Assessing organizational social context in surgical domains: perspectives of nursing staff and first-line nurse managers and their associations with nurse-focused outcomes
- Open Access
- 02.03.2026
- Research
Erschienen in:
Abstract
Introduction
Global healthcare systems are facing major challenges, particularly the shortage of nursing staff [1]. Public healthcare organizations play a critical role in adapting to these evolving demands [1], while organizational culture and climate are proving to be key factors influencing organizational attractiveness [2] and workforce engagement [3]. Previous research has examined organizational culture and climate in healthcare organizations primarily in relation to organizational functioning, performance, quality of care, and work environments [4‐9]. However, empirical evidence on how organizational culture and climate relate to nurse-focused outcomes, such as sickness absences and gross turnover, remains more limited.
Surgical care is characterized by a high degree of complexity and interdependence within healthcare organizations [10]. Work in surgical settings requires continuous coordination across professional roles, as well as effective communication and role clarity [11]. In such settings, organizational culture and safety climate have been identified as particularly relevant for staff functioning and patient safety [10, 12]. Nevertheless, existing research in surgical care has predominantly focused on patient safety-related processes [10‐13], while nurse-focused outcomes have received considerably less attention.
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Organizational social context as a theoretical framework
The social context of an organization consists of both organizational culture and climate, which together shape the behavior of employees [14]. Organizational culture and climate are multi-layered concepts integral to every healthcare setting. Glisson defines organizational culture as the shared values, beliefs and norms within an organization that form the basis for decisions and practices [15]. Organizational climate is defined as the collective perception of employees of their work environment, which is shaped by the prevailing culture [15]. In addition, interactions among group members are considered one of the most important determinants of organizational climate [16]. The evolving nature of organizational values and norms and their impact on current organizational dynamics have been highlighted [17]. The two concepts are conceptually separate but interconnected [15]. Bitsani underscores the interaction between culture and climate, pointing out that culture influences the interactions that produce organizational climate [16]. In this study, organizational culture and climate are understood in accordance with Glisson’s definitions [15] in the context of public healthcare surgical settings, as perceived from the different positions of nursing staff and first-line nurse managers. They are conceptualized as analytically distinct but interrelated components of organizational social context and are examined separately while interpreted within a shared theoretical framework.
Outcomes related to the nursing workforce are understood to be influenced not only by nursing practice but also by the broader organizational environment in which care is delivered [18‐20]. Within this broader conceptual framework, nurse-focused outcomes include employment-related indicators such as sickness absence and turnover [21]. Previous research has hypothesized associations between organizational context and nurse-focused outcomes as well as organizational functioning [e.g. 22]. From a theoretical perspective, such outcomes can be examined through the organizational social context framework, as organizational culture and climate shape work-related interactions and behavioral norms that may be relevant for nurse-focused outcomes [15].
Previous empirical evidence on organizational social context and nurse-focused outcomes
Previous research in healthcare suggests that organizational social context may be associated with nurse absenteeism, although direct evidence remains limited. Among hospital personnel, including nursing staff, organizational psychological climate has been shown to influence sickness absence mainly indirectly through its associations with job satisfaction, with lower satisfaction predicting higher absenteeism [23]. However, a meta-analysis by Gohar et al. found no clear association between job satisfaction and sickness-related absenteeism [24]. Complementary evidence from the Finnish public sector suggests that ethical aspects of organizational culture are relevant, as a strong ethical organizational culture has been associated with fewer sickness absences at the individual level, although not at the work unit level [25].
Associations between the organizational social context and nursing staff turnover have also been reported, although empirical evidence on actual turnover remains more limited than that on turnover intentions. Systematic reviews indicate that organizational culture is an important determinant of turnover intentions among nursing staff [26], with similar patterns observed in the broader organizational literature, including healthcare contexts [27]. In hospital nursing settings, organizational culture has been associated with nurses’ turnover intentions both directly and indirectly. Cultures characterized by relationship- or innovation-oriented features are associated with lower turnover intentions [28, 29], whereas hierarchy- or task-oriented cultures are linked to higher intentions to leave [29]. Several studies further suggest that these associations may not be direct but mediated through work-related factors. In particular, organizational culture has been linked to turnover intentions through organizational commitment [30], job stress, general fatigue [31], change-related fatigue and burnout [32]. Evidence on actual nurse turnover is more limited but broadly consistent with these findings: in long-term care settings, market culture has been associated with higher turnover rates, while group and hierarchical cultural values have been associated with lower turnover in specific nursing staff groups [33].
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In addition, more positive organizational climates have been associated with lower turnover intentions indirectly, with organizational commitment acting as a mediating factor [34]. Other research suggests that organizational climate, together with emotional labor, may influence turnover intentions through a chain mediation linking organizational justice and turnover intention [35], or by buffering the negative effects of job stress on employees’ intention to stay [36]. In addition, specific climate dimensions such as reward and physical comfort have been associated with lower turnover intentions [37].
Despite evidence linking organizational culture and climate to nurse-focused outcomes, the relationship between organizational social context and nursing staff gross turnover remains insufficiently understood. The interplay between organizational social context and nurse-focused outcomes is likely complex and multidimensional. Accordingly, organizational culture and climate may shape nurse-focused outcomes such as sickness absenteeism and gross turnover, while nurses’ collective behaviors may, over time, also contribute to changes in the organizational environment.
Aim of the study
The aim of this study is to analyze the perception of organizational culture and climate by nursing staff and their first-line nurse managers in the surgical domains of public healthcare organizations and to examine how these perceptions differ from each other. Furthermore, it will be analyzed how these perceptions and possible discrepancies correlate with nurse-focused outcomes such as sickness absences and gross turnover. The study also aims to analyze how the contextual characteristics, the unit size and the care setting, influence the relationship between the organizational social context and the aforementioned nurse-focused outcomes.
The study will address the following research questions:
1.
How do the nursing staff and their first-line nurse managers perceive the organizational culture and climate in surgical units, and how do these perspectives differ from each other?
2.
How do the organizational culture and climate correlate with nursing staff sickness absences and gross turnover?
3.
How do the differences in the assessments of the organizational culture and climate between nursing staff and their first-line nurse managers correlate with nursing staff sickness absences and gross turnover?
4.
Do unit size and care setting moderate the associations between the organizational culture and climate and nursing staff sickness absences and gross turnover?
Methods
Study design and sample
This study employed a descriptive cross-sectional design to examine organizational culture and climate and their associations with nurse-focused outcomes in surgical care settings. The reporting of this study was guided by the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) checklist for cross-sectional studies [38].
The cross-sectional survey data were collected from November 2020 to February 2021 (4 months) in the surgical domains of Finnish public healthcare organizations selected from geographic regions with similar populations that comprehensively represent the entire country. The original power calculations were conducted for a related but not identical analytical setup to that adopted in the present study [39, 40]. These calculations informed the estimation of an adequate number of individual respondents. Based on these calculations (mean difference = 1; standard deviation = 0.8; power = 0.95), a sample size of approximately 210 respondents was considered sufficient at the individual level.
Within the selected organizations, a census approach was applied at the unit level, aiming to include all eligible units within the surgical domains. Units with fewer than four nurses were excluded from data collection due to the instrument’s requirement for studying group phenomena. Within the included units, all eligible nursing staff and first-line nurse managers were invited to participate.
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Data collection
A unit-specific invitation to participate in the web-based survey was sent by email to first-line nurse managers. They then distributed the survey to the nursing staff. Each participant received a personal invitation to the survey, which they completed independently. In addition, first-line nurse manager groups were formed based on the domain of the organization, with the surgical unit managers of the organization forming a group together. The questionnaire instructed the respondents to select the response options that best reflected their personal opinions. First-line nurse managers were asked to assess the social context from their personal perspective, not just from the perspective of the unit(s) they manage. The researcher informed all first-line nurse managers of this distinction. This was considered important, as the social context for first-line nurse managers extends beyond the units they manage; they form a group with their colleagues, interacting both with their peers and with the next level of management.
The analytical sample was formed through the following steps. The structured survey was originally sent to 76 units, which were identified as having more than four nurses per unit. Responses were received from 74 units, but only 62 (81.6%) of those provided the required minimum of four nursing staff respondents. In addition, one organization’s surgical domain did not meet the criteria for the number of first-line nurse manager respondents. From the qualifying groups, a total of 841 individual responses were received. Subsequently, respondents with more than 10 missing responses (n = 12) were removed from the data. This threshold was applied in accordance with the guidelines provided by the instrument developer for handling missing responses.
Based on the rWG index values, one respondent was removed due to markedly divergent responses. Given the small group size, this single divergent response resulted in an rWG value that was not meaningfully interpretable. As a result, this one group included three members instead of the intended four, which was accepted because sufficient internal consensus was indicated after the removal (rWG ≥ 0.70).
The participating organizations provided data on examined nurse-focused outcomes, including nursing staff sickness absence and turnover rates, obtained from HR administration records at the unit level for the same period in which the survey was conducted. The analysis included the units that responded to the survey. However, for two organizations, it was not possible to provide data on sickness absences and gross turnover according to the specified criteria, so these organizations were excluded from the analysis. As a result, the final analytical sample consisted of seven (n = 7) organizations.
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Following the described sample formation procedure, the final sample consisted of 7 organizations, 52 groups of nurses (with group sizes ranging from 3 to 41, and organizationally from 53 to 136) and 7 organization-specific groups of first-line nurse managers (with group sizes ranging from 6 to 13), totaling 688 participants (627 nurses and 61 first-line nurse managers). Ethical considerations are reported in detail in the Declarations section.
Measurements
Organizational social context (OSC)
We assessed the key dimensions of organizational culture and climate using Glisson’s Organizational Social Context (OSC) measurement instrument [41], which had already been translated for earlier data collection by the research team [42]. However, we excluded the morale dimension from our assessment, as it focused on individual characteristics rather than shared group-level characteristics. In the OSC framework, morale is conceptualized as an individual construct, analytically distinct from organizational culture and climate, which are defined at the collective level [41]. The OSC measure assesses organizational culture using the dimensions of rigidity (centralization of decision-making and formal regulation), proficiency (professional ambition and customer orientation) and resistance (competition, criticism, avoidance of challenges). Organizational climate was measured using the dimensions of stress (emotional exhaustion, role conflict, workload), engagement (commitment, achievement) and functionality (growth, career development, clarity, collaboration). A total of 88 statements on a five-point Likert scale (from 1 = not at all to 5 = very strongly) provided a comprehensive assessment of the culture and climate of the organization. The internal consistency of the OSC (Organizational Social Context) measurement dimensions was assessed using Cronbach’s alpha. This assessment yielded reliabilities for the cultural dimensions of rigidity (nursing staff: 0.83, managers: 0.80), proficiency (nursing staff: 0.86, managers: 0.85), and resistance (nursing staff: 0.74, managers: 0.78) as well as for the climate dimensions of stress (nursing staff: 0.94, managers: 0.92), engagement (nursing staff: 0.82, managers: 0.80), and functionality (nursing staff: 0.86, managers: 0.81). These results are consistent with previous studies confirming the reliability of the OSC for measuring the organizational social context in Finnish healthcare (e.g. 39, 40, 42, 43). In addition, several studies have confirmed the reliability and validity of the OSC internationally (e.g. 44‐46).
Nurse-focused outcomes
Nurse-focused outcomes were measured by the sickness absences and gross turnover of nursing staff. The examined time period was defined as the same period during which the survey was conducted (4 months). Sickness absence included all recorded sickness absence days among nursing staff employed in the unit and was not restricted to specific diagnostic categories. For the analysis, the sickness absence rate was calculated as the total number of sick days accrued in the unit over a four-month period divided by the average number of nursing staff in the unit.
Nursing staff gross turnover was based on all recorded entries into and exits from the unit among employed nursing staff, regardless of reason. Gross turnover was analyzed by examining the average gross turnover rate of the units. This rate was calculated as the total number of incoming and outgoing employees among the nursing staff divided by twice the average nursing resources. Average nursing resources are determined based on the mean number of nursing staff in the unit.
Contextual characteristics of the work unit
Contextual characteristics of the work unit, considered as background factors, included the unit size and care setting. These variables reflect structural and task-related aspects of the service context which, according to the organizational social context framework, may condition how organizational culture and climate relate to nurse-focused outcomes [15]. Their potential influence on the relationships between organizational social context and nurse-focused outcomes was therefore examined.
Unit size was measured as the average number of nursing staff per unit. The care setting was determined by asking the respondents about their unit, with the following response options: (1) outpatient clinic, (2) day hospital, (3) inpatient ward, (4) procedure unit, (5) operating room, (6) intensive care unit, and (7) other (please specify). After analyzing the open-ended responses, the variable was recoded as: 1 = outpatient clinic/day hospital/procedure or examination unit, 2 = inpatient ward, 3 = operating room, 4 = intensive care or advanced monitoring, and 5 = maternity ward and clinics. The information was cross-checked to ensure consistency with the register data.
Statistical analysis
Organizational culture and climate were analyzed using methods suitable for investigation at the group level [47]. For a more accurate representation, a standardized T-score was used rather than a mean value [48]. To ensure that organizational culture and climate were group-level phenomena, rWG (interrater agreement) values were calculated [49]. Values of rWG equal to or greater than 0.70 were considered acceptable to indicate sufficient within-group agreement on organizational culture and climate. Differences between the nursing staff and first-line nurse managers were examined using paired samples t-tests, as each nursing staff group was matched with a corresponding first-line nurse manager group from the same surgical domain. The assumptions of normality were checked. The threshold for statistical significance was set at a p-value of 0.05.
In the group-level analyses, each group of nursing staff was paired with a corresponding group of first-line nurse managers from the same surgical domain. This was done by matching 52 nursing staff groups with 52 first-line nurse manager groups, which were derived from seven domain-specific manager groups, representing first-line nurse managers working within those surgical domains. Aggregation of first-line nurse manager groups was considered necessary to reflect the actual organization of first-line nurse managers working in the participating surgical domains. Several first-line nurse managers held responsibility for more than one unit, and their perceptions were considered to be formed through domain-wide leadership structures and boundary-spanning coordination carried out in daily collaboration with employees and through peer interaction between other first-line nurse managers within the same domain. In addition, individual units included too few first-line nurse managers to support the construction of unit-level managerial groups.
The correlations between the assessments of organizational social context and the nurse-focused outcomes (sickness absence and gross turnover) were examined using Spearman’s correlation coefficient. In addition, a unit-specific variable was created based on the absolute difference in perceptions between nursing staff and their first-line nurse managers (absolute difference in T-scores). The relationship between this discrepancy in perceptions and nursing staff sickness absences and gross turnover was examined using the same correlation coefficient (Spearman’s).
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We conducted a linear regression analysis with interaction terms to examine the interaction effects of unit size and surgical care setting on the relationships between organizational culture and climate and selected nurse-focused outcomes (sickness absences and gross turnover). For the analysis, the skewed gross turnover variable was square-root transformed to meet normality assumptions. Either sickness absence or gross turnover was used as the dependent variable, while unit size or surgical care setting, one organizational culture or climate variable, and their interaction term were included as independent variables. The analyses were conducted separately for nursing staff and first-line nurse managers, as both groups described the social contexts from their own perspectives. All the statistical analyses were performed using SPSS version 28.0 (IBM Corp, Armonk, NY).
Results
The characteristics of the participants
The characteristics of the participants are listed in Table 1. The participating nursing staff groups (n = 52) included 627 nurses aged between 19 and 67 years (mean 43.4, SD 11.1). The first-line nurse manager groups (n = 7) consisted of 61 first-line nurse managers aged between 28 and 63 years (mean 49.4, SD 9.1). The characteristics of the participating units are presented in Table 2. The units represented a variety of surgical care settings. Outpatient clinics, day hospitals, and procedure/examination units made up the largest proportion of units (32.7%), followed by inpatient wards (23.1%), operating rooms (15.4%), intensive care units (15.4%), and maternity wards and clinics (13.5%). The median number of nursing staff per unit was 37 (range 4.5–152). During the follow-up period (4 months), the units recorded an average of 5.8 sickness absence days (SD 2.9) per nursing staff member, with unit-level means ranging from 0.95 to 14.1. The nursing staff gross turnover percentage during the follow-up period had a median value of 0.1 (range 0.0–3.1%).
Table 1
Characteristics of the participating nursing staff (n = 627) and first-line nurse managers (n = 61) from the surgical domains
Characteristic | Nursing staff (n = 627) n (%) | First-line nurse managers (n = 61) n (%) |
|---|---|---|
Gender | ||
Women | 575 (91.9) | 58 (95.1) |
Men | 42 (6.7) | 3 (4.9) |
Other or did not want to respond | 9 (1.4) | - |
Age, mean (SD) | 43.4 (11.1) | 49.4 (9.1) |
Work experience in the current position (years) | ||
≤ 4 | 168 (28.1) | 31 (51.7) |
5–10 | 144 (24.1) | 16 (26.7) |
11–20 | 173 (29.0) | 11 (18.3) |
≥ 21 | 112 (18.8) | 2 (3.3) |
Number of managed units | ||
1 | - | 37 (60.7) |
2–3 | - | 14 (23.0) |
≥ 4 | - | 10 (16.4) |
Table 2
Characteristics of the participating units from the surgical domains (n = 52)
Characteristic | Units (n = 52) |
|---|---|
Care setting (% of the units) | |
Outpatient clinic, day hospital, procedure/examination unit | 32.7 |
Inpatient ward | 23.1 |
Operating room | 15.4 |
Intensive care | 15.4 |
Maternity ward and clinic | 13.5 |
Number of nursing staff in the units, median (min-max) | 37 (4.5–152) |
Mean (SD) of sickness absence days per nursing staff member in the units | 5.8 (2.9) |
Gross turnover % in the units, median (min-max) | 0.1 (0.0–3.1) |
Organizational social context assessed by nursing staff and their first-line nurse managers
The rWG indices for both nursing staff groups (0.94–0.96) and first-line nurse manager groups (0.95–0.97) indicated strong within-group consistency in their perceptions of organizational culture and climate, suggesting that the constructs are viewed as group-level phenomena. In all the dimensions of organizational culture and organizational climate examined, the assessments of the first-line nurse managers were more positive than those of the nursing staff (Table 3). In particular, first-line nurse managers reported significantly lower organizational culture rigidity and resistance, and higher proficiency compared with nursing staff. In terms of organizational climate, first-line nurse managers perceived lower stress and higher functionality, whereas no statistically significant difference was observed for engagement.
Table 3
Organizational culture and climate in the nursing staff groups (n = 52) and first-line nurse manager groups (n = 52). Mean values, standard errors and p-values
Nursing staff groups (n = 52) | First-line nurse manager groups (n=52a) | ||||||
|---|---|---|---|---|---|---|---|
mean (SE) | min–max | rWG | mean (SE) | min-max | rWG | p-valueb | |
Organizational culture | |||||||
Rigidity | 50.07 (0.80) | 37.54–66.78 | 0.95 | 46.89 (0.62) | 39.58–51.83 | 0.96 | 0.001 |
Proficiency | 49.59 (0.54) | 40.27–57.72 | 0.96 | 52.27 (0.40) | 47.84–55.19 | 0.97 | <0 .001 |
Resistance | 49.47 (0.65) | 36.14–58.06 | 0.94 | 46.54 (0.47) | 43.10–52.40 | 0.96 | <0 .001 |
Organizational climate | |||||||
Stress | 50.07 (0.77) | 35.64–67.04 | 0.95 | 47.92 (0.58) | 41.23–53.90 | 0.97 | 0.028 |
Engagement | 50.28 (0.68) | 37.70–60.99 | 0.94 | 51.38 (0.44) | 45.33–56.18 | 0.95 | 0.175 |
Functionality | 49.42 (0.67) | 37.29–62.94 | 0.96 | 55.46 (0.35) | 52.16–59.42 | 0.97 | <0 .001 |
Correlations between organizational social context and nurse-focused outcomes
The nursing staff groups’ assessments of the organizational climate functionality showed a statistically significant negative correlation with nursing staff gross turnover (correlation coefficient = -0.294, p = 0.034). Although statistically significant, the correlation was relatively weak.
Among the first-line nurse manager groups, several dimensions of organizational culture and climate showed significant correlations with nurse-focused outcomes. Organizational culture resistance (correlation coefficient = -0.469, p < 0.001) and rigidity (correlation coefficient = -0.337, p = 0.014) showed a negative correlation with nursing staff gross turnover. In addition, first-line nurse managers’ ratings of organizational climate stress were negatively correlated with nursing staff gross turnover (correlation coefficient = -0.566, p < 0.001), whereas engagement showed a significant positive correlation with nursing staff gross turnover (correlation coefficient = 0.460, p = 0.001).
Figure 1 presents heat maps depicting the correlations between the organizational social context dimensions and nurse-focused outcomes, separately for nursing staff and first-line nurse manager groups. The color gradient visualizes the direction and relative strength of the correlations: negative correlations are represented by shades of blue, and positive correlations by shades of red. Statistically significant correlations are highlighted in bold and reported in the text.
Fig. 1
Heat map of correlations between organizational social context and nurse-focused outcomes. Statistically significant correlations (p < 0.05) are highlighted in bold
The relationship between differences in organizational culture and climate perceptions among nursing staff and first-line nurse managers with nursing staff sickness absences and gross turnover
The analysis of the differences in the perceptions of organizational culture and climate between nursing staff and first-line nurse managers revealed two statistically significant correlations. A greater discrepancy in the perceptions of rigidity correlated with a lower sickness absence rate (correlation coefficient = -.290, p = 0.037). In addition, a greater difference in the perceptions of resistance correlated with a higher gross turnover (correlation coefficient = .279, p = 0.045). However, both of these statistically significant correlations were relatively weak.
Interaction effects of care setting and unit size on the relationship between organizational social context and nurse-focused outcomes
The regression analyses examined the interaction effects of the care setting and unit size on the relationship between the organizational social context and nurse-focused outcomes (sickness absences and gross turnover). The interactions were analyzed separately for nursing staff and first-line nurse managers.
For nursing staff, none of the models showed statistically significant interactions. However, in the model analyzing the interaction effect of the care setting on the relationship between the organizational social context and nurse-focused outcomes, particularly nursing staff gross turnover, three statistically significant interaction effects were identified for first-line nurse managers: rigidity (p = 0.010), stress (p = 0.005) and functionality (p = 0.012).
When analyzing the interaction effects of unit size on the relationship between organizational social context and nurse-focused outcomes for nursing staff and first-line nurse managers, none of the interaction effects were statistically significant.
Discussion
This study aimed to analyze how nursing staff and first-line nurse managers perceive the organizational culture and climate in surgical domains and how these perceptions differ. We also examined how these perceptions relate to nurse-focused outcomes, such as sickness absences and gross turnover, and how the unit size and the care setting influence these relationships. These findings are interpreted within Glisson’s organizational social context framework, which conceptualizes organizational culture and climate as group-level constructs shaping organizational practices and work-related behaviors [15].
In the present study, first-line nurse managers rated all dimensions of the organizational culture and climate more positively than nursing staff, which is consistent with previous research. Studies have found significant differences in the perceptions of the organizational social context [40, 44] and work environment [50] between managers and staff, with managers consistently rating the environment more positively. Greater differences between supervisors’ and providers’ ratings of leadership have been shown to be associated with a more negative organizational culture [51], while a more positive organizational climate has been reported when leaders rate their own leadership lower than their followers [52]. This discrepancy also extends to implementation leadership and climate, with higher ratings by managers being associated with greater differences in perception [53]. Although we compared the perceptions of nursing staff and their first-line nurse managers, it is important to recognize that the responses to the OSC measure reflect different perspectives, as the reported expectations of organizational social context are largely shaped by leadership. First-line nurse managers’ more positive views of organizational dynamics may be related to their role in decision-making and strategic planning, as well as to the differing levels of autonomy and control. In contrast, nursing staff are often more directly affected by daily operational challenges, which may contribute to a more critical assessment. Previous qualitative evidence has illustrated that managers often prioritize results and performance, whereas frontline staff emphasize teamwork, recognition, and participative management [54]. However, based on the present study, no causal conclusions can be drawn regarding the reasons underlying these differences in perceptions.
The negative correlation between organizational climate functionality rated by nursing staff and nursing staff gross turnover highlights the role that a well-functioning organization plays in retaining employees. This is particularly important in surgical domains, such as operating rooms and intensive care units, where clear, streamlined processes and well-defined roles are essential. As seen in previous research, improvements in teamwork and communication have been linked to better care efficiency [12]. Functionality encourages continuous improvement and is likely to contribute to a lower gross turnover by promoting stability and efficiency within the unit. Previous research has shown that a positive work environment, including effective leadership and adequate resources, is associated with lower turnover intentions [55]. Growth and development opportunities are also key to reducing intentions to leave [56]. In addition, organizational culture may indirectly influence turnover intention through work-related stress and fatigue [31], effects that may be mitigated within a functional and supportive organizational climate. Lower gross turnover is also likely to contribute to improved functionality within surgical units. With lower turnover, teams can maintain continuity, which can support task performance, stronger social ties, improved communication, and the retention of organization-specific knowledge, all of which can contribute to a more functional work environment [57]. Importantly, the present study does not allow examination of specific mediating mechanisms, and the observed association between perceived functionality and gross turnover may reflect indirect and reciprocal processes rather than a unidirectional effect. Accordingly, well-functioning surgical units may support staff retention, while staffing stability may in turn strengthen perceived functionality within the unit.
Our results showed a correlation between the higher organizational culture resistance perceived by first-line nurse managers and lower nursing staff gross turnover. One explanation could be that resistance may reflect greater employee engagement, as noted by Cinite and Duxbury, who found that employees who express concerns about change are often more committed to the organizational change [58]. However, it is also possible that lower gross turnover itself leads to more resistance. In low turnover environments, long-term employees may feel more committed to existing practices and be more likely to resist change that threatens their established routines in the surgical context.
The first-line nurse managers’ assessments of higher organizational culture rigidity correlated with lower nursing staff gross turnover. This could be due to the fact that rigid organizations often create barriers to external hiring and mobility. During data collection, strict COVID-19 guidelines and significant reorganization taking place in the surgical domains may have amplified first-line nurse managers’ feelings of rigidity. While rigid processes and hierarchies may slow down internal development, according to Alharbi et al. they can also provide stability and predictability, especially in reforming practices [59]. According to Modena, a strong organizational culture may be an obstacle to organizational health, but a consistent organizational identity is necessary to ensure cohesion [60]. This phenomenon is probably pronounced in a surgical context, as it involves processes that are often clearly defined and structures that are well established, which contributes to stability and predictability. The solution lies in the interplay of stability and conditional openness to external influences [60].
According to our results, organizational climate stress perceived by first-line nurse managers correlated negatively with nursing staff gross turnover. Previous research suggests that the effects of managerial stress on staff turnover may be indirect and contingent on managerial coping responses [61]. Higher perceived stress among managers may prompt prosocial behaviors toward subordinates, such as sharing knowledge and recognition, which have been associated with lower turnover intentions and, in turn, actual turnover [61]. In surgical care settings, this association may reflect the dual role and competing pressures faced by first-line nurse managers, who are required to meet organizational performance demands while simultaneously safeguarding staff well-being. The highly specialized nature of this work and the limited substitutability of staff may increase managerial workload, while at the same time supporting workforce stability. Furthermore, perceived organizational support has also been shown to moderate the impact of leadership on turnover intentions [62].
The observed positive association between higher organizational climate engagement among first-line nurse managers and higher nursing staff gross turnover should be interpreted with caution. Prior research has shown that turnover is linked to work disruption and additional replacement-related demands, requiring managerial time in recruitment, hiring, orientation and training [63]. Thus, the observed association may reflect increased managerial demands in contexts of elevated gross turnover. The association may be partly explained by multiple underlying staffing processes captured in aggregate gross turnover rates [64]. Furthermore, leadership factors have been found to show modest associations with actual turnover compared with proximal withdrawal variables [65]. As existing research has not explicitly examined the relationship between first-line nurse managers’ organizational climate engagement and nursing staff gross turnover, the underlying mechanisms remain insufficiently understood.
The present interaction analyses suggest that associations between organizational social context and nursing staff gross turnover may vary across care settings rather than follow uniform patterns. No interaction effects were observed in analyses among nursing staff, whereas some interaction effects emerged in selected models based on first-line nurse managers’ assessments. These findings are consistent with prior research characterizing turnover as a complex and context-dependent phenomenon [63, 64]. Within demanding care environments such as surgical settings, first-line nurse managers’ assessments of organizational conditions may be particularly sensitive to context-specific operational pressures. However, given the number of models examined, individual interaction effects should be interpreted with caution, and the findings are best understood as reflecting broader contextual differences rather than specific model-level effects.
Future research
Future research should extend and validate the present findings in larger and more heterogeneous samples and across diverse healthcare settings. Longitudinal and mixed-methods designs are needed to verify the directionality and potential reciprocity of the associations observed between organizational culture, climate, and nurse-focused outcomes including sickness absence and gross turnover. Additional studies could complement aggregated indicators by examining more specific forms of workforce mobility, including transitions to other employers and voluntary withdrawal processes. More detailed investigation is warranted into the mechanisms linking managerial assessments and manager–staff discrepancies with nurse-focused outcomes. Examination of factors such as leadership practices, communication processes, and decision-making structures may clarify how managerial perceptions and actions shape workforce dynamics.
Limitations
Several limitations of this study should be explicitly acknowledged. Due to the interdisciplinary nature of organizational culture and climate, these constructs have been defined and measured in numerous ways, which poses a challenge to making comparisons between different studies. However, by using a valid instrument that accurately reflects these concepts at the group level, we were able to position this study within the broader field of organizational culture and climate research. In line with the conceptualization underlying the OSC framework, we excluded the morale dimension from the analyses, as morale is defined at the individual level and analytically distinct from collective organizational culture and climate. As a result, individual attitudinal aspects that may influence nurse-focused outcomes were not examined in this study. In addition, although first-line nurse managers were asked to evaluate the social context from their personal perspectives, they may have had a conscious or unconscious motivation to present their unit’s organizational culture and climate in a more positive light, possibly leading to a bias in their assessments.
The group-level analysis can also present challenges, as it can obscure individual variations within units [49]. Although the rWG indices demonstrated sufficient within-group agreement to justify aggregating individual responses to represent unit-level constructs, our results may still have overlooked individual-level nuances. In the present study, the internal consistency of the resistance dimension was slightly lower than that of the other dimensions, as has been noted in some previous OSC studies (e.g., 66). However, all dimensions remained within the acceptable range and are therefore unlikely to substantially compromise the robustness of the findings.
In addition, the aggregation to the unit level posed a challenge to data sufficiency. A separate power analysis at the unit level was not conducted. Although we aimed for a comprehensive sample of surgical units, the final sample size of the units remained relatively small due to data limitations. Nevertheless, responses were obtained from the majority of eligible units, indicating broad representativeness of the surgical domains of the organizations. Another limitation arises from the domain-level construction of first-line nurse manager groups. Linking units to domain-based first-line nurse manager groups means that the study captures a broader first-line managerial social context, which may not fully reflect differences between individual units. This reduces the precision of unit-specific associations and should be considered when interpreting the results.
The investigated nurse-focused outcome, sickness absence, was measured at the unit level as the total number of sickness absence days divided by the number of nursing staff. The results might have been different if sickness absences had been examined individually and adjusted for the duration or cause of absence. In addition, turnover was measured as gross turnover because we wanted to capture the bidirectional relationship between the social context and gross turnover of nursing staff. Nevertheless, the findings might have varied if we had focused only on external turnover, such as resignations. This choice reflects a conceptual decision, but it nonetheless limits direct comparability with other studies focusing exclusively on voluntary exits. However, this would represent a different phenomenon. While the selected nurse-focused outcomes reflect a specific perspective and may limit interpretations, they also constitute one of the strengths of this study. Nurse-focused outcomes were derived from the organizations’ records using well-defined criteria, ensuring that the data are objective and not subject to the biases often associated with self-reported measures. Accordingly, although several associations reached statistical significance, most correlations were weak to moderate in magnitude, suggesting relatively limited practical significance based solely on these results.
A key limitation of the study relates to the cross-sectional design and the interpretation of associations between organizational culture and climate and nurse-focused outcomes. As this study used cross-sectional data, our ability to establish causality between variables is limited. Consequently, the direction of the associations between organizational culture and climate dimensions and nurse-focused outcomes remains uncertain, and the findings should be interpreted as descriptive rather than causal. It is plausible that organizational culture and climate influence gross turnover rates. However, it is equally possible that turnover shapes the existing organizational culture and climate. The observed correlations may largely reflect the complex and reciprocal nature of these relationships. In addition, the tendency of first-line nurse managers to report more favorable views of culture and climate may also lead to reversed correlations with outcome criteria. Given these limitations, our results should be interpreted with caution.
Conclusions
This study shows that the perceptions of organizational culture and climate differ significantly in most dimensions between nursing staff and first-line nurse manager groups in surgical care settings. First-line nurse managers consistently rate organizational culture and climate more positively than nursing staff. Based on this finding, it is important to pay attention to first-line nurse managers’ experiences in the surgical work environment, as their perceptions appear to be closely associated with nurse-focused outcomes. Reconciling the discrepancy between the perceptions of first-line nurse managers and nursing staff requires inclusive decision-making and effective communication strategies to ensure that the concerns and experiences of both groups are adequately represented and addressed. Systematic perception audits and light-touch OSC benchmarking could help managers monitor misalignment and strengthen mutual understanding in surgical units.
The negative correlation found between organizational climate functionality and nursing staff gross turnover in surgical care underlines the importance of a well-functioning work environment for employee retention. Clear processes and well-defined role expectations bring highly needed stability to surgical units, which may help reduce turnover. The relationship between functionality and gross turnover is likely to be bidirectional: well-functioning units are better able to retain staff, while a stable workforce improves the unit’s functionality. Consequently, a positive, mutually reinforcing cycle can form between functionality and staff retention.
The negative correlation between perceived organizational culture rigidity by first-line nurse managers and nursing staff gross turnover may reflect rigid surgical domains that can create barriers to external recruitment. While rigidity might ensure protocol adherence in surgical units, excessive rigidity might hinder innovation and adaptability.
Higher organizational culture resistance perceived by first-line nurse managers appears to be associated with lower nursing staff gross turnover, likely indicating that resistance may reflect employee commitment and dedication to particularly improving surgical care settings. In the surgical context, this resistance could signify a strong sense of ownership over the unit’s practices and standards of care. This could indicate that long-serving employees have assumed a strong role in existing practices, which manifests as resistance to change.
Furthermore, the results suggest that certain relationships between first-line nurse managers’ assessments of organizational social context and nursing staff gross turnover vary across surgical care settings. This underscores the context-specific relevance of care setting characteristics in interpreting managerial and staff perspectives. International guidelines could support the systematic recognition and assessment of organizational culture and climate as integral components of healthcare organizations and leadership.
This study contributes to understanding how nursing staff and their first-line nurse managers perceive organizational social context in surgical care settings and how specific dimensions of organizational social context are associated with nurse-focused outcomes. These findings add to the existing evidence on organizational factors relevant to workforce sustainability and quality of care.
Acknowledgements
The authors would like to express their appreciation to the nursing staff and first-line nurse managers who participated in the survey, and to the organizations for their invaluable collaboration. The authors also extend their gratitude to Paula Asikainen, PhD, Adjunct Professor, for her substantial contributions to this research.
Declarations
Ethics approval and consent to participate
The research was conducted in accordance with the Declaration of Helsinki [67]. Permission to use the Organizational Social Context (OSC) measure was obtained from the copyright holder. Research approval to conduct this study was obtained from each target organization, and each organization also assessed the ethical conduct of the research as part of their approval. The guidelines of the Finnish National Board on Research Integrity state that ethics committee approval is not required to conduct opinion surveys without anticipated harm, which was the case for this study [68]. The participants received detailed written information about the study and a data protection notice. They were also informed that participation in the survey was voluntary. Consent was a mandatory requirement for participation. All participants had to voluntarily check a box on the last page of the questionnaire to give their consent. The participants were only officially considered to take part in the study once they had filled in and submitted the survey.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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