Scale . Results and Conclusion : there was a positive correlation between total autonomy and its dimensions nursing practice environment, patient care management and educational back ground (r=0.934 p=0.000, r=0.975 p=0.000 and r=0.967 p=0,000 respectively), a positive correlation between total organizational culture and its internal and external focus dimensions namely empowerment (r=0.892 p=0.000), team orientation(r=0.937 p=0.000), patient focus (r=0.963 p=0.000),organizational learning (r=0.954 p=0.000), and finally vision (r=0.818 p=0.000). There was a positive correlation between total organizational cultures, internal and external focus dimensions and total autonomy. Recommendations : hospital administrators should: Build strategy makes staff nurses empowered and integrated which makes them involved in the work, develop system work to team up and collaborate to bring the group's basic ideals to life.


Introduction
Organizational culture was defined as a set of specific behaviors, rules, or norms, which members believe they should adopt to survive and work within such an organization.These behavioral patterns can be productive or not and can lead to behaviors and attitudes that determine how the members approach their work and interact with each other (Haller., Berends, & Skillin, 2018).Simply stated organizational culture is "the way things are done around here ( Deal , Kennedy ., 1982).Organizational culture is classified into internal and external focus, which internal focus consists of six areas: empowerment, team orientation, capability development, core value, agreements, and coordination and integration.The external focus of the organizational culture includes six areas; creating change, customer focus, organizational learning, strategic direction and intent, goals and objectives, and vision (Denison , 2011).However, the hospitals' organizational culture may be conflicts with the practice of professional nursing, adversely affecting patient outcomes, the nurses 'autonomy and the ability to practice professionally (Labrague.,McEnroe-Petitte, & Tsaras,.(2019).
Autonomy is an essential element of professional status (Porter-O'Grady, & Clavelle,.2020).Autonomy is defined as; the freedom to make independent decisions on behaves of patients, but in their interests, independently and without hindrance (Pedrosa, Sousa, Valentin, & Antunes, 2021).Professional autonomy is a vital element for health care professionals and an important aspect of a healthy and positive nurse work environment (Lee, & Jang, 2020).(Pedrosa et al. 2020) defined professional autonomy as; the practice of one's occupation following one's education, with members of that occupation governing, defining and controlling their own activities in the absence of external controls.
According to (Chandra, 2004).professional autonomy is classified into structural autonomy and attitudinal autonomy.Structural autonomy exists as it required that professional individuals use their judgment to assess or evaluate the provision of patient care in the context of the job requirement.It is classified into three components namely; practice environment of the organization, managed care, and educational background (Jones, 1998).

Significance of the study:
Unfortunately, nursing is undergoing pressure in many countries.It's common to learn that nursing positions have been reduced and replaced by non-nursing, generic workers, or that nurse-to-patient ratios are climbing.So, the support of nurses to ensure that their work environment not only allows them the autonomy of practice but also appropriate resources to do their job well is important.Moreover, the culture of a health care organization has a powerful characteristic that affects particularly hospital nurses' work environment and enhances hospitals' ability to adapt to environmental change (Aghamohammadi,., Dadkhah, & Aghamohammadi,.2019).Moreover, professional nurse autonomy is an essential attribute of a discipline striving for full professional status.Also, it is a complex, multidimensional concept that may be affected by the organizational culture of the work environment, one's beliefs, life experiences and socialisation.So, additional research is needed to clarify the concept and its value.It is hoped that this study will investigate the relationship between professional nursing autonomy and organizational culture.

Aim of the Study:
To examine the relationship between health care organizational culture and professional nurses' autonomy at Hosh Issa Central hospital, El-Beheira Governorate.

Research Question
What is the relationship between health care organizational culture and professional nurses' autonomy at Hosh Issa Central hospital, El-Beheira Governorate?

Research design
A descriptive correlational research design was used in this study.

Setting
The study was conducted in all inpatient care units (n=11) at Hosh Issa Central Hospital.It is divided as follows: 1-Medical units and their specialties (n=5) namely: general medical unit, obstetric unit, pediatric unit, burn unit, and hemodialysis unit.2-Surgical units and their specialties (n=3) namely: general surgical unit, an operation unit, an orthopedic unit.3-Intensive care units (n=3) namely: General ICU, neonatal ICU, and emergency unit.

Subjects
Two groups were included in this study: All head nurses and their assistants, (n=22).All staff nurses, who work in the previously mentioned settings (n=267).

Tools of the study
Two tools were used in this study : It is developed by ((Denison ,D., 2011).to assess health care organizational culture.It consists of 60 items classified into two main subscales; internal focus contains 30 items and external focus contains 30 items.Responses were measured on Likert scale with five points, Ranging from; 1= strongly disagree to 5 strongly agree The scoring levels were arranged as follow; less than 60% for negative perception, from 60% to less than 75 % for neutral perception and > 75% for positive perception Tool (2): Professional Nurses' Autonomy Scale: It is developed by (Elkasas ,2017) (11)  to determine professional nurses' autonomy.It classified into two main domains and it consists of 45 items.Responses will be measured on 4-points Likert scale, ranging from; 1= very unlikely happen to 4= very likely happen.The scoring system was categorized as low professional nursing autonomy = (45-89) score, average professional nursing autonomy = (90-134) score, and high professional nursing autonomy = (135-180) score.
In addition, a demographic datasheet will be developed by the researcher.

II-METHODS
1-An approval to carry out this study was obtained from the Dean of Faculty of Nursing Damanhour University and the responsible authorities of the study settings, at Hosh Issa Central hospital, after an explanation of the study aim.
2-Tool I and tool II were translated into Arabic by the researcher and were submitted in both Arabic and English languages to a five jury consist of experts in the field of the study to test its translation and content validity.Accordingly, the necessary modifications were done.
3-Reliability of the two tools were assessed by using Cronbach's Alpha test.
4-A pilot study was conducted on (10%) of head nurses (n=2) and staff nurses (n=27), to ensure the clarity and feasibility of the study's tools and to identify obstacles and problems that may be encountered during data collection.5-Data were collected from the study subjects at the previously mentioned setting (n=22) head nurse and (n =276) staff nurse.They were asked to fill the questionnaires independently, and it took about 30 minutes to be filled.Data collection took a period of three months ranged from the beginning of April 2021to the end of Jun 2021.

Ethical consideration :
• The research approval was obtained from the ethical committee at the Faculty of Nursing Damanhour University • An informed written consent was obtained from the study subjects after explanation of the aim of the study.• Privacy and right to refuse to participate or withdraw from the study was assured during the study.• Confidentiality regarding data collected were maintained.

Statistical analysis:
The collected data was revised, categorized, coded, computerized, tabulated and analyzed using Statistical Package for Social Sciences (SPSS) version 25.0.Reliability of the tool was determined by Cronbach's alpha and presented in descriptive, and association forms.

:
Table 1 Table (1) shows that more than two fifth (42.5%) of the nurses were working in intensive care units, while more than one third (36.7%) of them were working in medical units (20.8%) of them were from surgical units.Regarding their age, it ranges from 22 to 55years with a mean of 31.9±8.794years.More than half (51.6) of the nurses aged from 20 to less than 30 years, while around one tenth (9.7%) of them aged 50 years and more.

Discussion:
Regarding demographic characteristics of the study subject, the total number of staff nurses who shared in this study was 289 nurses from three units at the selected hospitals at Hosh Essa Hospital which were available during data collection.Concerning the nurses' age, about half of them aged from 20 years to less than 30 years, while those aged from 40 years to less than 50 years.
The nurses' scores of perceptions of internal focus organizational culture dimensions, were the highest score in the core values and the lowest score in capability development while the total internal focus of the nurses showed a positive perception.This result may be attributed that in an effective organizational culture, the staff nurses clearly understand, share, and stand for their organization's core values.
This finding is in opposition to a study by (Salem., Baddar., Putri., Mohamad., & Bassiouni, 2012) who demonstrated that physicians' and the nurse' scores were low with a statistically significant difference between total mean score of the perception of organizational culture, the four elements of the performance unit effectiveness and individual well-being dimensions of the organizational performance.The results of studies by ( Skela Savic and Pagon 2008) and (Rouhi-Balasi., Elahi., Ebadi., Jahani., & Hazrati,.2020)as they demonstrated that the physicians and staff nurses had a negative perception.They also indicated that staff nurses' work setting did not provide career advancement opportunities, and the skill mix was often inadequate.
Regarding the distribution of staff nurses according to their perceived level of internal focus on organizational culture; the results of the present study showed more than two-thirds of the nurses had a positive perception of capability development.From the researcher's point of view, a strong organizational culture will exert more influence on nurses than a weak culture.Therefore, if the organizational culture is strong and supports high ethical standards it will have a powerful and positive influence on staff development.These results agree with the results of (Bahadori., Hamouzadeh., Qodoosinejad., & Yousefvand,.2012). in their study which confirmed that nurses got the highest mean score related to the knowledge transfer and integration capability, and after them, systems perspective capabilities.
Regarding empowerment, coordination, and integration, the present study found that staff nurses had more than three-quarters of a positive perception about them.From the researcher's point of view, this result is due to effective organizational culture when nurses are empowered and integrated which makes them informed and involved in the work that they do which has a positive impact on the organization.As regards empowerment as an element of organizational culture, this result is consistent with (Kamel & Aref 2017) who found the highest percentage of studied staff nurses agree on nurse believes that he \ she can have a positive impact.Moreover, (Lundy, 2014) stated that nursing encompasses autonomous, coordinating, integrating, and collaborative care of individuals of all ages, families, groups, and communities sick or well and in all settings.This may be due to the nurses are the major assets of the hospital with different specializations, educational qualifications and work experiences that contribute effectively to a successful organization.So, the nurses have trust in their effective role in the hospital.Furthermore, (Wagner, Cummings, Smith, Olson, Anderson, & Warren, 2010).mention that the organizations can be successful when they are aware of the relationship between healthcare organizational culture and nurses' empowerment and can encourage their nurses to be empowered.Additionally, (Mendoza-Serra Orgambidez-Ramos,ALeon-Jariego,2019) point out empowered nurses are more satisfied with their work, committed and effective at work.

Concerning to the present study results
showed that the majority of the nurses had positive perception regarding team orientation, core values and agreement.The majority of the nurses had a positive perception concerning total internal focus.This result agreement with the result of (Körner., Wirtz., Bengel, & Göritz, 2015). in their study which showed that There is a high correlation between organizational culture and teamwork, which it can support teamwork.Organizational culture support teamwork relationship of organizational culture, teamwork, and job satisfaction in interprofessional teams.In an effective organizational culture, the nurses clearly understand, share, and stand for their organization's core values this according to the study done by (Flamholtz and Randle, 2016).(Tewodros 2016) mentioned that the effective organizational culture work to make the group's core values into reality through teamwork and cooperation.Moreover, (Givens ,2012)noted that in an effective organizational culture, employees behave in a way that is consistent with the core values.
Regarding the external focus dimensions in the present study results, it was found the nurses got the highest mean score in the organizational learning dimension.From the researcher's point of view, the staff nurses need scientific knowledge to improve decision-making and skills regarding the patients care and how to implement it for achieving a high-quality care for patients and families.The pervious result is agreed with study done by (Kamel & Aref ,2017) which revealed that the highest mean score of studied staff nurses' perception was related to organizational learning.This result is agreed with (Taylor, Lillis, & Lynn.2015).who stated that educational preparation for staff nurses, and lifelong learning has become a major issue of nursing to enhance health care services and staff nurses themselves.Also, the present study result was consistent with (Catheirne, 2011) who conducted study about ''continuing education a personal responsibility'', he stated that the learning for nurses enhance the quality of patients care that receive from nurse and enhance service delivery.
With respect to the external focus dimensions, it was found that nurses got the highest mean score in the creating change in the result of present study.From the researcher's point of view the staff nurses in the setting of the present study are constantly searching for and applying updated information to improve the patient's health care, with the encouragement of the hospital and to develop plans for improving their skills and inform them of what is new.This result too, is consistent with (Bharthvajan, 2014) who conducted study about ''organizational culture and climate''.He stated that the nurses show a strong resistance to the change in policies or procedures, but technological changes easily accepted because they improve the working conditions of the nurses and make them able to work with less strain and it would be more compatible and flexible for a nurse to understand.In addition, (Bahrami, Kiani, Montazeralfaraj, Zadeh, & Zadeh, 2016).supports this result who found that organizational learning acts as a mediator in the relationship of organizational intelligence and organizational agility.Also, organizational learning has a statistical relationship with organizational agility with a positive perception.
But the pervious result inconsistent with (Spetz, Burgess, & Phibbs, 2012).who conducted study about ''what determines successful implementation of inpatient information technology systems?''.They stated that the challenging of managing change in health care facilities and innovative technologies often incite resistance from nurses who already cannot find enough time to complete patient tasks in their shift.Also, they find lack of cooperation among staff, fear of using new technique appear when implementing a change in procedure.Additionally, (Kamel & Aref, 2017) showed in their study that the lowest mean score was related to creating change.Also, this result is inconsistent with (Gurková, Zeleníková, Friganovic, Uchmanowicz, Jarošová, Papastavrou, & Žiaková,.2020).who indicated that the majority of nurses had a negative perception for change.And (Farzi, Farzi, Taheri, Ehsani, & Moladoost. 2017).stated that among the dimensions; the highest scores were observed in creating change and patient focus.While the lowest scores belonged to the dimensions of strategic direction and intent.
According to the score of nurses' perception of structural autonomy in the present study; revealed that educational background of staff nurses was the first dimension of structural autonomy according to the mean percent score, came next the patient care management and nursing practice environment.While the total structural autonomy gave a high mean percent score.The researcher's attributed that to the fact that the higher level of education and thinking for staff nurses, lead to a higher level of their thinking, and more developed and professional, they become more ease in understanding the organizational structure and implementing development plans in more accurate.This result is consistent with study was done on staff nurse at Minia University Hospital by (Marzouk & Isamil .2019)who revealed a positive nurses' perception of structural autonomy.
Too, a studies was done by (Alshaikh, Diab & El-Kholy 2021) and (Ashtari & Bellamy.2021) who revealed that the majority of studied staff nurses had moderate perception of structural autonomy.And a study by (Khalaf & Adam .2018)who mentioned that, about half of the studied nurses had high score of perception structural autonomy.While this result of the present study was inconsistent with a study was done at Benha University Hospital by (Mohamed,El-Demerdash and Hasanin.2021) who demonstrated that more than two -fifth of staff nurses had a low perception level about professional nursing autonomy.
In relation to the distribution of nurses according to their level of structural autonomy, according to nursing practice environment in the present study, it was revealed that, more than one tenth of the nurses had a low level, while more than one quarter had a high level of nursing practice environment.Moreover, less than half of the nurses had a high level of patient care management.Furthermore, less than half of the nurses had a high level of educational background of staff nurses, while less than one fifth of them had a low level.Additionally, more than two fifths of the nurses had a high level of total structural autonomy.This result is consistent with (Ambani, Kutney-Lee and Lake.2020) who found that the studied participants had low level of nursing practice environment of the public hospital.According to (Cheng, Cui, Chen, Liu, Zhang, & Hu.2020).it was confirmed that the studied subjects had a moderating effect of nursing practice environment.Too, the study by( Molina-Mula & Gallo-Estrada .2020)confirmed the same results as their studied subjects had a perception of attitudinal autonomyautonomously, with the advice of professionals.Furthermore, this result of the present study is in line with the studies by ( Kim, Lee and Kim 2020) and (Grešš , Anna , Ľubomíra , Dagmar , Ľubomíra 2021) who confirmed that the studied staff nurses got a high level of educational background.
The present study revealed that a high mean score of the staff nurses' perception of attitudinal autonomy and a high level of attitudinal autonomy.This result was agreed with the studies by (Aghamohammadi, Dadkhah and Aghamohammadi, 2019) and (Perry, Richter and Beauvais.2018)as their results showed that the staff nurses reported a moderate level of autonomy.But this result is inconsistent with (Kaya & Karaca, 2018) who found that two thirds of staff nurse had low level of patient care management.

Conclusion
Based on the findings of this study it could be concluded that: that there was a positive correlation between total autonomy and its dimensions nursing practice environment, patient care management and educational back ground, and a positive correlation between total organizational culture and its internal and external focus dimensions.

Healthcare organizations directors should:
1-Build strategy makes staff nurses empowered and integrated which makes them involved in the work.2-Develop system work to team up and collaborate to bring the group's basic ideals to life.
3-Conduct regular and periodic meeting with staff nurses taking into account their suggestions for future development plans and fostering a positive workplace.

Staff nurses should :
1-Updating their knowledge to improve decision making and skills regarding the patients care.
2-Sharing suggestion and ideas with first line nurse managers to improve level of autonomy in the hospital.

3-
Provide creative suggestions for ways to enhance communication at the nursing units.

Table 4
reveals that educational back ground of staff nurses was the first dimension of structural autonomy according to the mean percent score 74.07%(29.63±7.264),followed by patient care management 69.02% (30.37±6.881),and nursing practice environment 66.98% (34.83±8.855).While, the total structural autonomy mean percent score was 69.73 % (94.83±22.036).