Culture

The original CFIR had extensive elaboration on Culture, including a general description of culture concepts and a more in-depth description of one concept of culture, the Competing Values Framework (CVF). Broadly, culture includes the norms, values, and basic assumptions in a setting (Gershon et al., 2004). Culture is often viewed as relatively stable, socially constructed, and subconscious (Martin, 2002). However, culture is not defined consistently in the literature (Gershon et al., 2004) and many definitions exist for culture (Martin, 2002). Some researchers have a relatively narrow definition of culture, while other researchers incorporate nearly every construct related to the Inner Setting. Culture and climate can be interchangeable across studies, depending on the definition used (Martin, 2002). One review identified 54 different definitions for organizational climate (Gershon et al., 2004).

Often, change efforts are targeted at visible, objective aspects of an organization that include work tasks, structures, and processes. Despite variation in use and definition, culture has been shown (Helfrich, Li, et al., 2007; Shortell et al., 2001) or theorized (A. Kitson et al., 1998; Rycroft-Malone, Kitson, et al., 2002) to have significant influence on implementation effectiveness. One explanation for why so many implementations fail centers on the failure to change the less tangible organizational assumptions, thinking, or culture (van Eijnatten & Galen, 2002). Individuals within a setting impart organizational culture to new members, and culture influences how people within a setting relate to one another (also see Relational Connections) and their work environment (Helfrich, Li, et al., 2007).

The CVF was originally developed by Quinn and Rohrbaugh (Quinn & Rohrbaugh, 1981) and has been used in healthcare (Shortell et al., 2001) and in the VA (Helfrich, Li, et al., 2007). It is an example of a “variable definition” approach to culture: a quantitative measure that purports to capture key aspects of the complicated dynamics of culture. Often measures of culture are elicited from senior leaders in the organization – not from non-supervisors. The CVF characterizes organizations along two dimensions, each representing a basic challenge that every organization must resolve to function effectively. The first set of competing values is the degree to which an organization emphasizes central control over processes versus decentralization and flexibility (see also Structural Characteristics: Work Infrastructure. The second set of competing values is the trade-off between focus on its own internal environment and processes versus the external environment and relationships with outside entities. Four archetypical organizational cultures arise: 1) team culture (high internal focus with high flexibility (aka personal)); 2) hierarchical culture (high internal focus with high control (aka formalized and structured)); 3) entrepreneurial culture (high external focus with high flexibility (aka dynamic and entrepreneurial)); and 4) rational culture (high external focus with high control (aka production oriented)) (Helfrich, Li, et al., 2007; Shortell et al., 2001). These “archetypes” are not mutually exclusive. In one study, CVF culture was not found to be influential in the number of evidence-based practices used by healthcare organizations (Shortell et al., 2001). Formalization is negatively associated with innovation because of lack of flexibility and/or low acceptance of new ideas (Damanpour, 1991) and can foster continuance of status quo (Klein et al., 2001). A “balanced” culture with respect to the CVF (how close organizations are to 25-25-25-25% on each of the four archetypical quadrants using a Herfindahl-type measure) contributes to perceptions of team effectiveness and the number of changes implemented (though not the depth of change) (Shortell et al., 2004).

Qualitative coding guidelines that are aligned with the Updated CFIR will be added in the future.

Regarding quantitative measurement of this construct: In a systematic review of quantitative measures related to implementation, Powell et al. identified 21 measures (Powell et al., 2021). Using PAPERS criteria of measurement quality with an aggregate scale ranging from -9 to +36 (Lewis, Mettert, Stanick, et al., 2021), the Organizational Social Context – Culture Scale (Glisson et al., 2008) had the highest score of 11 followed by the Organizational Description Questionnaire (Parry & Proctor-Thomson, 2001) with a score of 9. Thirty-six measures were also identified for organizational climate. Of the 31 measures that were scored, The Texas Christian University Program Training Needs Survey (Simpson, 2002) had the highest score of 13, followed closely by The Organizational Social Context—Climate (Glisson et al., 2008) with a score of 12, and The Organizational Climate Measure (Patterson et al., 2005) with a score of 9. Results indicate the need for continued development of high-quality measures.

As we become aware of measures, we will post them here. Please contact us with updates.

Damanpour, F. (1991). Organizational Innovation: A Meta-Analysis of Effects of Determinants and Moderators. The Academy of Management Journal, 34(3), 555–590.

Dorsey, C. N., Mettert, K. D., Puspitasari, A. J., Damschroder, L. J., & Lewis, C. C. (2021). A systematic review of measures of implementation players and processes: Summarizing the dearth of psychometric evidence. Implementation Research and Practice, 2, 263348952110024.

Gershon, R., Stone, P. W., Bakken, S., & Larson, E. (2004). Measurement of Organizational Culture and Climate in Healthcare. Journal of Nursing Administration, 34(1), 33–40.

Helfrich, C. D., Li, Y.-F., Mohr, D. C., Meterko, M., & Sales, A. E. (2007). Assessing an organizational culture instrument based on the Competing Values Framework: Exploratory and confirmatory factor analyses. Implementation Science: IS, 2, 13. https://doi.org/10.1186/1748-5908-2-13.

Kitson, A., Harvey, G., & McCormack, B. (1998). Enabling the implementation of evidence based practice: A conceptual framework. Quality and Safety in Health Care, 7(3), 149–158. https://doi.org/10.1136/qshc.7.3.149.

Klein, K. J., Conn, A. B., & Sorra, J. S. (2001). Implementing computerized technology: An organizational analysis. Journal of Applied Psychology, 86(5), 811–824.

Lewis, C. C., Mettert, K. D., Stanick, C. F., Halko, H. M., Nolen, E. A., Powell, B. J., & Weiner, B. J. (2021). The psychometric and pragmatic evidence rating scale (PAPERS) for measure development and evaluation. Implementation Research and Practice, 2, 263348952110373. https://doi.org/10.1177/26334895211037391.

Martin, J. (2002). Organizational culture: Mapping the terrain. Sage Publications.

Quinn, R. E., & Rohrbaugh, J. (1981). A Competing Values Approach to Organizational Effectiveness. Public Productivity Review, 5(2), 122. https://doi.org/10.2307/3380029.

Rycroft-Malone, J., Kitson, G., Harvey, B., McCormack, K., Seers, A. T., & C. Estabrooks. (2002). Ingredients for change: Revisiting a conceptual framework. (Viewpoint). Quality and Safety in Health Care, 11(2), 174–180.

Shortell, S. M., Zazzali, J. L., Burns, L. R., Alexander, J. A., Gillies, R. R., Budetti, P. P., Waters, T. M., & Zuckerman, H. S. (2001). Implementing evidence-based medicine: The role of market pressures, compensation incentives, and culture in physician organizations. Medical Care, 39(7 Suppl 1), I62-78.

Shortell, S. M., Marsteller, J. A., Lin, M., Pearson, M. L., Wu, S. Y., Mendel, P., Cretin, S., & Rosen, M. (2004). The role of perceived team effectiveness in improving chronic illness care. Med Care, 42(11), 1040–1048.

van Eijnatten, F. M., & Galen, M. (2002). Chaos, dialogue and the dolphin’s strategy. Journal of Organizational Change Management, 15(4), 391–401.