A Managerial Intervention to Strengthen the Healthy Organizational Culture in Major Health Care Facilities of Sri Lanka

LACS Dahanayake1*, A Jasinghe2 and HHDNP Opatha3

1Senior Registrar in Medical Administration, Institute of Medicine, University of Colombo, Director of Research (former), Education, Training and Research Unit, Ministry of Health, Nutrition and Indigenous Medicine of Sri Lanka, Visiting Research Fellow, The University of York, Heslington, The United Kingdom

2Director General of Health Services, Ministry of Health, Nutrition & Indigenous Medicine of Sri Lanka, Sri Lanka

3Department of Human Resource Management, Faculty of Management Studies and Commerce, University of Sri Jayewardenepura, Sri Lanka

*Corresponding Author:
LACS Dahanayake
Senior Registrar in Medical Administration
Postgraduate Institute of Medicine, University of Colombo
Director of Research (former), Education, Training and Research Unit
Ministry of Health, Nutrition and Indigenous Medicine of Sri Lanka
Visiting Research Fellow, The University of York, Heslington, The United Kingdom
Tel: 07464266903
E-mail: [email protected]

Received date: January 12, 2019; Accepted date: January 29, 2019;; Published date: February 5, 2019

Citation: Dahanayake LACS, Jasinghe A, Opatha HHDNP (2019) A Managerial Intervention to Strengthen the Healthy Organizational Culture in Major Health Care Facilities of Sri Lanka. Health Syst Policy Res Vol. 6 No.1: 79.

Copyright: © 2019 Dahanayake LACS, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Introduction: Healthy Organizational Culture of a health care facility is a reflection of the patient safety level. The major health care facilities in Sri Lanka are very complex organizations with massive health care workforces. Therefore, strengthening the healthy organizational culture is a challenge to leaders of major hospitals of Sri Lanka.

Objectives: To evaluate the effectiveness of an intervention in strengthening the Healthy Organizational Culture of National Hospital of Sri Lanka

Methodology: The newly designed Eight-Point Conflict Management Interventional Program was implemented at the level of Nursing Leaders of NHSL and effectiveness was tested through pre and post surveys among simply randomised control and experimental groups.

Results: There is a significant increase in the perceived level of Healthy Organizational Culture among Nursing Leaders in an experimental group following the intervention.

Conclusion: The newly designed Eight Point Conflict Management Program is successful in strengthening the healthy organizational culture of the NHSL and it can be recommended to apply in major health care facilities following feasibility studies.


Healthy organizational culture; McGregor’s theory X and theory Y; The consideration and initiation spectrum; The leader-subordinate relationship; Assertiveness; Transactional analysis; Negotiation skills


Hospitals are high-risk organizations as they deal with life and death of human beings around the clock. The purpose of existence of a hospital is to cure patients with its optimal capacity while ensuring patient safety. Therefore, a healthy organizational culture is a significant prerequisite to ensure patient safety processes in a hospital setup. A healthy organizational culture treats employees of the organization as one of the most necessary recourses and attempts to enhance employees' wellbeing. Motivated, happy, productive health care worker is a key determinant of error-free, certain, efficient patient care services. Therefore, it is evident base reporting that patient safety culture can easily be built upon by well-developed, sustainable, healthy organizational culture [1-3].

There are three major dimensions of healthy organizational culture; the level of leaders’ attitude orientation about subordinates (Douglas McGregor’s Theory X and Theory Y), the degree of leaders’ Consideration and Initiating spectrum and the leader-subordinate relationship. Leaders are supposed to have appropriate attitudes about subordinates, to exhibit an optimal level of both Consideration and Initiation behaviours, and to maintain a strong superior-subordinate relationship to build a healthy organizational culture in their entity [4,5].

In general, there are two major mechanisms that leaders can use to embed a culture; primary embedding mechanism and secondary embedding mechanism. Above all, leaders’ conflict management competencies determine the state or degree of healthy organizational culture of an organization and hence it is a major primary embedding mechanism [6,7].

The objective of this Research project is to study the effectiveness of a newly designed conflict management interventional program for enhancing the healthy organizational culture of Nursing Heads in the National Hospital of Sri Lanka [8-10].


As far as this interventional study is concerned, a conflict management program plays a significant role in creating right competencies within the unit of analysis that is individual level: nursing head in respect of conflict management. If leaders have right competencies of conflict management, they understand that dysfunctional conflicts need to be avoided; subordinates need to be valued; getting things done with subordinates and through subordinates collaboratively is indispensable and engage in actions that will avoid or minimize the occurrence of dysfunctional conflicts. Thus, the conflict management program, which is expected to be developed under this study, is considered as the independent variable while healthy organizational culture is considered as the dependent variable [11-13].

The study area selected for this research project is National Hospital of Sri Lanka (NHSL). National Hospital of Sri Lanka is the biggest tertiary care center in Sri Lanka as well as South East Asia. The study population in this research project is nursing heads as the study was conducted by using control and experimental groups (Figure 1).


Figure 1: Representation of the cause-effect relationship between dependent and independent variables of the research project


This study consisted of four main stages.

During stage 1

The working definition of HOC was formulated, and The HOC Description Questionnaire consisted of 3 main dimensions, and 30 sub-dimensions were developed. The Perceived level of HOC of Nursing Heads was assessed as the pre-interventional survey using this study instrument.

During stage 2

The key leadership competencies concerning conflict management and three dimensions of HOC were identified, the gaps of these competencies were measured using eight point competency index test, and the intervention was designed to fill the identified gaps of given competencies. The methods used to design included the best possible intervention literature review, Delphi technique among subject experts, key informative interviews with Chief Nursing Officer and Nursing Sisters, Focal group discussions among unit leaders and experts’ opinions. Then the Manual on Eight Point Conflict Management Program for nursing leaders was written, and implementation plan consisted with preparing action plans, arranging logistics, preparing workshop agenda and budgeting workshops were finalized [14-18].

During stage 3

The control and experimental groups of nursing heads in NHSL Sri Lanka were separated by simple randomization. Then only the experimental group was exposed to a series of newly designed Leadership Skill Building Workshops based on the newly written manual. The total number of working hours was 22 (Table 1).

Point Principle / competency Applications/ Skill Builders/ Tools/ Techniques
Point 01 Assertiveness Assertiveness Inventory
DESI Model
Assertiveness game
Pictorial analysis
Point 02 Five Styles of Conflict Management Conflict Management Style Index
Techniques to apply conflict management styles in working place
Role play on the understanding link between assertiveness, cooperation and effective conflict management techniques
Point 03 Negotiation Skills Steps to achieve integrated negotiation
Strategies to negotiate with labour unions
Negotiate with peer leaders in implementing new projects
Negotiate with subordinates in grievance settlements
Role play on ethics in negotiation
Classic story   
Point 04 Transactional Analysis Exploring own ego status
Apply change model to embed the Adult ego status
Role play- Life Positions
Demonstration-complementary transaction, crossed transaction, ulterior transaction
Pictorial display-Relationship between life positions, ego status and conflict management style
Sharing latest workplace conflict and replay with the application of transactional theory
Point 05 Patience and Tolerance Explore the Patience and Tolerance Index
Role Play- "There is no limit for the patients."
A classic story about patience 
Point 06 Empathy Traits of an empathetic leader
Emotional Intelligence
Self-evaluating tool for empathy
Critical Incident 
Point 07 Changing People without arising Resentment Apply nine recommendations of Carnegie to Workplace
Point 08 Ten Commandments of Human Relations Skill builder: freezing- unfreezing model to embedded ten recommendations in leaders
Total Working Hours - 22 hours of a nursing head.

Table 1: Brief illustration of key elements of newly designed eight- point conflict management program for strengthening healthy organizational culture of major health.

Care facilities-stage 4

Post-interventional surveys, the last stage (stage 4) of the study was conducted by reapplying the HOC Description Questionnaire and competency index to both experimental and control groups following this intervention package.


The quantitative measures of pre and post-interventional survey exhibit that there is a significant improvement of percentages of the higher levels of HOC, such as good and strong in the experimental group after the intervention. However, the levels of control group were poor or low during the study period (Table 2).

Study Group Perceived Level of the strength of the parameter Dimensions of Healthy Organizational culture Level of the Perceived level of Healthy Organizational Culture
Leader’s attitude orientation toward theory Y Leaders behaviour between Consideration and Initiation Spectrum The degree of Leader-  Subordinate Relationship
Number % Number % Number % Number %
Before Intervention
Experimental Group   Poor 20 43.48 18 39.14 19 41.30 22 47.80
Low 15 32.62 17 36.96 11 23.91 12 26.10
Satisfactory 9 19.56 9 19.56 14 30.43 10 21.70
Good 2 4.34 1 2.17 1 2.17 1 2.20
Strong 0 0.00 1 2.17 1 2.17 1 2.20
Total 46 100 46 100 46 100 46 100
Control Group Poor 19 41.30 17 36.96 21 45.65 21 45.60
Low 16 34.78 18 39.14 9 19.56 11 23.90
Satisfactory 10 21.70 8 17.39 14 30.43 11 23.90
Good 1 2.17 2 4.34 1 2.17 2 4.40
Strong 0 0.00 1 2.17 1 2.1 1 2.20
Total 46 100 46 100 46 100 46 100
After Intervention
Experimental Group Poor 3 6.52 2 4.34 1 2.17 2 4.40
Low 3 6.52 4 8.69 1 2.17 2 4.40
Satisfactory 10 39.14 9 19.56 10 21.70 10 21.70
Good 18 39.13 18 39.13 22 47.82 20 43.50
Strong 12 26.09 13 28.26 12 26.09 12 26.10
Total 46 100 46 100 46 100 46 100
Control Group Poor 20 43.47 18 39.13 21 45.65 19 41.30
Low 12 26.09 14 30.43 11 23.91 13 28.20
Satisfactory 8 17.39 10 21.74 9 19.56 9 19.60
Good 5 10.87 3 6.52 3 6.52 4 8.70
Strong 1 2.17 1 2.17 2 4.34 1 2.20
Total 46 100 46 100 46 100 46 100

Table 2: Frequency distribution of level of perceived level of healthy organizational culture and its dimensions before and after the newly designed Eight Point Conflict Management Interventional Program by experimental group and control group of nursing leaders in HSL.


There is renewed interest in policymakers, health care managers and practitioners in the importance of developing organizational cultures in health care settings. Culture is a representation of values, beliefs and styles of employers, main stakeholders, employees of an organization [19-21].

Hospitals are high-risk organizations, where culture should ensure the quality and safety of patient care. Therefore, the survival and growth of hospitals rely on policies and practices towards strengthening towards best matching organizational cultures. The healthy organizational culture is the best suitable culture for the major curative center’s where leaders have to manage and maintain shared leadership styles with professionals, especially clinical experts. HOC is the fundamental culture that values human resource as the most critical assets of the organization [11,22]. Toxic organizational cultures are organizational cultures in which people feel that they are not valued and Healthy organizational cultures are ones in which people feel that they are valued [3]. HOC has dignity and critical importance given to employees in the organization by being the opposite of toxic organizational culture. HOC treats employees of the organization as the most important resource (at least one of the most important resources) and attempts to enhance employees’ wellbeing [23-25].

This study identified the multidimensional quantitative measurements to determine the level of HOC. This HOC Description Questionnaire consists of 3 main dimensions and 30 sub-dimensions, and it measures the leaders' perceived level of HOC of major curative settings [26-28]. The intervention package consisted of dimensions toward strengthening leadership competencies of leaders in curative setups; directors, clinical consultants and nursing leaders. Assertiveness, Five Styles of conflict management, Negotiation skills, Transactional analysis, Patience and Tolerance, Empathy, changing people without arising resentment and Ten commandments of human relations are the identified best possible competencies to develop HOC [29-31].

The study was conducted at the biggest tertiary care institute of Southeast Asia; National Hospital of Sri Lanka at the randomised controlled environment. The study population was limited to nursing leaders of the hospital due to time, technical and financial constraints.

The results showed a significant level of improvement of all three dimensions of HOC; leader's attitude orientation toward theory Y, leaders' behaviour towards consideration and initiation spectrums and the degree of leader-subordinate relationship. The computed value for satisfactory, good and excellent levels of HOC has improved from 26.1% to 91.3% following the intervention. The intervention took place within twenty-two working hours of the experimental group [17,32-34].

Conclusion and Implication

This interventional study was a success story of enhancing organizational culture among nursing leaders in The National Hospital, Sri Lanka. This framework can be adapted and researched in any other major health care institute. Further, medical administrators and clinical leaders are the other study groups to be targeted and tested.

The manuals had been developed to implement all eight competencies under the intervention. Those can be adapted to developing leadership curium of curative sector leaders following feasibility studies to establish the much healthier culture in the hospitals.

Further research should be developed to understand the values, attitudes and human relationship factors contributing to strengthening healthy organizational culture. The studies consisting of both quantitative and qualitative methods will fill the gaps seen in quantitative studies [35-37].


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