Much like organizational leadership and worker support have been central to the improvement of workplace safety through the creation of a "culture of safety" among American companies, the creation of a "culture of health" is not likely to succeed without leadership and worker engagement. Workplace culture may be regarded as a somewhat elusive concept for many companies and may be remarkably difficult to measure. It also needs to be recognized that a workplace culture, which exists at any and all organizations, is not necessarily a culture of health. As such, Edgar Schein, Ph.D., defines culture as "a pattern of shared basic assumptions that was learned by a group as it solved its problems of external adaptation and internal integration, that has worked well enough to be considered valid and, therefore, to be taught to new members as the correct way to perceive, think, and feel in relation to those problems" (6, p. 17). In other words, as groups evolve over time, they face two basic challenges. First, to integrate individuals into an effective whole; and second, to adapt effectively to the external environment to survive. As groups identify solutions to these problems, they actively engage in a collective learning experience that allows for the creation of a set of shared values, assumptions, and beliefs that is then referred to as "culture." Shaping the thoughts, values, and beliefs of a group of people brought together in the context of the workplace into a pattern of shared basic assumptions that is conducive to health in all its dimensions is the challenge for organizations that pursue a culture of health. Pursuit of this challenge is typically a reflection of the organization's interest to achieve excellence, not mediocrity, in business performance (5).
TOWARD A FORMAL DEFINITION OF CULTURE OF HEALTH
When we consider the notion of culture as defined by Schein (6) and apply it in the context of health, we have to consider how it supports both individual and population health while supporting the marketplace performance of the business. A culture of health will address issues related to worker job fulfillment, work and family balance, worker performance, and team performance, among others, and do so by providing a supportive environment in which both workers and the company can flourish. When these ideas are pulled together succinctly, a culture of health may be formally defined as "a workplace ecology in which the dynamic relationship between human beings and their work environment nurtures personal and organizational values that support the achievement of a person's best self while generating exceptional business performance" (5, p. 224).
Given this definition, a culture of health represents the interaction between personal values, organizational values and norms, and business performance. The relationship among these factors is depicted in the Figure. These are, of course, broad concepts that are supported by more specific components. Let's take a look at a set of important components related to cultures of health.
COMPONENTS OF A CULTURE OF HEALTH
In Table 1, a set of components is identified and briefly described. These components may be regarded as a set of attributes that has associated thoughts and beliefs that eventually shape behavior of individual employees and the group as a whole. Whereas this list is by no means ranked, leadership is positioned at the top of the list for a reason. Leadership and culture are closely associated but may be considered two sides of the same coin; neither is understood by itself, yet they are closely connected. Cultural norms will determine how a given organization will define leadership. A good example of this is represented in who will get promoted and who will attract the attention of others who follow. Leaders, on the other hand, arguably are the ones who create and manage the workplace culture. Ultimately, this is what differentiates leadership from management - leadership creates and changes culture, whereas management and administration act within a culture. When components or elements of an organizational culture have become poorly suited to the company's situation and threaten the business performance aspects of being competitive in its marketplace or create a negative impact on overall health indicators of the workers, the function of the company's leadership at all levels is to recognize and address this situation. Hence, leadership and culture are clearly intertwined but separate concepts.
CAN A CULTURE OF HEALTH BE MEASURED?
Several good examples of measurement approaches have been described in the literature. At General Mills (2), employee attitudes toward health improvement programming that were described as being representative of a "culture of health" were measured using an employee questionnaire. The questionnaire consisted of a core set of health value questions, along with several demographic questions and an open-ended comment section. Results of the survey demonstrated a quantifiable method to measure health values consistent with a culture of health.
Golaszewski and colleagues (3) tested an organizational health culture audit and found it to show acceptable reliability and validity. Their data support the use of instruments that measure a culture of health and suggest that such cultures are indeed multidimensional.
A very different approach to measuring and changing the culture of an organization was deployed by Home Depot. The blueprint for culture change at Home Depot included a focus on four mechanisms: metrics encouraging desired new behaviors, programs strengthening managers' support of the new strategy for growth and change, processes to change and sustain the new culture, and structures eliminating inefficiencies (1). Results of this approach included a doubling of earnings per share from 2000 to 2005 and an increase in the number of employees who began recommending Home Depot to friends as a place to work.
DOES A CULTURE OF HEALTH MATTER?
Culture provides directions to the company and its employees by influencing behavior so that organizational goals and objectives can be accomplished. A culture of health emphasizes the health of the worker, creates processes and structures to support management and workers in achieving health-related objectives, and provides access to resources to reduce health risks and optimize function and performance. Several essential strengths associated with an organizational culture approach include (4):
* focusing attention on the human side of organizational life
* making clear the importance of creating shared meaning to help people work together toward desired outcomes
* requiring members-especially leaders-to acknowledge the impact of their behavior on the organization's culture.
So, does a culture of health matter? The degree to which a shared culture of health is accepted throughout the organization is an important attribute in considering to what degree a culture of health truly matters. Shared cultures can have a profound impact on the organization. When a shared culture of health is pervasive across the organization, accepted widely, and highly valued by employees, then such a culture tends to have greater potential to adapt to change, be cooperative in nature, be respectful, and be innovative, customer focused, strategic, resilient, and productive.
However, we also must recognize that our own perceptions, thoughts, beliefs, and feelings are culturally determined and affected. Can we accept our own cultural assumptions and see them for what they are? Our struggles of learning and change may be painful and involve mental and emotional fatigue, but yet as leaders in shaping the culture of health across an entire organization, the worksite health practitioner carries this flag without question. We ought not to forget that cultural understanding and learning starts with self-insight.
ADDITIONAL INFORMATION AND RESOURCES
Some resources that may be of interest for further learning and reference are outlined in Table 2.
1. Charan R. Home Depot's blueprint for culture change. Harvard Bus Rev.
2006 (April); Product No. 4079:1-12.
2. Crimmins TJ, Halberg J. Measuring success in creating a "culture of health." J Occup Environ Med
3. Golaszewski T, Hoebbel C, Crossley J, Foley G, Dorn J. The reliability and validity of an organizational health culture audit. Am J Health Studies
4. Morgan G. Images of Organization
. Thousand Oaks (CA): Sage Publications; 1997.
5. Pronk NP, Allen CU. A culture of health: creating and sustaining supportive organizational environments for health. In: Pronk NP, editor. ACSM's Worksite Health Handbook
. 2nd ed. Champaign (IL): Human Kinetics, Inc; 2009. p. 224.
6. Schein E. Organizational Culture and Leadership
. 3rd ed. San Francisco (CA): Jossey-Bass; 2004. p. 17.