Perceptions on Ideal and Real-world Social and Healthcare Services Management : Evidence from the Czech Republic , Finland , and Portugal Comparison

The purpose of this exploratory qualitative research is to map the situation of culture and quality management in social and healthcare (SH) services as experienced by management students in the Czech Republic, Finland, and Portugal. The intercultural theories and contemporary principles of healthcare management form the theoretical background of the research. The explored central phenomenon is conceptualized as the experience of the differences between ideal and real-world situations in the SH sector. Three mutually dependent analytical categories—management perceptions, environment for SH services, and country-level perceptions with 12 subcategories—have been constructed from the testimonies. The common underlying ideals mirrored in the perceptions have been deconstructed as the result of the cultures of business management and care, which influence the students’ perceptions. This exploration has been valuable in defining an under researched territory of cross-cultural management in healthcare. Specific variables and potential dynamics among them are identified, allowing for a more focused study of the phenomenon in the future.


Introduction
With more extensive European integration and increasing cross-border mobility, cultural diversity has become a key factor in the education of managers.Even in the training of human resource management (HRM) specialists, international variations and contextual effects are issues that should be considered so that an appropriate level of commonality can be established (Noble, 1997).Numerous studies have acknowledged the effects of cultural values on managerial behavior and actions (Aycan et al., 2000;Hofstede, 2001;Schwartz, 2004) but no such research has been devoted to management in the social and healthcare (SH) sector.This backdrop motivates the present study, which is the first phase of the initiative to develop an international educational program for the SH industry.
The interviews were carried out in four FGs, in which a total of 29 students participated.Each university organized one FG (with 3-10 participants) with their own students; the national FG sessions were conducted in the students' native language.The last FG session was international, was conducted in the English language, and featured two participants from each university.The data were collected in 2013.The interviews were video-and audio-recorded and then transcribed for analysis.

Ethical Issues
Ethical approval was obtained from each university attended by the students.The students consented to participate in the FGs.In all the stages of the study, we thoroughly explained the ethical issues to the participants.The students were informed about the study's aims and their right to freely decide on participating in or withdrawing from the study.All the participants were assured anonymity and confidentiality.

Data Analysis
The testimonies from the FGs were coded.Clusters of similar testimonies were conceptualized; first-and second-order clusters were categorized.These clusters were then related to the original testimonies (triangulation was particularly necessary because four languages were used in the process) during team discussions.The similarities and differences within the categories were identified by the same procedure (a draft was discussed and then presented for approval in a triangulation process).Three substantial analytical categories-management perceptions, environment for SH services, and country-level perceptions-were constructed.

Background for Conceptualization
Based on Schein's (2004) work, the concept of culture is understood in the current study as the relatively stable pattern of meanings, attitudes, and practices that result from shared learning and mutual experiences in reaching common goals over a period of time within specific environments.
In formulating the management perception category, we draw on the theoretical framework of managerial culture that is based on the Western rationalist, means-ends paradigm.This paradigm assumes that people have goals and act in a rational manner in satisfying such goals and dealing with the logical consequences of pursuing the goals.An alternative understanding of this paradigm primarily revolves around the consideration of the functional models and practices expressed in the literature on business management.The dominant approach to teaching management in all the three participating universities is HRM.
A specific subculture of management, which is based on the general culture of the same field, has developed accordingly in the area of health and social management.This is a matter of relatively recent development and has arisen as one of the effects of new public management ideologies that have prevailed in most European countries since 1990.In the Czech Republic, the first master's programs oriented toward SH organizational management (Charles University in Prague, Faculty of Humanities [FHS UK], 2014) were initiated in 2000.An official specialization in the field of health management was established only five years ago.In Finland and Portugal, the master-level programs for SH management are also still rare.
Several researchers found differences in values between business-oriented managers and managers with a professional background in healthcare.Carney (2006) examined the different outcomes of the values held by healthcare clinicians and nonclinician managers.Hopkirk and Deuchar (2011) described the tensions between managerial and professional values in the National Health Service (NHS) system in Great Britain.Similar tensions could have been reflected in the perceptions of SH students.Kwantes and Dickson (2011) used the concept of isomorphic pressure to express the perceived influence of a certain culture on the values, attitudes, and practices of its members.The authors argued that the larger the number of cultures, in which the person has a membership, the greater are the effects of such additional pressures, with possibly contrasting influences.
In this sense, the SH management students could be expected to be under the influence of two relatively contrasting isomorphic pressures: those from general "business" models and practices and those from the SH culture, which might both influence their expectations from the ideal situation in SH services.
In the Czech Republic, Finland, and Portugal, the category of environment of the SH sector services is characterized by a mixture of public and private ownership but the former has a dominant influence.The nature of public administration in each country creates a specific environment that affects how SH services function.This feature is reflected in some of the testimonies as a phenomenon that strongly conditions SH management practices.
In their model of HRM culture fit, Aycan et al. (2000) referred to an "enterprise environment" with subcategories such as market characteristics, nature of the industry, ownership/control, and resource availability.The last one has also been prominent in this research.
The third category, country-level perceptions, cannot be labeled "national" or "cultural," as argued by Sawang, Tian, and Yong (2006).Aycan et al. (2000) constructed two categories with similar meanings: sociocultural environment and sociocultural dimension.In the current research, we have chosen only one category that covers both because we have limited qualitative data, which do not resemble the cultural dimensions used by Aycan et al. (2000).As indicated in the Results section, we have incorporated some details and data from previous intercultural management research into our category.We have borrowed mainly from two theoretical frameworks proposed in the works of Hofstede (2001) and Schwartz (1992Schwartz ( , 2004)).Hofstede (2001) conceptualized well-known dimensions of national cultures.The author understood culture as a collective programming of the mind, with such programming manifested in symbols, heroes, rituals, and values (Hofstede, 2001).He postulated that culture can be represented in terms of five dimensions: power distance, individualism/collectivism, masculinity/femininity, uncertainty avoidance, and future orientation.In a cross-national study GLOBE, House, Hanges, Javidan, Dorfman, & Gupta (2004) measured the same constructs under two alternatives that considerably differed from the representations proposed by Hofstede (2001).These alternatives were "should be" (values) and "as is" (practices) representations.Empirical studies have shown that national dimensions of culture predict which organizational processes and managerial practices are designed and/or adopted (Hofstede & Peterson, 2000).The specific country profiles in the cultural dimensions can be found on the website of the Hofstede Center (Hofstede, 2013).
Cultures and subcultures are often defined through shared values and norms, which are becoming key issues in understanding the underlying, historically developed patterns of thinking, behavior, and social habits that form in a specific culture.Studying cultural values has therefore become an implicit component when examining cultural differences.Schwartz (1992) treated values as criteria that people use for discretion and choice among activities, people, and directions for the future.The author determined how social experience and intercultural and international differences affect the prioritization of values and vice versa (Schwartz, 1992).Based on several empirical studies, he gradually constructed ten types of values, which he represented in a circular diagram that mirrors the motivational proximity of such values.The types close to the horizontal poles are self-direction and stimulation against conformity, tradition, and security.Those that are close to the vertical poles are universalism and benevolence against hedonism, power, and achievement.
The large-scale, international comparative research that the ESS conducted in 2002 and 2004 showed consistent prevailing differences in preference for values (assessed by Schwartz's questionnaire) among various groups of European countries.The data from the 2012 ESS round 6 on the three countries examined in the present study are used as reference in the discussion of the results.

Results
The conceptualized categories are not mutually independent.A metaphor of soil interfusion can be used to represent their mutual and simultaneous effects.The first category of critical management perceptions can be understood as a result of underlying management assumptions and care culture assumptions.The other two categories have been labeled the environment of the SH sector services and country-level perceptions (Figure 1).Each category contains subcategories, which specify its content.Examples of the testimonies are used to illustrate each constituted category and the interpretation of such a category is based on the professional literature.The codes and numbers are used for the participants, where testimonies illustrate the category, e.g.P1, C9 etc.

Management Perceptions
The students' critical attitudes toward real-life situations are centered on seven categories of testimonies, addressing the expectations on the management process (communicating visions and strategies, coordination of work, quality in practice), nature of leadership (leadership), knowledge management (adequate use of knowledge and competencies), moral expectations concerning human behavior and attitudes (responsibility, participation, and initiative), and core task (care-related perceptions in SH).
The perceptions concerning top and middle managers in the first two subcategories under management perceptions clearly mirror the effects of the Western rationalist means-ends approach and the resultant concepts of strategic and operational planning.

Communicating Visions and Strategies
The students argue that top managers often fail to unify and motivate organizations to follow a clear common direction.C1: … not to get crushed by the operative things, by what happens, but have the ideal and steer toward it.F3: The attitude toward clients starts from above, so there must be a completely new vision, mission, and communication by management with those at the bottom.P4: We learned a lot about communicating, and that the manager should be in contact with the employees, and getting the sort of input from the real work and what's happening there, and it's just not happening.

Coordination of Work
Employees are perceived by the participants as accomplishing unnecessary or overlapping work.This problem is attributed to the lack of specificity in competencies and the inability of team leaders at the middle management level to coordinate the members' performance of concrete tasks.

Quality in Practice
The concept of quality represents a specific source of pressure on isomorphism, not only in management (quality assurance systems, such as the International Standard Organization, Total Quality Management, and the European Foundation for Quality Management), but also in the SH sector.In 1997, the Council of Europe, in alliance with the World Health Organization (WHO) and the Organization for Economic Co-operation and Development, recommended the introduction of systems of quality and safety evaluation in healthcare (Council of Europe, 1997).International accreditation principles for quality in healthcare were defined by The International Society for Quality in Health Care (ISQuA) and the WHO.The focus on patients, the responsibilities of care providers, optimal resource use, risk management, and the implementation of all activities in strategic planning and other demands represent a general basis for quality management.Despite such progress, the students assert that no clear and common understanding of quality exists.Some of the students understand quality as a task of top management but the others call for a common understanding at the employee and client levels as well.The concept of quality and its corresponding perspectives originated in the business sector, and only recently were these infused into the culture and quality standards of care.Such incorporation might have been a source of confusion, as evidenced by the experiences in the three countries studied.
The implementation of quality standards appears to depend more on organizational and sectoral differences than on country-related dissimilarities.Nevertheless, more exhaustive research is required to obtain definitive results.Such a scale is beyond the scope of the present study.
C3: On the level of general concepts, we have norms and standards of quality of care; however, when it comes to a concrete situation, different people and stakeholders understand it differently.Without team supervision, a common understanding of this concrete interpretation does not develop.
In summary, we perceive a belief among the students from the three countries that quality should be valued and adhered to as part of the effective delivery of services by SH organizations.This result indicates that quality, as a key concept included in the recommendations of the Council of Europe and the WHO, exerts a general effect on students' perceptions.

Leadership
Expectations based on assumptions concerning the role of leadership emerge as another important common category.The basic assumptions only slightly differ among the students; however, variations are observed in their perceptions regarding practices and practice-related improvements that they suggest should be implemented.
The testimonies of the Portuguese students reflect a strong dissatisfaction with authoritarian leadership in the SH sector.P7: ... the relationship between us nurses and managers, or like I said it before, even doctors, is very distant.I think it should be more collaborative and the leadership shouldn't be so authoritative.No, it's not authoritative, it's authoritarian; it's something that I am not going to say... dictatorship?P8: … they don't talk with us; we are just like puppets in their hands, you know?That's what we are feeling.
The Portuguese students call for leaders to more strongly respect employees and differences in opinions."Today's society is very rude nowadays in Portugal," P7 states.For their part, the Czech students highlight the need to listen and be listened to as a managerial requirement.
Another source of criticism is the short-term orientation of leaders who secure a given position and then maximize the privileges and opportunities that come with the position.The students evaluate such leaders as motivated only by their own interests.P7: I think there is a little too much focused vision on the here and now.I don't know, perhaps a little too much of individualism or egoism.Who is in power or who is in management now tends to grab, to hire some friends, some people whom she trusts, not necessarily the persons who are more fit for the job and have more competencies.
The Czech and Finnish students also observe certain authoritarian traits in the health sector.The Czech students particularly underscore the need for value-based leadership.They ask for leaders who "do not fear" taking responsibility and are willing to struggle for change and overcome resistance to ideal care services.Such a proactive attitude toward a better quality of care has been equally desired by employees, clients, and entire societies.Dedicated leadership and proactive behavior have been strongly favored over "lax" attitudes and passivity, which developed during the period of communistic totalitarianism in the former Czechoslovakia.The effects of the past dictatorship in Portugal are also criticized by the Portuguese students.

Adequate Use of Knowledge and Competencies
The students from the examined countries generally have high expectations from leaders and managers, as well as from their skills and high-value knowledge acquired from their universities.A crucial perceived problem in the countries is the lack of educated managers and general management knowledge and skills."The management as we learn it in fact does not exist in practice" (C3).Transparent top-down communication and sincere bottom-up listening are viewed by the students as unfulfilled ideals.Given the lack of appropriate knowledge and coordination among the members of an organization, managers have inadequate understanding of employee competencies and needs, employees often accomplish unnecessary and overlapping work, and employees do not cooperate in a fruitful manner.Managers should possess adequate knowledge and competencies, which are acquired through a good management education.In contrast, on the level of direct care, employees are perceived as possessing a high degree of education that is not fully utilized in their work.
Middle managers should develop appropriate competencies for motivating and training people so that they acquire and maximize overall proficiencies.The optimal use of limited resources necessitates the adequate use of knowledge and competencies.The students identify the inadequate use of existing capabilities and the lack of motivation to learn from others as common sources of I-R differences.
In contrast to the education of employees in direct care, management education is regarded as a weak point in all the countries.According to the students, the corresponding management principles and methods are lacking.Compared to nursing education, which is characterized by a long history and tradition, the education for managers in the SH field in European countries has only been offered for a decade or two.This short history must be a factor that contributes to the small number of educated managers in the SH sector.

Responsibility, Participation, and Initiative
The students generally expect not only managers and employees, but also clients to display responsibility, participation, and initiative.The normative values of responsibility and initiative are characteristic of the Protestant morality of Anglo-Saxon and North European countries.In this case, the effect of rhetoric on horizontal engagement, empowerment, and participation can perhaps be observed.This impact can be related to the ideal of individual moral autonomy and has become a solid belief of the students.The students thus identify with this ideal: "… the clients are often not engaged and active in optimally using the possibilities to become active partners of the employees ..." (F2); "… if the family explains the client's needs better, the service could be more effective ..." (C6).This ideal-that everyone, including the clients and their families, should be more active and participative in exemplary care-shows that the students not only internalize the value of the right to participate in decision making (WHO, 2011), but also view engagement as a moral obligation.This perception is stronger among the Portuguese students, who affirm that employees should participate in decision making about their own work ("not to be just puppets").This standpoint can be interpreted as evidence that the Portuguese students uphold a personal-political attitude toward this ideal.
Based on Schwartz's six core cultural types (Sagive & Schwartz, 2007), Portugal is categorized as a country that highly emphasizes success and control (mastery and hierarchy); in contrast, Finland (low mastery and hierarchy) and the Czech Republic are in the middle position under the cultural categories.The Hofstede dimensions (Hofstede Centre, 2013) repeatedly characterize Portugal as having a high-power distance culture.This approach can contribute to the powerlessness felt by people who do not occupy decision-making positions, an observation perceived by the Portuguese students as well.
The Czech students express the ideal of active engagement and courage of all actors in the SH sector as being an important condition for high-quality care (i.e., to overcome obstacles).This perception reminds us that countries such as Portugal or the Czech Republic have endured a long period of totalitarian, nondemocratic systems.Power misuse (as well as courage and active participation) is therefore a prominent issue for these countries.
3.1.7Care-related Perceptions in SH As previously stated, the SH sector's specific task (goal) is the delivery of services that are grounded in a culture of care.The dominant values in such a culture are the dignity of clients, safety, and acceptance of relationships without discrimination.The social and public health services in Europe have been based on the values of health and person-centered care in an aging and multicultural society.One of the core principles of Health 2020 (WHO, 2011) is responsiveness to the needs of persons/citizens.The two succeeding subcategories concretize this principle through the students' perceptions.

Match between Services Provided and Clients' Needs
Although the processual aspect of care (safety and dignity of clients) is important, the students' perceptions also focus on results, as well as on whether they regard the services as appropriate for clients' needs.Patient-centered care necessitates an orientation toward both process and result.The establishment of a patient-caregiver relationship should be accompanied by a needs assessment (diagnostics) and appropriate care planning.Ideally, these measures guide competent SH practice.In all the FGs, the students highlight the differences between what clients need and what services they receive.C8: So I would like to say ... that the care is not effective in principle or that mostly, the patient is not in the centre of interest because of bad communication among the doctor, the family, and the agency; each of them has their own interest so that sometimes the patient has too much care, which he doesn't need in reality.
The lack of focus on clients sometimes results in excessive, inadequate, or irrelevant care.This deficiency is phenomenologically perceived by the students as pointing to an inadequate match between services and needs.

Conditions for Individualization of Care
Responsiveness to individual needs, even when appropriately recognized, is limited by many personal, as well as organizational, financial, and similar factors.The possibilities of individualization are thus limited, relative to the perceived ideal environment and organizational conditions.C9: Individualized care and focus on the client's needs have been spoken about often, and the multidisciplinary teams always emphasize providing enough time for the therapy, but in my experience, it does not work in reality ... the multidisciplinary teams are not available, there is not enough time, and there are no regular services in the agency for the therapy that a patient needs exactly.
All the students perceive certain obstacles to fulfilling the ideal of individualized or person-centered care.They evaluate current situations as suffering from mismatch between clients' needs and delivered services, nonoptimal conditions for individualization of care, and inadequate use of employee knowledge and competencies.
An interesting point is that none of the students complains about the lack of education and knowledge in direct care.A solid SH education is recognized by the participants as a typical condition and valuable aspect (together with the value of health) in all the three European countries.

Environment for SH Services
Under the category of environment for SH services, environment is perceived as a source of strong coercive pressure on SH services with its unstable, corrupted, and uncooperative nature and the lack of educated managers.

Unstable Environment
Many organizational and legal changes that are grounded in a nonunified vision impose high pressure on adaptation and result in work fragmentation.F6: Over the last ten years, we have permanently [implemented] some legal and organizational changes in the sector and many people leave for more stable jobs.It takes a lot of energy to adapt to these changes; nothing can be really planned.
The students' belief is that the legal and organizational changes are too many and the environment has become unpredictable.Hence, the development cannot be really based on planning.
An unstable environment involves the two aspects of resource allocation and improvisation, as perceived by the students.

Resource Allocation
Resource allocation is nontransparent, unstable, and inappropriate.The students believe that the public sector should maintain a comprehensive plan for allocating resources; that is, allocation should be characterized by time-bound targets and specific resource quantities.C5: You know, usually we get the resources after considerable delay and much less than we need; sometimes they give us a large amount too late in the decade and we have no [more] time to spend it on [what] we had [earlier] needed.

Improvisation
The instability of environments gives rise to the need to rethink and constantly improvise.Such a requirement is not considered by the students as purely negative.
F7: New ways to work, we have to put all our energy into the work and we have to find new ideas and improvise .... Be creative and I'd like the word rethink, because that's what we have to do.This perception revolves around providing avenues for creativity but excessive improvisation also negatively influences task fulfillment.

Corruption
Another issue that emerges during the FGs is corruption,particularly that involved in obtaining chief positions in certain sectors.The students criticize the selection of people for top positions, which they regard as depending more on whom you know than what you know.
C9: I see as a big problem in public agencies, in social services in public institutions, that managers are not chosen according to their competencies, knowledge, and experience, but according to their relationships, let's say.
This perception revolves around fair recruitment, which should take into account "what they know" (i.e., professional knowledge) and individual abilities, instead of being based on private relationships and one's own advantage.

Cooperation in the Community
Service cooperation in the community is not appropriately facilitated because of the failure of government social policy.This issue also affects clients, who are forced to depend on inadequate SH services because no other options are available or because cooperation is lacking.C3 states that "there is a lot of struggle for finances and the coordination of services is then rather absent." This perspective centers on the coordination of services to ensure that clients receive the services that they need.However, external pressures negatively affect the internal environments wherein such services are provided so that practitioners are unable to adhere to many care and management values, such as responsiveness, cooperation, transparency, and planning.
The dominant opinion in the testimonies is that the SH sectors in the three countries lack an ideal controllable environment that is regarded as a condition for effective planning.As previously stated, the other common ideals identified are fairness in recruitment and the provision of avenues for creativity.When evaluated against these ideals, the entire public sector is characterized by instability and insecurity.Many legal and organizational changes, the reduction in staff, the high number of service users at one time, and the inadequate allocation of resources bring higher stress and result in fragmented work.These factors also give rise to the necessity to improvise and rethink many aspects of individual practice.The effects of the economic crises in Europe in 2013, during which the FGs were conducted, were most strongly emphasized by the Portuguese students.Nevertheless, the students from all the three countries felt threatened by the potential reduction in available jobs and worsening of the worker-client (number) ratio.

Country-level Perceptions
Three broad I-R subcategories are classified under the category of country-level perceptions: trust in authorities and the government, adherence to rules and regulations, and managing time and the future.The students' testimonies are related to the history or socioeconomic situation of a country; alternatively, the students view it as typical of their country.For the most part, the students are emotional, with their testimonies in this category accompanied by either laughter or anger.

Trust in Authorities and the Government
In the international FG, the students identify differences in terms of trust in authorities.A marked difference is observed between the attitudes of the Finnish students and those of the Portuguese and Czech students.The variances in levels of trust in the government, the police, and other institutions among the North, South, and East European countries have been well documented in early intercultural research (e.g., ESS, 2012;Lewandowski & Znoj, 2008).The latest ESS (ESS, 2012) indicates that the general and individual trust levels in Finnish institutions are very high, whereas those in Portuguese institutions are very low (relative to those in other European countries).The Czech Republic also occupies the lower segment of country ranking (Figure 2).The qualitative testimonies in our sample correspond to the quantitative statistical findings.These are discussed by the students as follows: F2: I want to believe and I admit that I am naive, but I still do believe that the people we have elected are doing the best for us.
C3: I was just thinking, when you said that you completely trust that your government and the legal staff will do their best.I think it's a bit different in the Czech Republic.I don't know if people even want to trust now, with the developments after the era of communism... we are still learning to trust and we are not so sure about the system and about the government doing the right thing.It's still changing so you don't know what you should believe in.
The students relate the people's low trust to their experiences under the totalitarian regimes in their countries.The low or high trust in authorities is also perceived as evident in situations wherein certain rules and regulations are imposed from "above" (i.e., a government body or the top management in an SH organization).This characteristic predetermines the commitment to compliance with rules and implementation of changes.

Adherence to Rules and Regulations
A remarkable difference is found between the Finnish and Portuguese students' adherence to rules and regulations.The Finnish students report being used to working under regulations and perceive these as providing security, guidance, and clear boundaries on what tasks they should accomplish.The Portuguese students view such regulations more as a challenge to their egos, creativity, and (low) autonomy; these compel the students to devise ways to "go around" the rules.
The Czech students are receptive to effective rules, which they can easily follow and from which they can attain security.Nevertheless, the low trust in and negative experiences with authorities create a certain distance and an attitude of criticism.This backdrop raises the need to test every rule by oneself and then eventually create a new and better rule.However, given that everybody would be the author of "his/her" rules (as indicated in the testimonies), cooperation in policy making would be difficult and would cause numerous conflicts and chaotic changes.In turn, this situation would diminish initiative and engagement.Resolving such a problem would necessitate the direction of a leader who would be proficient in integration, listening, and fairness (a "listening" leader).
As indicated in the foregoing discussion, people react differently to rules and regulations, depending on their local political history and general level of trust.

Managing Time and the Future
This category is constructed from two groups of testimonies: one related to a general attitude toward time and punctuality and the other related to the attitude toward planning.A sample testimony elucidates this category: "Here in Portugal, we are very relaxed and we never get anywhere on time" (P7).The Portuguese students have experienced situations wherein a lax attitude toward time exists among students and teachers.They have also observed the effects of such an attitude on the coordination of a common program.The Portuguese students consider this trait typical of southern countries (Spain, Greece, Portugal, etc.).
The level of planning in Portugal and the Czech Republic is yet another issue criticized by the students.Their testimonies point to the correspondence between the financial insecurity and low political stability in their countries and the resulting lack of motivation for planning.In contrast, the Finnish students agree that the SH sector in their country is characterized by a high level of planning.
Figure 3 visualizes the structural model of perceived entities according to the testimonies influencing situations in SH services.Each segment affects the other segments (interfusing them).The broad country level category is understood metaphorically by the authors as a field surrounding the other categories, which are interfused by the specific country-level perceptions.Environment of SH services and the management perceptions are illustrated as relatively separate entities.The quality of care as a management task, specific to the territory of the SH sector, is illustrated as a separate column, as an entity with its own culture, highly influencing the management's expectations.Some variables are observed as common among all three countries; those with asterisks are different.

Appropriate Level of Commonality
One aim of this research is to explore if the CareMan project can rely on a common basis of understanding the aims and values of SH management.If so, a joint training of specialists can be established on such basis, despite the international contextual variations.The questions that guide the data analysis focus on the similarities and differences experienced by the student participants, as well as on the tacit perceptions behind such commonalities and disparities.The perceptions are most similar in terms of management issues, and such similarities are deconstructed as the possible result of the isomorphic pressures exerted by two identified cultural influences: the culture of Western business management (with its means-ends orientation, also part of the new public management in Europe) and the culture of care (with its person-centered ideal of service).Clearly, the students in all three universities have been exposed to similar cultural influences being manifested in their perception.
The culture of care and culture of management are expected by the students to merge in such a way that patient-centered care should be the definitive target of management.Moreover, the testimonies implicitly identify with the values and guidelines that we found in the London Department of Health's (DH) ( 2002) Code of Conduct and Health 2020 (WHO, 2011), although these have not been directly used in the education programs of the three universities.Both documents explicitly refer to the importance of underlying values, such as respect, mutual communication, and cooperation, which the students also mention.The DH's (2002) Code of Conduct mandates managers to implement the following standards: 1. Prioritize patient care and safety.
2. Respect the public, patients, relatives, caregivers, NHS staff, and partners in other agencies.
3. Be honest and act with integrity.
4. Accept responsibility for your own work and the performance of the people you manage.
5. Demonstrate a commitment to team work.
6. Take responsibility for your own learning and development.
All these standards correspond to the ideals expressed by the students.We argue that these values form the common basis on which all three universities can rely.
The perceptions on management and the environment of the SH sector are also similar in other aspects.From the above-mentioned standpoint, the students maintain that controlling effective SH measures (e.g., top-down and bottom-up communication, coordination, and appropriate education of employees) will result in planned outcomes in a theoretically stable environment.In relation to this common ideal, the students present similar criticisms, which particularly revolve around the unstable environment of SH services.Such instability causes unpredictable effects on the SH sector, particularly in terms of resource provision.
Another common area of criticism involves the human factor (managers, employees, clients, and their families).
The students lament over individuals who fail to fulfill the moral ideals of responsibility, initiative, moral autonomy, participation, and fairness.This failure is then perceived as the cause of the inability of people to adequately use existing knowledge, engage in effective planning, and efficiently deliver services so that clients receive the services that they need.
The last commonly perceived value that emerges from the FGs is good education, which is regarded as fulfilled in direct care but unfulfilled at the management level in the SH sector.

Cultural Differences and Their Impact on Management
Our theoretical orientation throughout the analysis is grounded on intercultural research findings and on the theories of Hofstede (2001) and Schwartz (2004) regarding intercultural values and their impact on perception.However, these theories are supported primarily by statistical data in the field of business or country cultures.To our best knowledge, no study has been devoted to SH management and no qualitative research that relates these theoretical concepts to managers' experiences has been carried out.Driven by this deficiency, we have developed an exploratory research design.We assume that certain cultural dimensions described in the above-mentioned theories and research may also have impacts on the perceptions of the students in our sample.This pre-concept has influenced our analysis.Nevertheless, no testimonies have been identified which would directly respond to any of the established dimensions.Instead, three other varying phenomena have manifested in the testimonies: trust in authorities, adherence to rules and regulations, and management of time and the future.In this discussion, we now interpret our findings and make some hypothetical inferences from the cultural dimensions.
The most important differences in country-level perceptions involve trust in authorities and institutions.We do not repeat the arguments regarding how important trust is in society and the historical reasons for the substantial commonality among East and South European countries in terms of this issue (e.g., Lewandowski & Znoj, 2008).We instead explain our understanding of the reaction patterns with which the Portuguese and Czech students differently express their attitudes toward rules and regulations.Although low trust was a common perception, the differences in their views revolve around attitudes toward planning and maintaining schedules, of which typical behaviors are recognized in southern countries.In such regions, these issues are the subject of many jokes (the same phenomenon is observed by our group).These perceptions are also theoretically related to general trust (particularly to a certain belief that the future is predictable) and conformity (in terms of common, planned schedules).Hofstede (Hofstede Centre, 2013) proved high power distance and uncertainty avoidance in Portugal, in sharp contrast to the case in Finland.According to Schwartz's value types (ESS, 2012), Portugal scores lower in conformism than do the Czech Republic and Finland.In relation to ambition, Portugal scores higher than both Finland and the Czech Republic (Table 1).

Note.
A low score means the high average group identification with the value type.
We interpret low punctuality and planning, for which the Portuguese students collectively admit responsibility ("we," with laughter), as related to low conformism and high ambition scores in their country (ESS, 2012).These tendencies, together with low trust in authorities, may lead to high improvisation and unpredictability in organizing.In turn, such improvisation may be perceived as an adaptive way of bypassing the rules and regulations that are imposed by authorities, who are generally perceived as untrustworthy (both long and recent history of paternalistic totalitarianism in Portugal).
The Czech students also exhibit some collective reactions that are in common with or different from those of their counterparts from the other two countries.Typically, the Czech students have low trust in authorities.The scores for their country (ESS, 2012) show a high tolerance for unequal distribution of power in society, as well as high uncertainty avoidance, similar to those for Portugal (Hofstede, 2013).The Czech students prefer to have rules as a source of control and regulation; however, the best rules for them are those that they create themselves (see 3.3.2.Adherence to rules and regulations).
We now sum up the experience of low trust, the attitudes toward rules and regulations, the attitudes toward managing time and future influence (according to student testimonies), and the everyday behavior of managers, employees, and clients in the SH sector.Two types of reactions are perceived in countries with low trust (ESS, 2012), hypothetically depending on the levels of uncertainty and power distance (Hofstede, 2013), ambition and conformism (ESS, 2012).The tendency is to create one's own rules if the dominant need involves facing uncertainties, whereas the inclination is to bypass rules if the primary need is to protect one's own autonomy.In a country with high trust, low ambition and high conformism (ESS, 2012), low uncertainty avoidance, and low power distance (Hofstede, 2013), as it is for Finland, the rules and regulations are deemed useful guidelines.However, these hypothetical patterns need verification in further research.
The main point of difference among the Czech, Finnish, and Portuguese students constitutes critical perceptions about the moral state of society.These disparities are also particularly related to expectations on leadership (non-authoritarian and listening) and perceived readiness for planning.These are theoretically related to general trust (particularly to a certain belief that the future is predictable) and conformity (in terms of adherence to common, planned schedules and its expected effects).The testimonies also indicate the association between the financial insecurity and low political stability in a country and the resulting lack of motivation for planning.

Originality and Limitations of the Study
In this exploratory study, three findings give rise to three implications.We discuss the limits and originality of this study in terms of each implication.
The first implication is for establishing the common basis of values and management perceptions among the students participating in the three master's programs in SH care management (Lahti University of Applied Sciences, FHS UK Prague, and Evora University).Here the limitations are related to the composition of the FG participants; the study does not cover the whole spectrum of the views of students of the master's programs but only those of its voluntary participants.A strong base of common concepts and values has been proven among those students.The findings can be considered relevant to the educational activities under such programs for the voluntary participating students.From an educational point of view, no similar study has been found in the literature.The design of intercultural FGs can also be considered an original route to the provision of intercultural education in management for students in an international context.
Another implication of the study centers on the interpretation of the underlying ideals and associated cultural differences mirrored in the expressed testimonies.In this regard, the study is characterized by two limitations: one is the language used in the exploration and the other concerns the different cultures of the researchers.All the testimonies have been translated into English and analyzed in the same language, even though this is not the native language of either of the researchers.Many nuances in expression may have been misinterpreted or lost in translation.Given that the researchers are members of the analyzed "cultures" (i.e., country culture, SH management culture), their abilities to reflect on and interpret cultural differences may have been biased.The views of students, although they are mature professionals who are already working in the field, can be considered as indicative only in relation to the general views of managers in this sector.
The originality of the study stems from its exploration of a new research territory.It is the first comparative study on the crossroads of country culture and SH management.Specific entities of interest have been identified, which allow for more focused studies on the potential dynamics among the variables suggested by this study.
Systematically refining the research findings on the interplay of such cultures as country-level, management, public administration, and direct care types invites researchers to conduct further studies into this novel field.

Conclusion
The chief purpose of the research was to map the perceptions of ideal and real-world social and health care services among social and health care management students in the Czech Republic, Finland and Portugal in order to explore the differences in perceptions, underlying ideals and country-culture differences in the material produced.Three conclusions resulted from the research and are presented below.

Perceived Differences in Ideal and Real-world Situations in SH Services
Large-scale differences between the perceptions of students regarding the ideal and realistic situations (values vs. practices) that characterize the SH sector were found.The differences must be partly attributed to the critical attitudes of students, which were evoked by the research questions during the focus groups.Three mutually dependent analytical categories -management perceptions, environment for SH services, and country-level perceptions with 12 subcategories -were constructed from the testimonies to represent the experiences of students and their management and care assumptions.The analytical categories represent mutually dependent fields of factors (see Figure 1 and 2).The factors have been described as subcategories and concretely illustrated by the testimonies.According to the students' testimonies, the critical management perceptions and the negative characteristics of the environment of social and health care services, which is seen by students as being more unstable and corrupt than is suitable for planning and financing the services, have an impact on the management task which is seen in the quality of care.The following two categories characterise the difference between the ideal and real situation in the quality of care: the gap between the services provided and those needed and inadequate conditions for the individualisation of care, which is commonly seen as the value crucial for providing good-quality care.All of the abovementioned factors were perceived as being embedded in the category of country-level differences found in the following three broad subcategories: general trust and trust in institutions, attitudes toward rules and regulations, and the way the time and future is managed.According to the testimonies, these country-level factors influence the processes and attitudes expressed as management perceptions and the environment for SH services and have a fundamentally negative impact on the core task of SH management.

Underlying Ideals
The common underlying ideals mirrored in the discrepancies in perceptions of students in all three countries were deconstructed as the possible result of two cultural influences: the culture of Western business management and the culture of care, including a number of principles and procedures.Those two cultures merge in the view of all participating students in such a way that patient-centered care is seen as the definitive target of management.
Values such as respect, mutual communication and cooperation, responsibility, participation, and initiative form a common basis of understanding among all participating students.
In all three groups the value of education has been acknowledged.Students appreciated the good level of professional education in all three countries.However, the ideal of good education was not fulfilled in the management in the SH sector.Students expressed their criticisms of the lack of educated managers in the SH sector, which they thought to be an important source of other differences between ideal and real-world situations in their field.

Socio-cultural Differences
No testimonies were identified which would directly respond to any of the socio-cultural dimensions established by Hofstede and Schwartz.Instead, three other phenomena manifested in the testimonies -trust in authorities, adherence to rules and regulations, and management of time and the future.The socio-cultural differences found in the perceptions of general trust and trust in institutions, attitudes toward rules and regulations, and the way the time and future are managed corresponded to the understanding of the different political histories of the countries and the long-term levels of financial insecurity and political instability expressed by students.In this sense, the main point of difference among the Czech, Finnish, and Portuguese students were the different perceptions of the moral state of their society and the resulting critical attitudes toward authority and rules.The differences were related to expectations on the nature of leadership, particularly the non-authoritarian approach stressed by the Portuguese students and the importance of requiring leaders to listen and have courage stressed by Czech students.Finnish students had the highest perceptions of the readiness to plan and Portuguese students had the lowest.These are hypothetically related to general trust (particularly to a certain belief that the future is predictable) and conformity (in terms of adherence to keeping common, planned schedules).The testimonies also pointed to the correspondence between financial insecurity, low political stability in the country, and the resulting lack of motivation for planning.
Another hypothetical pattern (which needs further research) has been described as the correspondence between the level of uncertainty, power distance (Hofstede, 2013), ambition, andconformism (ESS, 2012) in the countries with low trust in relation to rules.The hypothesis says that there is a tendency to create one's own rules if the dominant need in the country is to face uncertainty and a tendency to go around rules if the dominant need is to protect one's own autonomy.
With regard to the effects of our findings on the design and process of the master's program, we drew the following conclusions.
a) The common perceptions of the management expectations, particularly quality as a concept in SH care, a common vision of the individualisation of care, and coordination of the services in the network, are in tune with the contemporary European expectations expressed in regulations and leading SH documents.They can therefore serve as the basis for common educational activities for the master's degree in SH management in the Czech Republic, Finland, and Portugal.
b) The differences in some of the conceptualized categories, particularly in the level of trust, attitudes toward rules and regulations, and expectations concerning the possibility of managing time and the future, point to the value of intercultural research and cross-cultural experience in the education of managers.The firsthand experience of the intercultural differences encountered when conducting a common research project seems to be a necessary and fruitful source of learning, which can be fostered under an international master's program.
c) The discrepancy among the values, principles, and practices model and the rhetoric and results model taught in schools of management and actual practice should be clearly addressed in education.Future graduates should not be confronted with a huge disparity between the theoretical knowledge that is provided and expected in the classroom and practical managerial needs (Huotari et al., 2010).The presented common research process in the international educational program (CareMan) is therefore seen as an example of a strategy for supporting critical thinking and reflective learning in relation to intercultural management issues.
d) Future research should be directed toward the suggested dynamics of the relations between trust, adherence to rules and regulations, attitude toward time and the future, and variables from Hofstede and Schwartz's research, particularly uncertainty, autonomy, and power, which is currently an under-researched domain of cultural co-existence in the SH sector.

Figure 3 .
Figure 3. Perceived Differences between ideal and real-world social and healthcare services Source: Havrdova et al., 2014

Table 1 .
Identification level with Schwartz's ten value types for the four country groups