Organizational cultures were first conceptualized as part of the human relations movement in the 1930’s, but did not become widely known in the healthcare field until the 1980’s. Organizational culture has been defined as the organization’s norms, values and assumptions [1]. In healthcare settings, organizational cultures represent the visible façade of how physical spaces are organized and how staff behave to get their jobs done. This includes the range of behaviours that are seen as normal and acceptable, the pathways to care, clinical practices, shared ways of thinking, patterns of communication, and patterns of interaction [2]. Gillin and colleagues note that over the last twenty years, there has been a growing understanding that negative healthcare cultures (such as those where fear, bullying, acceptance of poor standards) can create safety failings (such as medication errors) and poor quality of care. Consequently, shaping cultures of care is increasingly viewed as an important means of improving safety and performance outcomes across the full spectrum of healthcare settings, and promoting high-quality, person-centered care. The management of cultures of care is increasingly considered to be a key aspect of health system reform and interest in the concept of promoting more caring cultures has grown [3].

Toward this end, mental health system reformers and advocates have repeatedly called for massive transformations in the way healthcare is provided to people with mental health and substance use disorders. Within the mental healthcare system, recovery-oriented care principles have been highlighted as one important element of organizational cultures in need of improvement. While many specific definitions of recovery exist, recovery-oriented environments have been conceptualized as ones that encourage individuality, promote accurate and positive portrayals of people with mental illnesses, fight prejudice and discrimination, focus on strengths, use hopeful language, offer a variety of treatment and support options, support risk-taking even when failure is a possibility, actively involve clients and family members in decision making, encourage participation in advocacy activities, help develop connections with communities, and help clients develop valued social roles, interest, and other meaningful activities [4]. Outside of the mental health system, many of these principles are embodied in the notion of person-centred care. Person-centred care values people, respects people as individuals, values the totality of the individual, and organizes care to meet their needs [5]. Cultures of care that exude negative and disempowering policies and practices, defined here as ‘stigma cultures’, undermine every aspect of recovery-oriented and person-centred care and act as an important barrier to system transformation, including the development of professional competencies.

Several reviews [6, 7] have noted that people with mental and substance use disorders experience considerable stigma in healthcare settings. Recurrent themes in the literature include feeling punished, patronized, humiliated, spoken to as if they were children, being excluded from treatment decisions, and being assumed to lack capacity to make treatment decisions. Other problems include prognostic negativism (being told they will never recover), not being given sufficient information about their illness or the treatments (such as medication side effects), experiencing an unspoken threat of coercive care, or in some instances, experiencing overtly coercive care such as involuntary hospitalization or seclusion [6, 7]. Indeed, fear of experiencing stigmatizing healthcare cultures is an important determinant of treatment avoidance, particularly among people who have been exposed to historical or current mistreatment by punitive healthcare systems, such as racialized, Indigenous, or immigrant populations [8]. In discussing lessons learned from anti-stigma initiatives, Stuart and Sartorius [8] describe how structural stigma works at multiple levels in the health system, from government decisions concerning funding, to fragmentation of care at the local service level, to punitive cultures of care within health systems. Rather than cultures of caring, they report that people with mental illnesses or substance use disorders are often confronted with care experiences that are punitive, demeaning, dehumanizing, and patronizing. Staff don’t relate to their clients as people and there is little awareness or expression of recovery principles. Care routines are experiences as invasive, coercive, repetitive—for the convenience of the system rather than the individual patient or their family members. In this paper, structural stigma is understood as located in the fabric of healthcare organizations through organizational structures such as policies, procedures, and practices, and expressed and experienced by clients through stigmatizing cultures of care that are not patient-centered or recovery oriented [9]. Structural stigma in healthcare settings creates poor quality of care and a lack of person-centered care. In some settings, such as emergency rooms or specialized mental health facilities, structural stigma may be expressed through overtly negative provider interactions, punitive or coercive care. Structural stigma in healthcare settings is one aspect of the broader stigmatization process such as that described by Link and Phelan [10].

A central approach to understanding stigma has been to focus on micro-level interactions that occur between people, such as one-on-one interactions with a particular healthcare professional such as a family doctor and a patient. More recently, researchers have begun to examine macro level influences recognizing that disadvantage can flow from broader structural factors such as cultural norms and institutional policies that constrain opportunities and impact the health of individuals with a mental or substance use disorder [11]. Indeed, a growing body of research is examining how structural disadvantage accumulates over time through social policies, laws, institutional practices, and negative attitudinal social contexts [12].

To assess the effectiveness of initiatives designed to reduce stigma cultures in healthcare, it is necessary to have appropriate and well tested measures that can be generalized across different healthcare settings. Valid and reliable measures are not only important to furthering research into stigma cultures, but also for developing and monitoring healthcare policies and system reform.

Numerous quality of care measurement instruments have emerged, but rarely have they undergone extensive testing, validation, or structural confirmation [13]. Existing tools typically measure quality of care from the perspective of employees and focus on climate related aspects such as relationships, communications, quality of work life, and healthcare worker outcomes [1], and quality of care is only one aspect of a stigmatizing healthcare culture. In 2009, for example, Scott and colleagues [14] systematically reviewed 13 instruments. All examined employee, rather than patient perceptions.

Jung and colleagues [15] reviewed instruments measuring organizational cultures. Out of the 70 instruments they identified, none had robust reliability or validity data, and none took the perspective of the client. An extensive review and description of measurement tools designed to assess organizational cultures conducted by Rafferty and colleagues showed similar results. Few had grounded their development in the experiences of service users and most targeted the opinions of healthcare workers focusing on domains such as organizational values, leadership styles, team support, or relationships with colleagues. Few had been rigorously tested [16]. Finally, in an extensive review of 503 measures designed to assess person-centered healthcare commissioned by the Health Foundation in the United Kingdom [17], researchers found that the largest portion of studies (two-thirds) were conducted in hospital settings using research that had been developed by academic researchers who had worked with healthcare teams as part of quality improvement initiatives—not clients. Just over half addressed person-centred care as a holistic concept, but none would be appropriate to a range of healthcare settings beyond hospitals. The remainder measured one or more specific processes such as choice, compassion, integration, privacy, or trust. Only 18 of the holistic measures were directed to service users or family members.

While all the measures contained in these reviews assessed some aspect of organizational culture, none was purpose built to assess key aspects of stigmatizing healthcare cultures such as poor quality of care, negative interactions, or lack of person-centered care as they are experienced by people with mental or substance use disorders. This paper describes the development and testing of a measure designed to fill this important gap.