Archives of

. Introduction
Knowledge is a valuable resource for the growth of people and an invaluable capital for the organization. In fact, in stable societies, the relationship between knowledge management and healthcare has always been considered a vital element for social development [1,2]. Knowledge management is defined as the process of creating, acquiring, sharing, preserving, and applying knowledge [3,4]. Organizational knowledge management generally focuses on facilitating knowledge transfer among people and the development of shared knowledge within an organization [5]. In healthcare organizations, similar to other organizations, knowledge-based groups and intellectual asset protection cores are frequently seen among individuals and sectors, but these are not utilized for learning and organizational decision-making. On the other hand, losing human resources due to various reasons leads to the exit of intellectual capital from the system, highlighting the necessity of the effective use of organizational knowledge resources [6]. Compared to the business sector, healthcare agencies have recently accepted the philosophy of knowledge management [7]. Therefore, it is necessary to use knowledge management systems to enforce the sustainability and feasibility of health processes [8]. On the other hand, knowledge creation raises a stable competitive advantage in the functional performance of organizations and leads to the provision of the best possible services [2,9]. For this reason, healthcare experts have recently shown research interest in evaluating the quality of a hospital-oriented knowledge environment [10]. Executive managers, experts, and specialists working in healthcare centers have wide knowledge needs; however, professional knowledge assets are often limited or difficult to possess, which subsequently limits the creation of professional knowledge [2,3].
Knowledge creation is one of the ways to achieve a competitive advantage, and this important is accessible through interaction and Collaboration. Therefore, in organizations where people have high Collaboration
The Effects of Collaboration Culture on Knowledge Creation: A Study in Hospitals Affiliated to Qom University of Medical Sciences
Shahrokh Rahbar1ID, Alireza Omidi Oskouei2ID, Ahmad Rahbar2*ID
1Department of Physiology and Pharmacology, Qom University of Medical Sciences, Qom, Iran
2Department of Public Health, School of Health, Qom University of Medical Sciences, Qom, Iran
*Corresponding Author: Ahmad Rahbar, Email: ahm418rahbar@yahoo.com
Abstract
Background & Aims: Organizational culture and knowledge management affect all aspects of an organization. Thus, in this study, we aimed to investigate the impact of the components of Collaboration culture on knowledge creation in hospitals affiliated with Qom University of Medical Sciences in 2017.
Materials and Methods: This cross-sectional-analytical research was conducted on 570 employees of the hospitals affiliated with Qom University of Medical Sciences. The research tool was a researcher-made questionnaire with a five-point Likert scale. The validity of the questionnaire was confirmed through content validity and convergent validity, and its reliability was assessed by Cronbach’s alpha method and composite reliability. The data were analyzed using SPSS 20 and Lisrel 8.8 software employing exploratory factor analysis, confirmatory factor analysis, and structural equation modeling.
Results: The means and standard deviations of Collaboration culture and knowledge creation were 3.071 ± 1.301 and 3.28 ± 1.11, respectively; their Cronbach’s alpha coefficients were 0.972 and 0.944; their composite reliability indices were obtained as 0.782 and 0.847, and the convergent validities of these domains were as 0.810 and 0.852, respectively. Exploratory factor analysis classified the constructs into the two sections of learning culture and knowledge creation, which were confirmed by fit indices.
Conclusion: The results showed that the Collaboration culture component has a positive and meaningful relationship with the knowledge creation component. Therefore, hospital managers should notice the benefits of providing the necessary infrastructure for the implementation of knowledge management and holding workshops for employees to educate them on the fundamentals of cooperation culture and knowledge creation.
Keywords: Hospitals, Intersectoral collaboration, Culture, Knowledge
Received: December 15, 2021, Accepted: February 2, 2022, ePublished: December 29, 2022
https://jhygiene.muq.ac.ir/
10.34172/AHS.11.4.373.1
Vol. 11, No. 4, 2022, 240-247
Original Article
Arch Hyg Sci. Volume 11, Number 4, 2022 241
The Effects of Collaboration Culture on Knowledge Creation
attitudes, knowledge management and, accordingly,
professional knowledge creation have a special place [1].
New professional knowledge can be created by experts
through exchanging and merging knowledge [11].
One of the basic and inherent features of knowledge
management in healthcare centers is its competitive
advantage, rendering the capability of producing
professional knowledge essential to remain in such a
competition [1,12]. Because of this, having a positive
attitude or perception toward knowledge management
can facilitate knowledge creation or knowledge sharing
by hospital staff [13].
Organizational culture refers to social ideologies,
functions, norms, and behaviors and can provide the
organization with opportunities for integration and
distinction [14]. Organizational culture, as an important
knowledge infrastructure, refers to an organization’s
perspectives and values and the determinants that nurture
learning and cooperation [15]. The most valuable ideas
emerge when employees can put together their mental
efforts based on the cooperation culture [11]. Poor and
inflexible organizational culture causes employees to
accustom to the existing procedures, so there will be
no desire for cooperation to solve the organization’s
problems. On the other hand, in a dynamic and flexible
organizational culture, employees can keep their
organization on the path of progress and react well to
sudden changes [16].
Available research shows that organizational culture
plays an important role in supporting knowledge
management plans in hospitals [3] and contributes
to the continuance, expansion, and stability of the
organization in a competitive environment [12]. The
results of studies show that the culture of cooperation
among employees in official and non-official meetings is
one of the knowledge-creation methods in hospitals [1].
Other studies have reported that socio-technical drivers,
such as the culture of cooperation, trust, and learning,
can independently predict the knowledge-creation
process [12]. Other studies conducted in this area have
highlighted the need to pay attention to interactions
Collaboration, and information exchange among
personnel, as a valuable collection in order to produce
professional knowledge [11]. It has also been indicated
that Collaboration and interaction between employees,
networking, objectification, and information sharing
can lead to knowledge creation [17]. Other researchers
have described a strong correlation coefficient between
organizational culture and knowledge management,
as well as a positive relationship between the culture
of Collaboration and knowledge management [18,19].
According to the aforementioned, it can be concluded
that the culture of Collaboration plays an important role
in knowledge management and, particularly, knowledge
creation. Nowadays, hospitals are facing many challenges
in delivering the best possible services to clients [2]. On
the other hand, healthcare provision is a knowledgebased
process; therefore, knowledge management and
having a dynamic and flexible culture in hospitals can
be an opportunity for the organization to improve its
functional performance and place itself on the path of
progress [5,20]. So far, little research has been conducted
on the effects of the culture of Collaboration on knowledge
creation in healthcare centers, and most of the available
studies have been carried out in administrative and
service environments. Thus, the present research aimed
to investigate the impact of the culture of Collaboration
on knowledge creation in the public hospitals of Qom
province, Iran.
2. Materials and Methods
This was a cross-sectional-analytical study conducted
in 2018. The statistical population of the study included
all the headquarters staff (administrative, financial,
and support), medical staff (doctors, nurses, midwives,
operation room technicians, and anesthesiologists),
and paraclinical staff (laboratory and radiology) of the
six teaching hospitals affiliated with Qom University
of Medical Sciences. Based on the standard sample size
proposed in factor-analysis studies, suggesting between 3
and 20 samples per variable [21,22], the sample size was
calculated as 200. As the statistical population consisted
of six independent hospitals with different numbers
of employees, we initially used the stratified sampling
proportional to size method so that the number of
subjects from each hospital is proportional to the number
of its employees. In the next step, from a list of personnel
provided by the administrative unit of each hospital,
subjects were randomly recruited from each ward using
a systematic sampling strategy. It should be noted that in
order to increase the accuracy of the data, a total of 570
samples were recruited in this research. The participants
in this study were selected among those having at least
four years of work experience and full-time activity in
the hospitals studied. Therefore, these participants were
completely familiar with procedures because of their rich
4-year experience, attending numerous meetings, and
being members of hospital committees. Incompletely
answered questionnaires were excluded from the study.
Eligible participants were initially requested to sign a
written informed consent form and were assured that
their information would remain confidential.
The research tool in this study was a researchermade
questionnaire. These items (variables) in this
tool were identified and modified after conducting a
library study, reviewing related articles, and based on
consultation with experts who were university professors.
This questionnaire consisted of two sections. The first
part included demographic information (age, gender,
educational level, work experience), and the second part
Rahbar et al
242 Arch Hyg Sci. Volume 11, Number 4, 2022
included questions about the dependent and independent
variables. The items related to the dependent variable
(i.e., knowledge creation) were extracted from studies by
Gold et al and Najafbeygi et al and then were modified
and adjusted accordingly [23,24]. The items related to
the independent variable of the culture of Collaboration
were extracted from studies by Islam et al, Gold et al,
and Najafbeygi et al [23-25]. and then were modified,
adjusted, and used. Finally, the variables of the culture
of Collaboration and knowledge creation were measured
based on four and six items, respectively, on a 5-point
Likert scale. Complete agreement (i.e., completely agree)
was assigned with a score of five, and full disagreement
(completely disagree) with a score of one.
In this study, the questionnaire’s psychometrics
features were assessed using content validity, face
validity, and convergent validity. Regarding content
validity, the content validity index (CVI), and content
validity ratio (CVR) were measured by ten experts in
the field. For calculating CVR, the questionnaire was
provided to ten university professors in the field of health
management to express their opinions about each of the
questions as either “it is necessary”, “it is not necessary,
but it is important”, or “it is not necessary”. Using the
related formula, CVR was then calculated, and according
to Lawshe’s table, the items acquiring values greater than
0.62 were accepted [26]. Moreover, the same ten experts
were requested to assess the queries in terms of relevancy,
simplicity, and clarity on a four-point Likert scale (for
example, 1: irrelevant, 2: somehow relevant, 3: relevant,
and 4: completely relevant) to calculate CVI. Then the CVI
score was calculated by summing up the scores of positive
responses (i.e., the highest scores, 3 and 4) given by all the
scorers, and finally, the items that acquired a score higher
than 0.79 were selected [26]. Face validity, as a qualitative
parameter, assesses the level of difficulty, inconsistency,
and ambiguity in the questionnaire’s phrases, as well
as in the meanings of words for each item. Experts’
opinions were considered, and minor modifications were
introduced to the items of the questionnaire.
Also, in this study, Cronbach’s alpha and composite
reliability were used to evaluate the tool’s internal
consistency and reliability. Exploratory factor analysis
was used to summarize and categorize the variables,
and confirmatory factor analysis was used to assess the
measurement model and determine the construct validity
(or latent variable) of the instrument using SPSS20 and
Lisrel 8.8 software. Also, structural equation modeling
was used to determine the model’s fit indices.
3. Results
The results showed that 33.3% of the participants were
male, and 66.7% were female. Also, the mean age of the
participants in this study was 35.41 ± 6.901 years. Of the
participants, 62.6% were nurses; 1.8% were midwives,
14.5% were working in the middle-level managerial
sectors; 4.6% were paraclinical experts, and 10.2%
were working in other parts of the hospitals. Regarding
education level, 88% of the participants had bachelor’s
degrees; 7.4% held master’s degrees; 1.1% had professional
doctorate degrees, and 3.5% had specialized doctorate
degrees. The mean (standard deviation) scores of the
cooperation culture and knowledge creation components
were obtained as 3.07 ± 1.30 and 3.28 ± 1.11, respectively.
The results of exploratory factor analysis, along with
varimax rotation, showed that the Kaiser-Meyer-Olkin
(KMO) value of the sample population in this study
was equal to 0.938. Bartlett’s sphericity test rendered
a statistically significant result at the level of P = 0.001.
Further, the two factors revealed eigenvalues greater
than one, explaining 86.872% of the total variance of
the dependent variable by the predictor variables. The
predictor variables that had commonalities of less than
0.5 were omitted in the exploratory factor analysis.
Table 1 summarizes the results obtained from the
measurement model (or confirmatory factor analysis),
showing that standard coefficients were between 0.85 and
0.95, which are suitable for subsequent analyses. Also,
the factor load of each indicator, along with its construct,
revealed a “t” value greater than 1.96, reflecting that the
hidden construct had the least required accuracy. Table 1
demonstrates the R2 value, which ranges from 0.72 to
0.90. The internal consistency of the instrument was
evaluated by Cronbach’s alpha coefficient and composite
reliability, rendering the values of 0.944 and 0.782 for
the cooperation culture component and 0.972 and 0.847
for the knowledge creation component, respectively.
Also, convergent validity, which examines each item’s
correlation with its questions, and in fact, represents
the average shared variance (AVE) of each item with its
questions, was obtained as 0.810 for the Collaboration
culture component and as 0.852 for the knowledge
creation component.
Fit indices generated by Lisrel software have been
provided in Table 2, revealing good fit indices in all cases.
Table 3 shows the direct, overall, and indirect standardized
effects of the collaboration culture component on
knowledge creation. As shown, the Collaboration culture
component, with a path coefficient of 48%, had a direct
effect on knowledge creation in hospitals affiliated with
Qom University of Medical Sciences.
Figure 1 describes an estimation of the standard
coefficients of the study’s model, which is an output of
LISREL software and represents acceptable standard
coefficients. All these coefficients and their numerical
values have been presented in Table 1.
Figure 2 shows the estimation of the significant
coefficients of the study’s model obtained from Lisrel
software. All significance coefficients were acceptable,
representing the acceptability of the results of structural
Arch Hyg Sci. Volume 11, Number 4, 2022 243
The Effects of Collaboration Culture on Knowledge Creation
Table 1. The results of descriptive statistics and evaluation of reliability and convergent validity in confirmatory factor Analysis
Construct Items Mean ± SD
Standard
Coefficients
Significance
Coefficients
Outcome R2 Cronbach’s
Alpha
CR AVE
Collaboration
culture
Employees help each other perform
their job duties to achieve common
goals in their ward.
3.67 ± 0.854 0.92 28.25 confirmation 0.84
0.944 0.782 0.810
When doing teamwork, employees
prefer collective benefit over personal
benefit.
3.22 ± 1.04 0.92 28.39 confirmation 0.84
Hospital employees tend to work as
a team
3.39 ± 0.975 0.91 28.21 confirmation 0.82
When doing their work, hospital
employees accept honest feedback and
new ideas from each other.
3.32 ± 0.931 0.85 25.01 confirmation 0.72
Knowledge
creation
Employees are interested in producing
novel ideas and knowledge related to
their job.
3.27 ± 1.18 0.93 - disapproval 0.86
Employees are interested in doing
scientific research to solve their work
problems.
3.28 ± 1.19 0.92 41.02 confirmation 0.84
0.972 0.847 0852
Employees tend to develop new ideas
through the system of recommendations
and consultation meetings.
3.29 ± 1.18 0.92 40.26 confirmation 0.84
Employees learn from their mistakes
and provide feedback to the relevant
department.
3.29 ± 1.19 0.91 38.53 confirmation 0.82
After visiting pioneering teaching
hospitals, employees present some new
ideas
3.29 ± 1.20 0.91 39.34 confirmation 0.82
Employees participate in brainstorming
sessions to find solutions to problems.
3.26 ± 1.19 0.95 45.13 confirmation 0.90
Fit indices generated by LISREL software have been provided in Table 2, revealing good fit indices in all cases.
Table 2. Variables, test results, and fit indices in structural equation modeling
Fit Indices
Chi-square/df 1.58 Normed Fit Index (NFI) 1.00
The goodness of fit index (GFI) 0.98 Relative Fit Index (RFI) 0.99
Adjusted Goodness of fit index (AGFI) 0.97 Incremental Fit Index (IFI) 1.00
Comparative fit index (CFI) 1.00 Root Mean Square Error of Approximation (RMSEA) 0.032
Non-Normed Fit Index (NNFI) 1.00 Standardized Root Mean Square Residual (SRMR) 0.014
Standard and Significance Coefficients of Research Items in Structural Equation Modeling
Independent variable Beta coefficient Significance coefficient
Cooperation culture 0.48 11.46
Table 3. Investigating the direct, indirect, and overall effects of learning culture on knowledge creation in the public hospitals of Qom province
Type of effect Variable
Collaboration
culture
Collaboration
Culture1
Collaboration
Culture2
Collaboration
Culture3
Collaboration
Culture4
Direct Impact Knowledge Creation 0.48 - - - -
Indirect Impact Knowledge Creation - 0.441 0.441 0.436 0.408
Total effects
K. Creation1 - 0.410 0.410 0.406 0.379
K. Creation2 - 0.406 0.406 0.402 0.375
K. Creation3 - 0.406 0.406 0.402 0.375
K. Creation4 - 0.401 0.401 0.397 0.371
K. Creation5 - 0.401 0.401 0.397 0.371
K. Creation6 - 0.419 0.419 0.415 0.387
Rahbar et al
244 Arch Hyg Sci. Volume 11, Number 4, 2022
equation modeling and confirmatory factor analysis. All
these coefficients and their numerical values have been
presented separately in Table 1.
4. Discussion
In this study, structural equation modeling provided
acceptable results in order to understand the effects
of the culture of Collaboration on knowledge creation
in hospitals affiliated with Qom University of Medical
Sciences, understanding which can improve the process
of knowledge creation in teaching hospitals. The present
study is among few studies that have solely investigated
the impacts of the culture of Collaboration and its related
items on knowledge creation. Therefore, our findings can
provide a basis for conducting more research in this area
in the future.
In this study, we proposed an integrated framework
regarding the link between cooperation culture and
knowledge creation based on the available literature and
previous studies and using factor analysis, confirmatory
factor analysis measurement models, as well as structural
equation modeling. Moreover, these findings were
confirmed by various fit indices. As stated by Liao et
al [27], factor loadings above 0.45 are significant and
acceptable. In this study, the factor loadings of the items
ranged from 0.85 to 0.95. Considering that significant
coefficients (or “t” values) for all sub-factors of each main
factor exceeded 1.96, it can be said that the variables
assessed provided an appropriate estimation of the
corresponding main factor, and therefore, the factors and
variables could fit into modeling structural equations of
the research (i.e., structural equations did not need to
modify any factor or variable) [28]. Cronbach’s alpha
coefficients of the cooperation culture and knowledge
creation components were obtained as 0.944 and 0.972,
respectively, which are higher than the recommended
Figure 2. The estimation of the significant coefficients of the study’s model Through structural equation modeling and confirmatory factor analysis
Figure 1. Estimating the standard coefficients of the research model by structural equation modeling and confirmatory factor analysis
Arch Hyg Sci. Volume 11, Number 4, 2022 245
The Effects of Collaboration Culture on Knowledge Creation
acceptable level (i.e., 0.70), as noted by Liao et al [27].
The composite reliability obtained in this study is higher
than the recommended minimum value of 0.7, which
shows acceptable composite reliability [29]. In their
study, Taghavi et al recommended an AVE higher than
0.50 for variables [30]. In this study, the AVE values
obtained for the culture of collaboration and knowledge
creation components were higher than the standard,
indicating good convergent validity (i.e., consistency of
each component with its questions).
In the present study, the fit index of RMSEA was
below the recommended upper limit of 0.05, reflecting
the suitability of the fit model [31]. The results of this
study showed that the ratio of Chi-square to the degree of
freedom (χ2/df) was lower than the recommended upper
limit of 5. In addition, the SRMR fit index was lower than
the recommended upper threshold of 0.08, and the GFI,
AGFI, NFI, CFI, and IFI indices were also higher than the
suggested lower limit of 0.90, reflecting a good fit [32].
The results of the present study showed that the
culture of Collaboration component had a positive and
significant effect on knowledge creation. In this regard,
the direct effect of the culture of collaboration on
knowledge creation attained an impact factor of 0.48. In
line with the results of the present study, Najafbeygi et
al, in a study on the state organizations of the Khorasan
Razavi province of Iran, reported a net impact factor of
0.40 for the culture of cooperation on knowledge creation
[24]. Consistently, Ajanaku and Mutula recognized that
organizational culture, as an important infrastructure
for the implementation of the knowledge management
process, had a positive and meaningful impact on nurses’
performance with an impact factor of 0.46, which was
statistically significant [15]. The results of Lee, who
conducted a study on four hospitals in South Korea,
showed that the independent variable of collaboration
culture had a positive and significant effect on the
dependent variable (i.e., knowledge creation) in only
two of the four hospitals with the impact factors of 0.13
and 0.26, confirming our observation in the present
study [4]. In agreement with our results, Alavi et al
demonstrated that people working in environments with
an appropriate organizational culture, where cooperation
is considered a value and there is strong Collaboration
culture in the organization, employees feel more belong
to and dependent on the organization, which eventually
grabs their interest in participating in knowledge creation
and knowledge sharing [33]. In another study, Minh
and Loc declared that knowledge creation influenced
organizational performance mediated through
organizational culture (participation, Collaboration,
responsibility, and loyalty), reporting a total impact
factor of 0.31. These findings agree with the results of
the present study, suggesting a role for organizational
culture, as a crucial infrastructure in the process of
knowledge management, in upgrading the organization’s
status through knowledge creation [34]. Confirming
the results of the present study, Pourtaheri et al in their
research found a positive and meaningful relationship
between the culture of Collaboration and the knowledge
management process (β = 0.59, P = 0.001), reflecting the
high importance of the culture of collaboration in the
hospital [19]. In another study, Khalaj and Zareiyan
noted that the culture of cooperation had a positive
effect on the implementation of knowledge management
components with a path coefficient of β = 0.33 [35].
Also, Sohrabi et al, in their study, reported a positive
correlation (r = 0.92) between organizational culture and
knowledge management [18]. These findings, which all
are in line with our results, embolden the importance of
encouraging the collaboration culture in an organization
in order to implement knowledge management.
Figure 2 shows the estimated significant
coefficients of the model for the collaboration
culture and knowledge creation components,
as well as the variables clearly related to them.
In this figure, the t-value represents statistical
generalization calculations for all path coefficients.
If the coefficient obtained for each path is less than
1.96, the path is omitted because the calculations
related to that variable can only be applicable to the
studied population, but they are not generalizable
to the entire population with 95% confidence [36].
As demonstrated in Figure 2, this notion is true for
knowledge creation and its No. 1 component.
5. Conclusion
The results of the present study showed that the hospitals
affiliated with Qom University of Medical Sciences
acquired average scores in terms of the cooperation
culture and knowledge creation components. Also, the
items of cooperation culture had the largest impact on
the variable of “finding solutions to problems through
knowledge-creating brainstorming sessions”. Without
implementing and institutionalizing cooperation culture
and knowledge creation among hospital staff, it will
be troublesome to provide quality services to patients.
Therefore, it is of great importance to developing
knowledge-based strategies to objectify the organization’s
hidden assets so that the hospital can maintain its
competitive advantage. Therefore, it is suggested that
hospital managers, along with providing the necessary
infrastructure to implement the knowledge management
process, hold training sessions for employees to teach
them the basics of cooperation culture and knowledge
creation.
Acknowledgments
We appreciate all esteemed individuals who cooperated with us in
conducting this research.
Rahbar et al
246 Arch Hyg Sci. Volume 11, Number 4, 2022
Conflict of Interests
The authors declare that this work is the result of a research project
approved by Qom University of Medical Sciences and does not
have any conflict with the interests of other organizations and
individuals.
Ethical Approval
This article was a part of a research project entitled “Factors
Affecting the Implementation of Knowledge Management in
the Teaching Hospitals Affiliated to Qom University of Medical
Sciences in 2018”. This project received an ethics code (IR.MUQ.
REC.2017.136) from the Ethics Committee of Qom University of
Medical Sciences.
Funding
This study was financially supported by Qom University of Medical
Sciences.
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