Hudelson, Patricia M.

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International Journal for Quality in Health Care 2004; Volume 16, Number 5: pp. 345–346 10.1093/intqhc/mzh076International Journal for Quality in Health Care vol. 16 no. 5© International Society for Quality in Health Care and Oxford University Press 2004; all rights reserved 345EditorialCulture and quality: an anthropological perspectiveAnthropologists study culture. As a medical anthropologistinterested in the role of culture in health care, I have beenintrigued by the growing number of articles that point toorganizational culture as an important factor related to qualityof care [1]. What has most caught my attention are thediffering and sometimes conflicting views as to just what ismeant by ‘organizational culture’ and the best way to study it.Apparently one review cited 15 different definitions [2]. Inmuch of the literature I have seen, culture is defined as ‘an“attribute”, something the organization “has”, along withother attributes such as structure and strategy’ [3]. Cultureis seen as an independent variable that can be manipulatedthrough management interventions in order to achieve organ-izational goals.Research studies from this approach tend to reflect a posi-tivist stance, using structured instruments which pre-definethe institutional attributes of interest and explore the correlationbetween these attributes and the quality-related outcomes ofinterest. A number of studies have looked, for example, at therelationship between a ‘teamwork culture’ and quality-relatedoutcomes, such as hospital performance indicators [4], nurseturnover [5], and patient satisfaction [6]. However, as Scottet al. [7] point out, many of the studies that have suggested alink between culture and performance are methodologicallyweak and have difficulty defining and operationalizing culture.In addition, such studies contribute little to our understand-ing of how organizational cultures are created and communi-cated, and the mechanisms through which culture influencesperformance.Anthropology takes quite a different approach to culture.Most anthropologists would define culture as the shared set of(implicit and explicit) values, ideas, concepts, and rules ofbehaviour that allow a social group to function and perpetuateitself. Rather than simply the presence or absence of a parti-cular attribute, culture is understood as the dynamic andevolving socially constructed reality that exists in the minds ofsocial group members. It is the ‘normative glue’ [8] that allowsgroup members to communicate and work effectively together.It is an empirical question as to whether members of anorganization have a shared culture, and anthropologists havelong pointed out that in fact virtually all complex societies(including health care organizations) tend to have a number ofco-existing, overlapping and competing subcultures. In con-trast with studies that attempt assign cultural ‘typologies’ toorganizations, anthropological research would aim to identifygroups with shared cultural knowledge, and understand howsubcultures co-exist and interact within the larger organiza-tional environment.Anthropologists have traditionally used a qualitative researchapproach to study culture, and such an approach is well suitedto many of the complex questions confronting researchersinterested in quality and culture. More than just a set of datacollection methods, qualitative research is an approach whichseeks to understand events, actions, norms and values from theperspective of the people who are being studied (what anthro-pologists refer to as the ‘emic’ approach). It emphasizes contextand the ways in which features of a specific situation or settingimpact upon the phenomenon under study. Because qualitativeresearch tends to be flexible and iterative, it allows for thediscovery of unexpectedly important topics which may nothave been visible had the researcher been limited to a pre-defined set of questions or data collection methods.Identifying a group’s culture—that shared reference systemthat guides and is reflected in group members’ behaviour—is not a simple task, and requires a range of methodologicaltools. The classic form of qualitative research, with roots inanthropology and sociology, is often known as ethnographyor naturalistic enquiry. Ethnography is in fact, a researchstrategy that draws on a range of both qualitative and quanti-tative methods, and seeks to understand the ‘cultural lens’through which members of a group perceive their world. Thiskind of inquiry is most likely to be used when situations arenovel or complex and the researchers are not yet sure whatquestions to ask of whom. Examples of ethnography in healthcare include a study of clinical reasoning among haematol-ogists [9] and a study of the impact of managed care onclinical decision-making for mental health [10]. In this issue,Waring [11] reports on a qualitative study that explored thevalues, motivations and alliances that influence physicians’attitudes and behaviour towards incident reporting. The studysuggests the existence of professional subcultures whichpresent barriers to and opportunities for improving incidentreporting.Anthropologists also use a number of more structured datacollection techniques to study culture. The most commonof these techniques include free listing, pile sorts and rankorder methods [12]. These techniques produce numerical,quantifiable data but are included in the qualitative research‘toolbox’ because their purpose is to identify and analysecultural domains from the point of view of respondents.These methods have been used extensively in the field ofinternational health, but much less so closer to home. Culturalconsensus analysis is another method used by anthropologiststo identify groups with shared values, and which may beespecially useful to those interested in studying organiza-tional culture. Smith et al. [13] used this method to identifyEditorial: P. M. Hudelson346clinic subcultures with conflicting values that had potentialimportance for clinic operations.Culture is a complex and multi-faceted concept, and itsstudy requires conceptual models and research methods thatcan reflect this complexity and which acknowledge the exist-ence of multiple views and voices. Anthropology and qualita-tive research have much to offer those interested in cultureand quality, and I hope that more researchers in the future willbe motivated to apply these approaches to the understandingof organizational culture and its impact on the quality ofhealth care.Patricia M. HudelsonHôpitaux Universitaires de GenèveMédecine CommunautaireGenèveSwitzerlandReferences1. Davies HTO, Nutley SM, Mannion R. Organisational culture andquality of health care. Qual Health Care 2000; 9: 111–119.2. Brown A. Organisational Culture. London: Pitman, 1995.3. Scott T, Mannion R, Davies HTO, Marshall MN. Implementingculture change in health care: theory and practice. Int J Qual HealthCare 2003; 58: 111–118.4. Rondeau KV, Wagar TH. Hospital chief executive officerperceptions of organizational culture and performance. Hosp Top1998; 76: 14–21.5. Gifford BD, Yammuto RF, Goodman EA. The relationshipbetween hospital unit culture and nurses’ quality of work life.J Healthc Manag 2002; 47: 13–26.6. Meterko M, Mohr DC, Young GJ. Teamwork culture andpatient satisfaction in hospitals. Med Care 2004; 42: 492–498.7. Scott T, Mannion R, Marshall M, Davies HJ. Does organisa-tional culture influence health care performance? A review ofthe evidence. J Health Serv Res Policy 2003; 8: 105–117.8. Kropp R. The Importance of Organizational Culture. Advancedmanagement Services, Inc., USA: www.amsconsulting.com/ARTorgculture.htm 9. Atkinson P. Medical Talk, Medical Work. London: Sage Publi-cations, 1995.10. Ware NC, Lachicotte WS, Kirschner SR, Cortes DE, Good FBJ.Clinical experiences of managed mental health care: a rereadingof the threat. Med Anthropol Q 2000; 14: 3–27.11. Waring J. A qualitative study of the intra-hospital variations inincident reporting. Int J Qual Health Care 2004; 16: 347–352.12. Weller S and Romney AK. Systematic Data Collection. NewburyPark, CA: Sage Publications, 1988.13. Smith CS, Morris M, Hill W et al. Cultural consensus analysisas a tool for clinic improvements. J Gen Int Med 2004; 19:514–518.

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