title: Organizational hierarchies in Bulgarian hospitals and perceptions of justice.
abstract: OBJECTIVE
  Health care reform in Bulgaria has been ongoing for two decades. Since 1990, it has been transforming from a socialized system of medical care with free access, to one which is decentralized, includes private health care services, the general practitioner model and a National Health Insurance Fund. In this context, we are conducting an international EC Framework 7 project: 'Improving quality and safety in the hospital: The link between organizational culture, burnout, and quality of care'. We focus on health professionals' perceptions of organizational hierarchies in Bulgarian hospitals and how doctors and nurses connect these to organizational justice.
  
  
  METHODS
  We conducted seven focus groups and four interviews, with a total of 42 participants (27 nurses, 15 physicians and medical residents) in three hospitals. Data were analysed through thematic analysis and discourse analysis with Atlas.ti.
  
  
  RESULTS
  From the perspective of health professionals, health reform has intensified traditional hierarchies and inequalities and has created new ones in Bulgarian hospitals. These hierarchies are continuously (re)constructed through language and practices and also destabilized through resistance. The health professionals protest fact that these hierarchies are permeated with unfairness and silence voices. All health professions (nurses, doctors, residents) in our study experience being unjustly positioned and disempowered in various hierarchies. They connect these experiences to stress and anxiety.
  
  
  CONCLUSIONS
  Participatory action research needs to address multiple dimensions of organizational relationships in Bulgarian hospitals, including hierarchical relationships and ways of promoting organizational justice.
  What is already known on this subject? Health care organizations are hierarchically organized. Organizational injustice can contribute to burnout in health professionals. There is a high level of stress and burnout for health professionals in Bulgaria. What does this study add? This study adds understanding of changing hierarchies in hospitals during health care reform in the post-socialist period. Illuminates how health professionals' discourse sustains and resists hierarchical relationships in Bulgarian hospitals. Adds understanding of health professionals' perspectives on implications of injustice for their well-being.
authors.affiliation: Northeastern University, Boston, Massachusetts, USA.
authors.forename: Irina L G
authors.initials: IL
authors.lastname: Todorova
authors.forename: Anna
authors.initials: A
authors.lastname: Alexandrova-Karamanova
authors.forename: Yulia
authors.initials: Y
authors.lastname: Panayotova
authors.forename: Elitsa
authors.initials: E
authors.lastname: Dimitrova
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D002031:Bulgaria; D005260:Female; D017144:Focus Groups; D018166:Health Care Reform / Q000458:organization & administration*; D006785:Hospitals, University / Q000458:organization & administration*; D006801:Humans; D008297:Male; D008505:Medical Staff, Hospital; D008875:Middle Aged; D009741:Nursing Staff, Hospital; D015279:Organizational Culture; D009936:Organizational Innovation; D036301:Qualitative Research; D012935:Social Justice