Factors Influencing Hospital Culture Perception among Medical Staff at | PPA

Introduction

In international healthcare, hospital culture is the shared set of values, attitudes, beliefs, and behavioral norms that shape how healthcare providers interact, make decisions, and provide care to patients, the overall work environment plays a crucial role in patient safety.¹ They are fundamental components of a good work environment and are closely associated with improved and efficient performance of employees in healthcare settings.² Organizational culture significantly influences the adoption of evidence-based practices among medical staff members.^3,4 Organizational culture significantly shapes leadership practices, which ultimately influence organizational culture by setting behavioral norms.⁵ It is grounded in mature organizational management theory, forming a well-developed research system encompassing four classical theoretical frameworks: The Competing Values Framework (CVF), Just Culture Theory, the Job Demands-Resources (JD-R) model, and the Donabedian three-dimensional quality framework. They provide a solid theoretical foundation for defining different types of hospital culture, medical safety governance, regulation of healthcare-worker stress, and medical quality assessment.^6,7 Current international research hotspots concentrate on four areas: first, deepening research on patient safety culture, confirming that a positive in-hospital culture can reduce medical errors, lower occupational burnout, and improve patient satisfaction. Second, it focuses on leadership style and team climate, showing that transformational leadership and a strong sense of team psychological safety can effectively improve collaboration efficiency and care quality. Third, it emphasizing demographic and group differences, systematically examining the heterogeneous effects of factors such as education and professional title on cultural perception, which provides support for the hypotheses of the study. Fourth, focusing on the transition toward smart healthcare and humanistic development, exploring pathways for cultivating an innovation culture in the context of digitalization, and continuously strengthening humanistic care and occupational well-being for healthcare workers.^8,9

The ten-dimensional framework used in the present study can also be interpreted via the CVF without requiring a one-to-one correspondence between individual dimensions and four CVF culture types. This framework covers 10 dimensions, including hospital spiritual culture, moral culture, thinking culture, psychological culture, service culture, technological culture, environmental culture, organizational culture, institutional culture, and management culture. These ten dimensions represent more specific manifestations of cultural characteristics that may cut across the broader CVF orientations. This approach benefits hospitals because the institutions must maintain professional cohesion, meet service expectations, stimulate innovation, and ensure procedural control and regulatory compliance. Meanwhile, technological, psychological, and management cultures are expected to have a comparatively stronger direct association with the perception of medical staff. These cultures directly affect medical staff perceptions because they closely relate to medical staff members’ immediate capacity to perform technically complex work, cope with occupational demands, and experience organizational policies in routine daily practice.

Overall, international research has a well-developed theoretical system and mature empirical methodology, but is largely implemented and grounded in Western healthcare settings, making it difficult to fully adapt to the context of hospital culture development in China. Additionally, Western frameworks often emphasize individual autonomy, relatively low power distance, and participatory decision-making. Chinese healthcare systems generally operate within more hierarchical governance structures and Confucian values in Chinese healthcare.¹⁰

Previous research in Chinese public hospitals has shown that different dimensions of organizational culture are associated with employees’ attitudes and behaviors as well as organizational performance, suggesting that hospital culture should be understood as a multidimensional rather than a unitary construct.^11,12 In addition, due to the implementation of the Healthy China Strategy, public hospitals generally place great importance on cultural development, commonly establishing a four-dimensional framework encompassing spirit, institutions, behavior, and material aspects, relying on Party building to guide and improve workplace conduct, and shaping in-hospital cultural atmosphere through approaches, such as developing hospital mottos, honoring civilized-unit awards, and establishing role models among medical staff. At present, tertiary hospitals place particular emphasis on smart-hospital development using the innovative national policy of “Trinity”, accelerating growth in the technological dimension of hospital culture across regions, hospitals have continuously refined internal regulations and improved humanistic services, with the medical environment and external service culture steadily upgrading overall.¹³ Although many tertiary Grade-A hospitals across China have developed distinctive approaches to hospital culture, existing empirical research has largely focused on hospitals in more extensively studied regions and provides limited evidence on how hospital culture is perceived within the Xinjiang multi-ethnic region.¹⁴ In Xinjiang, tertiary hospitals operate within a distinctive geographic, demographic, and healthcare environment. Xinjiang is a large border region with considerable cultural diversity, with Uyghurs as the main group, representing 62% of the population, and 38% other Chinese groups.¹⁵ This demographic composition differs significantly from Eastern and Central Chinese provinces and creates an institutional environment in which healthcare professionals may routinely work with patients and colleagues from different cultural, social, and linguistic backgrounds. Because of this diversity, communication patterns can be influenced, therefore, organizational culture in Xinjiang hospitals cannot be assumed to operate in the same way as that observed in less heterogeneous regions of China. Therefore, this study aimed to investigate the factors influencing medical staff perception of hospital culture in tertiary healthcare institutions in Xinjiang, China. Specifically, the study sought to describe medical staff’s scores across the various hospital cultural dimensions. The study examined whether perceptions of hospital culture differed according to selected demographic factors through univariate and multivariate analyses. In addition, structural equation modeling (SEM) was used to examine the structural relationships between each hospital culture dimension and overall cultural perception.

Research Hypotheses

Demographic characteristics are significantly associated with hospital culture perception across multiple dimensions.

The ten cultural dimensions are positively correlated with one another, suggesting a unified underlying structure of hospital culture.

Structural equation modeling shows that hospital technological culture, psychological culture, and management culture have the strongest direct effects on overall cultural perception.

Education level and professional title are the most stable demographic predictors of cultural perception across dimensions.

Methodology

Study Design

A cross-sectional, multi-center survey design was employed, and the study was conducted from April to August 2025 across 7 tertiary Grade-A medical institutions in the Xinjiang Uygur Autonomous Region, China. This study was based on Schein¹⁶ three-level model of organizational culture (surface-level artifacts, espoused values, and underlying basic assumptions) and Cameron and Freeman¹⁷ competing values framework, conceptualizing hospital culture as a multi-level construct comprising ten dimensions,¹⁸ as described in Table 1.

Table 1 Hospital Culture Dimensions and Definitions

Eligibility Criteria

Inclusion criteria for participants were: age ≥ 18 years, full-time medical staff (including clinical and non-clinical positions) who had worked at their current institution for at least 1 year, and no history of severe psychological disorder. Similarly, certain exclusion criteria were also set, such as under-trained medical staff (students), non-full-time staff, and absent medical staff due to personal leave, sick leave, or any other reasons. Medical staff with any serious or severe psychological disorder, such as anxiety or depression.

Sample Size Calculation

Sample size was determined based on the principle of 10–20 times the number of items required for factor analysis,18 and with reference to the estimated effective response rates of similar domestic surveys (approximately 85%–90%), yielding a target sample of 960. However, this value represents a minimum threshold for the planned scale-based analysis and was not used as the final recruitment target. Our study examined hospital culture across multiple institutions within a heterogeneous medical workforce from tertiary healthcare institutions in Xinjiang. Therefore, we included a larger sample of 1500 to improve statistical precision and increase stability of multivariable estimates. A stratified sampling method was used, with proportional allocation by occupational category (physicians, nursing staff, medical technicians, administrative staff, logistics staff, and others). A total of 1500 questionnaires were distributed, and 1442 valid questionnaires were collected, for an effective response rate of 96.1%. Invalid questionnaires were mainly excluded due to missing-item rates exceeding 20%; missing values within valid questionnaires were handled using list-wise deletion.

Survey Instrument

With reference to relevant domestic literature and master’s theses concerning the division of hospital culture dimensions and questionnaire item design, the questionnaire items were adjusted and optimized to reflect the actual conditions of the sampled region, and the questionnaire was revised and refined based on feedback from experts with expertise in hospital administration, clinical medicine, emergency department, public health, health-services research, and organizational psychology with vast experience, ultimately forming the “Survey Questionnaire on the Current Status of Hospital Culture among Medical Staff”. Part one covers the general demographic characteristics of medical staff (14 items). Part two covers the current status of hospital culture development, comprising 10 dimensions, including hospital spiritual culture, moral culture, thinking culture, psychological culture, service culture, technological culture, environmental culture, organizational culture, institutional culture, and management culture, with 32 questions in total, including both single-choice and multiple-choice items (Supplementary Material 1). One question was regarding any suggestions (Supplementary Material 1).

The final questionnaire was piloted among 20 medical staff from each tertiary hospital, who were not included in the final study sample. The pilot study assessed item clarity, completion time, comprehensibility, response variability, and preliminary reliability. Based on the pilot study, all items were fine and included in the final study.

Reliability Testing

The overall scale in this study had a Cronbach’s α coefficient of 0.877, indicating excellent overall reliability; the hospital technological, institutional, and organizational culture dimensions met reliability standards, while dimensions such as spiritual and thinking culture fell within an acceptable range; the moral, psychological, and service culture dimensions had α coefficients slightly below 0.6, attributable to the relatively small number of items in these dimensions. Bartlett’s test of sphericity for each dimension yielded P < 0.001, indicating significant correlations among variables; combined with the results of confirmatory factor analysis, the overall reliability and validity of the scale met the requirements for subsequent statistical modeling, as shown in Table 2 and Figure 1.

Figure 1 Questionnaire reliability and validity metrics. (A) Internal consistency, (B) Bartlett’s sphericity (χ2).

Table 2 Reliability and Validity of the Questionnaire (Bartlett’s Test of Sphericity: χ2, Df, P)

Statistical Analysis

SPSS 27.0 and Stata 17 were used for data analysis. Reliability testing was done using Cronbach’s α coefficient. The basic characteristics of medical staff were described using descriptive statistics, continuous variables (dimension scores) were expressed as mean, minimum, and maximum, alongside their relative proportions. Categorical variables were summarized using frequencies and percentages. Univariate analysis was conducted using the Mann–Whitney U-test and the Kruskal–Wallis H-test to examine differences in each dimension of hospital culture across participants’ characteristics. Variables considered relevant on the basis of the univariate analysis were subsequently included in the multivariate analysis using multiple linear regression models to identify factors independently associated with the respective hospital-culture dimensions. For this purpose, education, age, and length of service were kept as ordinal, while gender, profession title, position, and department were kept as nominal. Additionally, dummy variables were created to perform multivariate regression analysis. The significance level was set at 5% (P < 0.05). The SEM command in Stata 17 was used to complete the model analysis: the ten dimensions of hospital culture served as first-order latent variables, and overall hospital culture served as a second-order latent variable; maximum likelihood (ML) estimation was used for model fitting, and a path-analysis diagram was drawn.

Ethics Statement

This study was approved by the Ethics Review Committee of Xinjiang Medical University (Approval No. XJMU-EC-2023-041), and it was conducted in accordance with the Declaration of Helsinki. All participants signed a written informed-consent form prior to participation. Data were anonymized, no personally identifiable information was collected, and participants had the right to withdraw at any time without justification.

Results

Basic Characteristics of Medical Staff at Tertiary Public Hospitals

Among 1442 respondents, females predominantly accounted for 1034 (71.7%), and males were 408 (28.3%). Most medical staff members were aged 30–39 years (445, 30.9%), and most medical staff members had a bachelor’s degree (842, 58.4%) and associate degree or below (452, 31.3%). Among medical staff members, most had a junior professional title or below (788, 54.6%) and nursing staff formed the largest occupational group (515, 35.7%), mostly working in non-surgical departments (895, 62.1%) and majority of the staff members had 9–15 years of experience (520, 36.1%), followed by 3–8 years (376, 26.1%), while 210 (14.6%) had > 15 years of experience, as shown in Table 3, and Supplementary Material 2 (A–F).

Table 3 Basic Characteristics of Medical Staff at Tertiary Institutions

Scores of Medical Staff Across Hospital Culture Dimensions

Table 4 and Figure 2 show that the proportion score for hospital-culture perception among medical staff at tertiary public hospitals ranged from 17.3% to 74.34%. Among the ten hospital culture dimensions, the top three by proportion and mean points, hospital moral culture, hospital technological culture, and hospital service culture had the highest scores, at 11.09 (74.34%), 10.20 (68%), and 9.46 (63.07%), respectively, indicating comparatively more favorable perceptions in these areas. The least considered dimensions were hospital institutional culture (1.73, 17.3%), hospital organizational culture (7.24, 42.59%), and hospital psychological culture (6.70, 44.67%), suggesting that these dimensions were perceived least favorably.

Figure 2 Comparison of observed mean score vs standard maximum values.

Table 4 Scores of Medical Staff Across Hospital Culture Dimensions

Univariate Analysis of Hospital Culture Dimension Perceptions Among Staff

Results showed: hospital spiritual culture differed significantly by gender, education, position, professional title, age, and length of service (P < 0.05); hospital moral culture differed significantly by education, professional title, age, and length of service (P < 0.05); hospital thinking culture differed significantly by education (P < 0.05); hospital psychological culture differed significantly by education, position, age, and length of service (P < 0.05); hospital technological culture differed significantly by professional title (P < 0.05); hospital environmental culture differed significantly by education and position (P < 0.05); hospital organizational culture differed significantly by age and length of service (P < 0.05); hospital institutional culture differed significantly by professional title (P < 0.05); and hospital management culture differed significantly by education and position (P < 0.05), as shown in Table 5 and Figure 3.

Figure 3 Bubble plot of univariate associations between demographic and cultural dimensions. Dark/filled bubbles indicate statistically significant associations (p<0.05), whereas light/open bubbles indicate non-significant associations (p>0.05).

Table 5 Univariate Analysis of Hospital Culture Dimension Perceptions [Z (P)]

Multivariate Analysis of Hospital Culture Dimension Perceptions

Demographic characteristics found statistically significant in the univariate analysis were entered as independent variables, with each hospital culture dimension as the dependent variable, in multiple linear regression analyses, and all model VIF values were < 3.0. Regression analysis for hospital spiritual culture indicated that respondents aged 30–39 years (B = 0.432, p = 0.034), 40–49 years (B = 0.829, p = 0.003), and over 50 years (B = 0.950, p = 0.004) had significantly higher scores than those younger than 30 years. Higher educational attainment and senior professional titles were also positively associated with spiritual culture, whereas more than 15 years of service showed a negative association (B = −1.161, p < 0.001). Hospital moral culture was positively associated with bachelor’s and master’s degrees, senior professional titles, and 9–15 years of service. In contrast, bachelor’s and master’s degree holders reported significantly lower perceptions of hospital thinking culture (B = −0.482, p < 0.001; B = −0.485, p = 0.028) and psychological culture (B = −0.491, p < 0.001; B = −0.655, p < 0.001), respectively. Administrative and logistics staff, along with employees having more than 15 years of service, demonstrated significantly higher psychological culture scores, as shown in Table 6. Although a significant association was observed, the explanatory performance of the regression model was very limited, with negligible explained variance (R²=0.004-0.084). Therefore, these statistically significant associations should be interpreted as small in magnitude and of limited practical explanatory relevance.

Table 6 Multivariate (Multiple Linear Regression) Analysis of Hospital Culture Dimension Perceptions Among Medical Staff

Correlation Analysis

Pearson correlation analysis of the relationships among hospital culture dimensions showed that the correlation coefficients (r) among all dimensions were greater than 0, indicating all dimensions of hospital culture were positively correlated with one another (P < 0.05), as shown in Table 7 and Supplementary Material 3.

Table 7 Pearson Correlation Analysis Among Hospital Culture Dimensions

Structural Equation Model Analysis

The ten dimensions of hospital culture served as first-order latent variables, questionnaire items served as observed variables, and overall hospital culture served as a second-order latent variable, from which a path diagram was constructed. The study retained all items without adding or removing any measurement items, and the ten-dimension theoretical framework was not altered at any point. To avoid overfitting, split-sample cross-validation was used to verify model robustness, after which all fit indices improved markedly. Results showed that the top three path coefficients were hospital technological culture, psychological culture, and management culture, at 0.80, 0.70, and 0.68, respectively, and were closely associated with the higher-order latent construct of overall hospital culture within the specified measurement model. These coefficients should be interpreted as indicators of the strength of the measurement relationship between each dimension and the higher-order construct, rather than as evidence of causal influence. Meanwhile, hospital spiritual culture (λ = 0.25) showed a relatively low loading, suggesting a structural weakness in the current development of hospital culture with regard to spiritual value guidance and the cultivation of innovative thinking (see Table 8 and Figure 4).

Figure 4 Path analysis diagram of hospital culture dimensions and overall score at tertiary institutions. The values associated with the residual terms (ξ1–ξ10), shown on the right side of the diagram, represent the residual/error variances of the respective dimensions. The values shown within or adjacent to the dimension boxes (4.1, 7.9, 3.7, 5.9, 8.3, 6.2, 3.9, 3.2, 3.0, and 5.3) represent intercepts.

Table 8 Goodness-Of-Fit Indices for the Path Analysis Model at Tertiary Institutions

Discussion

In the current cross-sectional study, we investigated the associated contributing factors influencing hospital culture perception among medical staff at tertiary healthcare institutions in China. Predominantly, our study encompassed female medical staff aged 30–39 years with bachelor’s or associate degree, holding a junior professional title, and working in non-clinical positions with 8–15 years of experience. Among the ten hospital culture dimensions, hospital moral culture, hospital spiritual culture, and hospital institutional culture were found to have higher mean scores. Meanwhile, Chinese public hospital employees perceived the hospital culture as stronger in internal rules and regulations, while in empowerment, they considered it weak.11

Our findings indicated that education level and professional title are the most stable predictors across dimensions, warranting deeper interpretation. Medical staff with higher education levels (typically doctoral or master’s degree holders, often in management or academic positions) rated moral and spiritual culture more positively, but rated thinking and psychological culture relatively lower, presenting a kind of “expectation paradox”, they possess greater ethical sensitivity and organizational identification, yet also hold higher expectations for the hospital’s academic-innovation atmosphere and psychological-support system, expectations that may not yet be fully met, an interpretation that warrants further verification in future research. Differences in perception of hospital psychological culture among staff in different positions may reflect that in-hospital psychological-care resources are disproportionately directed toward clinical nursing staff, while administrative, medical-technical, and logistics staff often lack routine psychological support, with uneven resource allocation widening the perception gap between positions. The opposite effects of age and length of service on spiritual culture suggest generational value divergence. Older staff may have experienced an earlier period of hospital culture more strongly driven by a sense of mission, while longer-tenured staff may have experienced a dilution of values or occupational burnout over time. This finding is consistent with organizational socialization theory and carries important implications for hospital talent-retention strategy.¹⁹ Similarly, another study also concluded that employee age may influence workplace spirituality.²⁰ Hospital culture development should be guided by staff needs, implementing tailored, tiered strategies. For older, longer-tenured, and higher-titled medical staff, points of alignment between their career experience and hospital culture should be identified, with hospital culture explained and passed on to younger staff face-to-face through forums, such as discussion sessions and roundtable meetings. Given the observed age-related differences in the perception of hospital culture, targeted support for newly hired young medical staff may warrant consideration. Although our study did not directly evaluate specific interventions, previous research suggests that orientation training and mentorship systems may help facilitate their understanding of the hospital’s core culture, while promptly identifying their needs, encouraging their participation in hospital culture development, establishing feedback channels, and responding to their concerns in a timely manner, so as to continuously strengthen cultural identification among younger staff.²¹ For highly educated medical staff, hospital culture should be integrated into the full course of their research and work through approaches, such as research-team building and career-development planning, deepening their cultural identification. For medical staff with lower education levels, on-the-job training and case-based teaching should be used to translate cultural concepts into actionable daily behavioral norms, clarifying the intrinsic connection between cultural development and their own duties.²² Given the high-pressure working conditions of clinical medical staff, psychological counseling and emotion-management training can also influence the organizational culture, therefore, the in-hospital psychological-support mechanism should be improved, and a humanistic caring atmosphere should be fostered within departments to effectively strengthen cultural perception. For non-clinical staff, such as administrative and medical-technical personnel, position-value identification education, organized team stress-relief activities, and communication platforms can improve their perception of hospital culture. Through such tiered, category-specific approaches to strengthening cultural identification among different groups of medical staff, the inheritance and innovation of hospital culture can be achieved, ultimately supporting the high-quality, sustained development of hospitals.²³ Additionally, hospital type may be associated with physicians’ organizational commitments by shaping differences in management structure, resource availability, career development opportunities, and organizational support, and it also may modify the strength of associations between these workplace factors.²⁴

The SEM analysis revealed that hospital technological culture (λ = 0.80), psychological culture (λ = 0.70), and management culture (λ = 0.68) were the three dimensions with the strongest influence on overall cultural perception. However, the very low adjusted R² values observed for several other hospital-culture dimensions indicate that demographic and professional characteristics have limited explanatory relevance for staff perceptions of these cultural domains. Meanwhile, technological culture had the highest loading, closely related to the National Health Commission (NHC), which recently pushed for smart-hospital development and its encouragement of medical technology innovation, reflecting medical staff’s sensitivity when evaluating overall hospital culture to the innovation atmosphere and degree of digital transformation.^13,25,26 Future studies should examine whether stronger technological hospital cultures translate into a greater capacity to use routinely collected clinical data to capture otherwise hidden dimensions of patient complexity and improve risk assessment, resource allocation, and organizational decision-making.^27–30

The high loading is consistent with predictions of the JD-R Model in the high-pressure, socioculturally diverse work environment of Xinjiang, the degree to which the organization responds to staff emotional needs constitutes a core indicator of cultural evaluation. The high loading of management culture confirms the central role of leadership in shaping organizational culture transformational leadership style, participatory decision-making, and management integrity are important channels through which medical staff perceive hospital culture.^31,32 Meanwhile, at the practical level, hospital administrators should use management culture as the overarching institutional lever for improving top-level design, optimizing performance evaluation, and coordinating talent allocation to ensure the stable implementation of cultural-development initiatives, and use technological culture, given its substantial weight, as the core breakthrough point, consolidating the hospital’s professional cultural foundation through research-incentive mechanisms. The development of smart-healthcare platforms and the use of psychological culture to build a humanistic support system, introducing psychological-care measures suited to multi-ethnic settings and establishing tiered integration mechanisms to stabilize the workforce.³³ These three dimensions should work in coordination, accounting for regional and intra-hospital disparities to implement differentiated support strategies, comprehensively raising the overall perception of hospital culture at tertiary hospitals in Xinjiang, and supporting public hospitals in moving toward high-quality, substantive development.³⁴ With regard to the notably weak area of hospital spiritual culture, hospital administrators should move beyond superficial slogan-based promotion and instead, drawing on the regional characteristics of public medical institutions in Xinjiang, develop concrete hospital mottos and articulate a clear sense of medical mission, using senior medical staff to pass spiritual culture down across generations and conducting immersive programs to cultivate original aspirations among younger medical staff. A dedicated incentive and evaluation system for spiritual civilization should be established, and staff belonging strengthened through public-welfare medical practice and routine safeguarding of staff concerns, transforming the abstract notion of hospital spirit into a professional value consciously upheld by all medical staff, thereby addressing the developmental shortfall in hospital spiritual culture.¹⁶

Before interpreting the findings of the present study, several limitations need to be considered. First, the cross-sectional design cannot establish causality, associations between demographic factors and cultural perception may be affected by reverse causation or unmeasured confounding variables. Second, all data were derived from self-report questionnaires, carrying risks of social-desirability bias and common-method bias. Third, the analysis did not control for hospital-level variables (such as hospital size, teaching-hospital status, or bed-occupancy rate), so individual-level and institution-level effects may be confounded. Fourth, three dimensions of hospital culture in this study did not meet reliability standards, possibly due to the small number of items per dimension or the single geographic sampling region. A further limitation is that the study did not include detailed measures of ethnicity, language background, or other sociocultural characteristics specific to Xinjiang. Consequently, although the research was conducted in a multi-ethnic regional context, the present findings cannot determine whether hospital-culture perceptions differ across ethnic groups or are specifically attributable to multi-ethnic dynamics. Therefore, caution should be exercised when generalizing the conclusions of this study to other provinces or international contexts.

Conclusion

Our findings indicated that education level, professional title, and job position were the most stable demographic determinants significantly associated across multiple cultural dimensions. Meanwhile, the SEM analysis revealed that hospital technological, psychological, and management cultures had the strongest structural associations with cultural perception among medical staff members. The spiritual culture showed low integration. Future studies are warranted to ensure collaborative understanding of these highlighted dimensions among medical staff members.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Funding

Xinjiang Autonomous Region Youth Medical Science and Technology Special Research Project (WJWY-201944); Natural Science Foundation of Xinjiang Uygur Autonomous Region (2024D01C85).

Disclosure

All authors declare that they have no conflicts of interest, and that no commercial organization participated in the design, data collection, analysis, or writing of this study.

References

1. Qin X, Wang R, Huang YN, et al. Organisational culture research in healthcare: a big data bibliometric study. Healthcare. 2023;11(2):169. doi:10.3390/healthcare11020169

2. Rafi’i MR, Hanif SAM, Bin Daud F. Exploring the link between healthcare organizational culture and provider work satisfaction: a systematic review. BMC Health Serv Res. 2025;25(1):904. doi:10.1186/s12913-025-12973-6

3. Alodhialah AM. Exploring the influence of organizational culture on evidence-based practice adoption among nurses in tertiary hospitals: a qualitative study. BMC Nurs. 2025;24(1):1029. doi:10.1186/s12912-025-03647-z

4. Tietschert M, Bahadurzada H, Kerrissey M. Revisiting organizational culture in healthcare: heterogeneity as a resource. Soc Sci Med. 2024;356:117165. doi:10.1016/j.socscimed.2024.117165

5. Evliyaoğlu F, Erdost Çolak HE. Re-examining the relationship between societal and organizational culture and leadership: research in the People’s republic of China, the United States of America, and Türkiye. Int J Cross Cult Manag. 2025;25(3):771–16. doi:10.1177/14705958251387959

6. Bakker AB, Demerouti E. Job demands-resources theory: taking stock and looking forward. J Occup Health Phychol. 2017;22(3):273–285. doi:10.1037/ocp0000056

7. Bass BM, Riggio RE. Transformational Leadership. 2nd ed. Lawrence Erlbaum Associates; 2006.

8. Moreno-Domínguez MJ, Escobar-Rodríguez T, Pelayo-Díaz YM, Tovar-García I. Organizational culture and leadership style in Spanish hospitals: effects on knowledge management and efficiency. Heliyon. 2024;10(20):e39216. doi:10.1016/j.heliyon.2024.e39216

9. Hou N, Zara G C, F J. Building a culture of integrity in hospitals (colleges) in the context of medical humanities tradition – exploration and practice: the first hospital affiliated to a university in China as an example. J Educat Res Policies. 2024;6(3):32.

10. Meng M, Li X, Zhao J, Hao Y. When western concept meets eastern culture: exploring the impact of Confucianism on shared decision-making in China. Asia Pac J Oncol Nurs. 2024;11(11):100586. doi:10.1016/j.apjon.2024.100586

11. Zhou P, Bundorf K, Le Chang J, Huang JX, Xue D. Organizational culture and its relationship with hospital performance in public hospitals in China. Health Serv Res. 2011;46(6pt2):2139–2160. doi:10.1111/j.1475-6773.2011.01336.x

12. Ying L, Fitzpatrick JM, Philippou J, Zhang Y, Murrells T, Rafferty AM. Front-line staff perspectives on a caring culture in Chinese hospitals: validation of a Chinese version of the culture of Care barometer. J Nurs Manag. 2022;30(6):2093–2102. doi:10.1111/jonm.13657

13. Zhang GW, Gong M, Li HJ, Wang S, Gong DX. The “trinity” smart hospital construction policy promotes the development of hospitals and health management in China. Front Public Health. 2023;11:1219407. doi:10.3389/fpubh.2023.1219407

14. Hong C. Analysis on the information construction of human resource management in public hospitals. J Hum Resour Develop. 2024:6.

15. Grbović V. Ethnodemographic specifications of Xinjiang (PR Of china). Zbornik radova-Geografski fakultet Univerziteta u Beogradu. 2019;67(2):85–98.

16. Schein EH. Organizational Culture and Leadership. 989 Market Street. San Francisco, CA 94103-1741. Jossey-Bass; 2010.

17. Cameron K, Freeman S. Cultural congruence, strength, and type: relationships to effectiveness. Res Organizat Change Develop. 1991;5:23–58.

18. Comrey AL, Lee HB. A First Course in Factor Analysis. 2nd ed. Lawrence Erlbaum Associates, Inc; 1992.

19. Van Maanen JE, Schein EH. Toward a theory of organizational socialization. Res Organizat Beh. 1979;1:209–264.

20. Bannerman B, Snipes R. Cross-generational effects of workplace spirituality on employee Job and life satisfaction. J Bus Ind Econ. 2023;28(1):3.

21. Meng Z, Tang J, Yang J, et al. Fostering participation motivation and multidisciplinary teamwork collaboration through hospital culture and team leadership in Chinese tertiary public hospitals-A cross-sectional study. PLoS One. 2025;20(11):e0334831.

22. Chen J, Yang QX, Zhang R, Tan Y, Long YC. How does patient-centered hospital culture affect clinical physicians’ medical professional attitudes and behaviours in Chinese public hospitals: a cross-sectional study? BMC Med Ethics. 2023;24(1):57. doi:10.1186/s12910-023-00936-7

23. Dzeng E, Batten JN, Dohan D, Blythe J, Ritchie CS, Curtis JR. Hospital culture and intensity of end-of-life care at 3 academic medical centers. JAMA Intern Med. 2023;183(8):839–848. doi:10.1001/jamainternmed.2023.2450

24. Gao Y, Zhu J, Hu L, Chen C. Is there any difference in organizational commitment between general hospitals and specialized hospitals? Empirical evidence from public hospitals in Beijing, China. BMC Health Serv Res. 2023;23(1):1397. doi:10.1186/s12913-023-10362-5

25. Li L, Hong W, Xun L, CH H. The exploration of emotional exhaustion in developing patient safety culture in a tertiary hospital in China. Int J Med Pharm Drug Res. 2019;3:1–4.

26. Wu SW, Pan Q, Chen T, Ge YY, Luo J, Wang Q. Development and evolution of medical technology management in China. Chin Med J. 2019;132(14):1739–1741. doi:10.1097/CM9.0000000000000314

27. Cocchieri A, D’agostino F, Welton JM, Nurchis MC, Damiani G, Cesare M. Hidden nursing complexity within diagnosis-related groups (DRGs): a one-year retrospective study of standardized nursing diagnoses and actions among adult hospitalizations in Italy. BMC Nurs. 2026;25(1). doi:10.1186/s12912-026-04806-6

28. Cesare M, Nurchis MC, D’agostino F, et al. Variability of nursing complexity within medically homogeneous diagnosis-related groups: a retrospective analysis of pediatric electronic health records. J Pediatr Nurs. 2026;90:418–428. doi:10.1016/j.pedn.2026.07.002

29. Cesare M, Gray R, Cocchieri A. Stop silencing nursing complexity: why standardized nursing terminologies must Be heard. Nurs Rep. 2026;16(1). doi:10.3390/nursrep16010028

30. Cesare M, Nurchis MC, Damiani G, Cocchieri G. A nursing, public health, ranking nursing diagnoses by predictive relevance for intensive care unit transfer risk in adult and pediatric patients: a machine learning approach with random forest. Healthcare. 2025;13(11):1339. doi:10.3390/healthcare13111339

31. Sobia M, Muhammad K. The role of transformational leader in developing knowledge culture in public sector hospitals. Int J Organizat Leadersh. 2017;6(4):511–524.

32. Kube L, Kühlein T, Sebastiao M, Unger C. Hospital culture: defensive medicine as perceived by medical students: a qualitative study. Deutsches Arzteblatt Int. 2026;123(8):231–232. doi:10.3238/arztebl.m2026.0024

33. Alston L, Pu D, Wood S, et al. Embedding research into the organisational structure of smaller rural hospitals: building research culture and capacity and understanding perceived rural health workforce benefit. BMC Health Serv Res. 2025;25(1):1008.

34. NHC. Guidelines on Hospital Culture Construction (2021-2025). China: National Health Commission, Press; 2021.