Explain why Susan is behaving the way she has been over the past three months.

Critical Thinking: Case Study – Develop a Motivation Plan (110 Points)

First, read “Case Study 6-6 “Develop a Motivation Plan” on page 121 in Organizational Behavior in Health Care.

Within the principles of the content theories of Maslow, Herzberg, and Alderfer:

Explain why Susan is behaving the way she has been over the past three months.

Offer three specific recommendations to address the problem of Susan’s job performance.

Your well-written paper should meet the following requirements:

Four-to-five pages in length, not including the cover sheet and reference page.

Formatted according to APA 7th edition and Saudi Electronic University writing standards.

Provide support for your statements with in-text citations from a minimum of four scholarly articles. Two of these sources may be from the class readings, textbook, or lectures, but the other two must be external. The Saudi Digital Library is a good place to find these references.

You are strongly encouraged to submit all assignments to the Originality Check prior to submitting them to your instructor for grading.

Requirements: ,,,,,,,,,,,,,,,,,,,,,,,,,,, | .doc file

Requirements:

 

THIRD EDITIONOrganizational Behavior inHEALTH CARENancy Borkowski, DBA, CPA, FACHE, FHFMAProfessor, Department of Health Services AdministrationSchool of Health ProfessionsUniversity of Alabama at BirminghamBirmingham, AL

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Composition: Cenveo Publisher ServicesCover Design: Scott ModenRights & Media Research Coordinator: Mary FlatleyCover Image: © NadyaJema/Shutterstock, Inc.Printing and Binding: Edwards Brothers MalloyCover Printing: Edwards Brothers MalloyLibrary of Congress Cataloging-in-Publication DataBorkowski, Nancy, author.Organizational behavior in health care / Nancy Borkowski. — Third. p. ; cm.Includes bibliographical references and index.ISBN 978-1-284-05104-9 (paper)I. Title.[DNLM: 1. Health Services Administration. 2. Group Processes. 3. Health Personnel—psychology.4. Organizational Culture. 5. Personnel Management. W 84.1]RA971.35362.11068’3—dc2320150034976048Printed in the United States of America19 18 17 16 15 10 9 8 7 6 5 4 3 2 1

To my husband

ContentsPrefaceContributorsAbout the AuthorPART I—INTRODUCTIONChapter 1 Overview and History of Organizational BehaviorChapter 2 Diversity and Cultural Competency in Health CareChapter 3 Attitudes and PerceptionsChapter 4 Workplace CommunicationPART II—UNDERSTANDING INDIVIDUAL BEHAVIORSChapter 5 Content Theories of MotivationChapter 6 Process Theories of MotivationChapter 7 Attribution Theory and MotivationPART III—LEADERSHIPChapter 8 Power, Politics, and InfluenceChapter 9 Trait and Behavioral Theories of LeadershipChapter 10 Contingency Theories and Situational Models ofLeadership

Chapter 11 Contemporary Leadership TheoriesPART IV—INTRAPERSONAL AND INTERPERSONAL ISSUESChapter 12 Stress in the Workplace and Stress ManagementChapter 13 Decison MakingChapter 14 Conflict Management and Negotiation SkillsPART V—GROUPS AND TEAMSChapter 15 Overview of Group DynamicsChapter 16 GroupsChapter 17 Work Teams and Team BuildingPART VI—MANAGING ORGANIZATIONAL CHANGEChapter 18 Organization DevelopmentChapter 19 Managing Resistance to ChangeIndex

PrefaceIn 2005 with the first edition of this book, I wrote, “the U.S. health careindustry has grown and changed dramatically over the past twenty-fiveyears.” That was an understatement! Since the passing of the PatientProtection and Affordable Care Act of 2010, the industry has experiencedsome of the most dynamic changes health care managers have seen. In thecoming years, more system-wide changes will occur as we continue our pushforward to achieve value-based health care. Health care managers arequickly learning that what worked in the past may not work in the future.As such, I was compelled to write an organizational behavior bookspecifically for health care managers who are on the front lines every day,motivating and leading others in a constantly changing, complexenvironment. This is not an easy task, as I know firsthand!The purpose of this book is to provide health care managers and otherprofessionals with an in-depth analysis of the theories and concepts oforganizational behavior while embracing the uniqueness and complexity ofthe industry. Although health care is similar to other industries, it is alsovery different. As the nation’s largest industry, it employs more than 15million people in numerous interrelated and interdependent segments.Using an applied focus, this book provides a clear and concise overview ofthe essential topics in organizational behavior from the health caremanager’s perspective. It is my goal that this book will give you a greaterunderstanding of why and how people and groups behave the way they do inthe workplace. With this knowledge, you will be able to predict and thuseffectively influence the behavior of those you lead. Please let me know if Iaccomplish my goal! You can reach me at [email protected] addition, I tried to ensure that I referenced all the individuals whosework contributed to the development of this book. However, if by chance Ifailed to give credit to someone along the way, please contact me so I maymake the necessary correction.At this time I wish to acknowledge individuals without whose efforts and

support I would not have been able to complete this book. First, I wish tothank my colleagues and third edition contributors, Jean Gordon, PaulHarvey, Mark Martinko, and Jeff Ritter. Second, I thank my wonderfulfamily for their patience, understanding, and support over the years.Finally, I wish to thank the many wonderful and caring people employedthroughout the health care industry that I have had and will have theopportunity to work with. My life continues to be blessed by these dedicatedindividuals!Thank you for purchasing (and reading) my book. I welcome yourcomments and suggestions.With personal regards,Nancy M. Borkowski, DBA, CPA, FACHE, FHFMA

ContributorsJean Gordon, RN, MBA, MSN, DBAVisiting ProfessorFlorida International UniversityMiami, FloridaPaul Harvey, PhDAssociate Professor of ManagementPeter T. Paul College of Business and EconomicsUniversity of New HampshireDurham, New HampshireMark Martinko, PhDUQ Business SchoolUniversity of QueenslandBrisbane, AustraliaJeffrey Ritter, DBAAssistant ProfessorBarry UniversityHealth Management ProgramsCollege of Nursing and Health SciencesMiami Shores, Florida

About the AuthorNancy M. Borkowski, DBA, CPA, FACHE, FHFMA, is Professor in theDepartment of Health Services Administration at the University ofAlabama at Birmingham. She received her DBA with specializations inhealth services administration and accounting from Nova SoutheasternUniversity. Dr. Borkowski has over 20 years’ experience in the health careindustry and is a two-time past recipient of the American College ofHealthcare Executives’ (ACHE) Southern Florida Senior Career HealthcareExecutive Award, which recognizes individuals who have made significantcontributions to the advancement of health management excellence.A nationally recognized author, Dr. Borkowski is also a certified publicaccountant, board certified in health management, and a Fellow of both theAmerican College of Healthcare Executives and the Healthcare FinancialManagement Association. The first edition of her book OrganizationalBehavior in Health Care, referred to as “one of the most significantadvances in the field of health services administration,” was honored withthe American Journal of Nursing’s 2005 Book of the Year Award for nursingleadership and management. Dr. Borkowski is the author of three textbooksthat are widely used in graduate and undergraduate health administrationand nursing programs both nationally and internationally.Dr. Borkowski’s work has been published in the Journal of Ambulatory CareManagement, Leadership in Health Services, Group & OrganizationManagement, Organizational Behavior and Human Decision Processes,Health Care Management Review, Journal of Health AdministrationEducation, Journal of Health and Human Services Administration,International Journal of Public Administration, and various other journals.Her teaching interests are leadership, organizational behavior, and strategicmanagement. Dr. Borkowski is a past recipient of the ACHE’s Excellence inTeaching Award, which is given to faculty who engage in furthering

academic excellence and the professional development of healthmanagement students.Over the past decade, Dr. Borkowski has served in various leadership rolesfor the Academy of Management’s Health Care Management Division, theAmerican College of Healthcare Executives’ Southern Florida Regent’sAdvisory Council, the South Florida Healthcare Executive Forum, andvarious other health-related organizations. In 2013, Dr. Borkowski receivedthe Jessie Trice Hero Award for her leadership and commitment toimproving the lives of underserved and minority populations. She has alsobeen honored with the Exemplary Service Award from the American Collegeof Healthcare Executives (2012) and the Reeves Silver Merit Award fromthe Healthcare Financial Management Association (2014).

PART IIntroductionPart I includes four different but related topics. In Chapter 1, the historyof organizational behavior and its importance to today’s health caremanagers are discussed. Chapter 2 describes the changing environment inwhich health care managers find themselves. The chapter examines thenumerous issues that have emerged within the health care industry becauseof the nation’s changing demographics. Chapter 3 deals with attitudes andperceptions, which are the “backbone” to understanding organizationalbehavior. You will find the terms “attitude” and “perception” frequentlyreferred to within the various organizational behavior theories. Finally,Chapter 4 discusses the importance of communications. Recent surveysrevealed that 70 percent of small to mid-size businesses claim thatineffective communication is their primary problem. Sentinel event datafrom The Joint Commission estimates that communication failure was theroot cause of patient harm 70 percent of the time in 2,400 reported negativeoutcomes studied. No wonder the ability to communicate effectively isconsidered an essential job skill for today’s health care managers andleaders.

CHAPTER 1Overview and History ofOrganizational BehaviorLEARNING OUTCOMESAfter completing this chapter, the student should understand: The definition of organizational behavior. The major challenges facing today’s and tomorrow’s health careorganizations and health care managers. The importance of the Hawthorne Studies to the study oforganizational behavior. The importance of McGregor’s Theory X and Theory Y to the study oforganizational behavior. The difference between organizational behavior, organization theory,organizational development, and human resources management.OVERVIEWOrganizational behavior (OB) is an applied behavioral science thatemerged from the disciplines of psychology, sociology, anthropology, politicalscience, and economics. OB is the study of individual and group dynamicswithin an organization setting. Whenever people work together, numerousand complex factors interact. The discipline of OB attempts to understandthese interactions so that managers can predict behavioral responses and,as a result, manage the resulting outcomes.According to Ott (1996, p. 1), OB asks the following questions:1. Why do people behave the way they do when they are inorganizations?2. Under what circumstances will people’s behavior in organizationschange?3. What impacts do organizations have on the behavior of individuals,

formal groups (such as departments), and informal groups (such aspeople from several departments who meet regularly in the company’slunchroom)?4. Why do different groups in the same organization develop differentbehavior norms?From Ott. Classic Readings in Organizational Behavior, 2E. © 1996 South-Western, a part of Cengage Learning, Inc.Reproduced by permission.There are three goals of OB. First, OB attempts to explain why individualsand groups behave the way they do within the organizational setting.Second, OB tries to predict how individuals and groups will behave on thebasis of internal and external factors. Third, OB provides managers withtools to assist in the management of individuals’ and groups’ behaviors sothey willingly put forth their best effort to accomplish organizational goals.In the health care industry, OB has become more important because peoplewith diverse backgrounds and cultural values have to work togethereffectively and efficiently.WHY STUDY ORGANIZATIONAL BEHAVIOR IN HEALTHCARE?The largest U.S. industry is health care, which currently employs over 18million individuals. The industry will account for almost a third of thenation’s projected job growth through 2022, adding almost 5 million jobs.The projected 2.6 percent-per-year growth rate is the fastest among allmajor service producing sectors (Bureau of Labor Statistics, 2013).Each segment of the health care industry (e.g., hospitals, home health,rehabilitation facilities) employs a different mix of health-relatedoccupations, ranging from highly skilled licensed professionals, such asphysicians and nurses, to those with on-the-job training. Furthermore, eachsegment of the industry has various economic structures (e.g., for-profit,not-for-profit, governmental). As such, today’s health care managers need topossess the skills to communicate effectively with, motivate, and leaddiverse groups of people within a large, dynamic, and complex industry.Communication, motivation, and leadership are all concepts within thediscipline of OB. Furthermore, managers need to understand the causes ofworkplace problems, such as low performance, turnover, conflict, and stress,so that they may be proactive and minimize these unnecessary negativeoutcomes. With a greater understanding of OB, managers are better able topredict and, thus, influence the behavior of employees to achieve

organizational goals.Given the service-related intensity of the industry, the understanding ofindividuals’ behavior and group dynamics within health serviceorganizations is critical to a health care manager’s success. Researchindicates that the primary reasons managers fail stem from difficulty inhandling change, not being able to work well in teams, and poorinterpersonal relations. There is a saying that employees don’t leaveorganizations, they leave managers!THE HEALTH CARE INDUSTRYChanges within the health care industry over the past 30 years have beenpowerful, far-reaching, and continuous. Since readers are probably familiarwith most of these changes from either their own experiences or from aprevious health care delivery system course, the discussion will addresssome of the trends or future concerns that will impact tomorrow’s healthcare industry.Past changes and future trends are interrelating forces that have or willshape tomorrow’s health care organizations, whether they occur at thesystem level or the organizational level. Declining reimbursement andchanges in payment schemes for services has had, and will continue to have,two of the deepest impacts on the industry. Technology has also causedsignificant changes within the industry. Biomedical and genetic research,along with advances in information technology and use of “big data,” areproducing rapid changes in clinical treatments. In addition, the industry hasexperienced more government mandates, such as the Health InsurancePortability and Accountability Act of 1996; the Medicare Prescription Drug,Improvement, and Modernization Act of 2003; the American Recovery andReinvestment Act of 2009; and most recently, the Patient Protection andAffordable Care Act of 2010 (ACA). With an increased focus on chronicdisease management, patients are living longer and are requiring morelong-term and home health care services now and in the future. Patients’and health care workers’ characteristics are also changing. Both populationsare becoming older and more diverse. Patients are better informed and, assuch, have increasingly higher expectations of health care professionals.This trend has changed the way health care services are delivered, with afocus on patient satisfaction and safety, as well as on quality of services.Physician–patient relationships have changed because patients arebeginning to understand that much of the responsibility for wellness lieswith them. The economics of health care is in a state of flux. For example,

reimbursements are moving toward value-based payments; therefore, wesee an increase in the use of evidence-based medicine. There are continuingshortages of staff, especially in the areas of primary care physicians, nurses,imaging technicians, and pharmacists, leading to competition for well-qualified people. There are changes taking place in the disease environment.Many factors of modern life are contributing to the emergence of newdiseases, reemergence of old ones, and evolution of pathogens immune tomany of today’s medications. In addition, because of potential terrorismattacks, health care providers are concerned with biodisaster preparedness.Finally, even with some states’ Medicaid expansion programs and the ACA,there continues to be the issue of caring for the uninsured that contributesto the overuse and misuse of hospital emergency departments.To deal with these changes, we have seen a number of health careorganizations restructure themselves into integrated delivery networks,which may be part of a local, regional, or national system. We have seenincreased vertical, horizontal, and virtual integration. Vertical integrationfocuses on the development of a continuum of care services to meet thepatient’s full range of health care needs. This integration model, in which asingle entity owns and operates all the segments providing care, mayinclude preventive services, specialized and primary ambulatory care, acutecare, subacute care, long-term care, and home health care, as well as ahealth plan. Recently, we have seen the creation of accountable careorganizations (ACOs), in which groups of doctors, hospitals, and otherhealth care providers have joined together to provide coordinated care topredetermined patient populations. Horizontal integration usually occursthrough mergers, acquisitions, and/or consolidation within one segment ofthe industry. For example, during the 1990s there were numerous hospitalacquisitions by the large, for-profit, publicly held hospital chains of HospitalCorporation of America (HCA), Tenet Healthcare, and Health ManagementAssociates (now part of Community Health Systems)—and theseacquisitions continue today. In addition, not-for-profit hospitals havemerged with for-profit health systems as a result of competition and theneed to reduce cost by economies of scale. Virtual integration, whichemphasizes coordination of health care services through patient-management agreements, provider incentives, and/or information systems,has increased. This virtual integration has evolved to meet the need forbetter technology and information infrastructures that allow for informationsharing, patient care management, and cost control.Because of the dramatic changes and the future trends in the health care

industry, most managers have been required to change the way they andother employees carry out their job responsibilities. These changes havebeen forced upon the industry by the need to increase productivity due todecreasing reimbursement and increasing competition. At the same time,health care providers must deliver patient-centered, value-based care. Theseare not easy tasks. As a result, many health care providers are breakingdown their traditional hierarchical structures and moving towardmultidisciplinary team-managed environments. Employees are findingthemselves in new roles with new responsibilities. All of these changescause disruptions in the workplace. The study of OB will assist health caremanagers to minimize the negative effects (such as stress and conflict)related to this “new” environment and maximize their ability to motivatestaff and lead their organizations effectively.HISTORY OF ORGANIZATIONAL BEHAVIORThe beginnings of OB can be found within the human relations/behavioralmanagement movement, which emerged during the 1920s as a response tothe traditional or classic management approach. Beginning in the late1700s, the Industrial Revolution was the driving force for the developmentof large factories employing many workers. Managers at that time wereconcerned “about how to design and manage work in order to increaseproductivity and help organizations attain maximum efficiency” (Daft, 2004,p. 24). This traditional approach included Frederick Taylor’s (1911) well-known framework of scientific management, or “Taylorism,” as it is nowlabeled. Taylor believed that efficiency was achieved by creating jobs thateconomized time, human energy, and other productive resources. Throughhis time-and-motion studies, Taylor scientifically divided manufacturingprocesses into small, efficient units of work. Through Taylor’s work,productivity greatly increased. For example, Henry Ford developed hisassembly line according to the principles of Taylorism and was able to churnout Model Ts at a remarkable and economical pace (Benjamin, 2003).Although the classic approach to management focused on efficiency withinorganizations, Taylor did attempt to address a human relations aspect inthe workplace. In his book The Principles of Scientific Management, Taylorstated that:in order to have any hope of obtaining the initiative (i.e., bestendeavors, hard work, skills and knowledge, ingenuity, and good-will)of his workmen the manager must give some special incentive to his

men beyond that which is given to the average of the trade. Thisincentive can be given in several different ways, as, for example, thehope of rapid promotion or advancement; higher wages, either in theform of generous piecework prices or of a premium or bonus of somekind for good and rapid work; shorter hours of labor; bettersurroundings and working conditions than are ordinarily given, etc.,and, above all, this special incentive should be accompanied by thatpersonal consideration for, and friendly contact with, his workmenwhich comes only from a genuine and kindly interest in the welfare ofthose under him. It is only by giving a special inducement orincentive of this kind that the employer can hope even approximatelyto get the initiative of his workmen.Although Taylor discussed a concern for workers within the scientificmanagement approach, the human relations or behavioral movement ofmanagement did not begin until after the landmark Hawthorne Studies.THE HAWTHORNE STUDIESElton Mayo, Frederick Roethlisberger, and their colleagues from HarvardBusiness School conducted a number of experiments from 1924 to 1933 atthe Hawthorne Plant of the Western Electric Company in Cicero, Illinois.The Hawthorne Studies were significant to the development of OB becausethe researchers demonstrated the important influence of human factors onworker productivity. It was through these experiments that the HawthorneEffect was identified. The Hawthorne Effect is the bias that occurs whenpeople know that they are being studied. Roethlisberger and Dickson (1939)in their book Management and the Worker and Homans (1950) in his bookThe Human Group provided a comprehensive account of the HawthorneStudies. There were four phases to the Hawthorne Studies: the illuminationexperiments, the relay-assembly group experiments, the interviewingprogram, and the bank-wiring observation-room group studies. The intent ofthese studies was to determine the effect of working conditions onproductivity.The illumination experiments were conducted to determine whetherincreasing or decreasing lighting would lead to changes in productivity. Theresearchers were surprised to learn that productivity increased by both thecontrol group (no change in lighting) and the experimental group (lightingalternated upward and downward). The researchers determined that it wasnot the lighting that caused the increased productivity; rather, it resulted

from the attention received by the group.In the relay-assembly group experiments, productivity of a segregatedgroup of workers was studied as they were subjected to different workingconditions. The researchers and management observed the group closely forfive years. During the first part of the experiment, the working conditionsof employees were improved by extending their rest periods, decreasing thelength of their workday, and providing them a “free” day and lunches. Inaddition, the workers were consulted before any changes were made,because their agreement had to be obtained before the change would beimplemented. The workers of the group were given the freedom to interactwith one another during the workday. Furthermore, one researcher alsoserved as their supervisor who, during the experiment, expressed concernabout their physical health and well-being. The researchers eagerly soughtthe employees’ opinions, hopes, and fears during the experiment. During theimproved-conditions period, the workers’ productivity increased. In part twoof the experiment, the original working conditions were restored.Surprisingly, the researchers found that the employees’ productivityremained at the previous high level (when they had the improved workingconditions). This result was attributed to group dynamics because the groupwas allowed to develop socially with a common purpose.The bank-wiring observation-room experiment was similar to the relay-assembly experiment. A group of workers were segregated so theirproductivity and group dynamics could be studied. The workers were paidwith a piecework rate that reflected both group and individual efforts. Theresearchers found that the wage incentive did not work. The group haddeveloped its own standard as to what constituted a “proper day’s work.” Assuch, the group’s level of productivity remained constant because they didnot want management to know that they could produce at a higher level. Ifa member of the group produced more than the agreed-upon level, the othermembers influenced the “rate buster” to return his productivity level to thegroup’s norm. In addition, if a member of the group failed to produce therequired level of output, the other members traded jobs to ensure that thegroup’s output level remained constant. The results of the bank-wiringexperiment mirrored the relay-assembly experiment results. Theresearchers concluded that there was no cause-and-effect relationshipbetween working conditions and productivity and that any increase ordecrease in productivity was attributed to group dynamics.As a result of the bank-wiring experiment, researchers became veryinterested in exploring informal employee groups and the social functions

that occur within the group and that influence the behavior of the individualgroup members. As part of the Hawthorne Studies, the researchersconducted extensive interviews with the employees. Over 21,000 interviewswere conducted to determine the employees’ attitudes toward the companyand their jobs. A major outcome of these interviews was that theresearchers discovered that workers were not isolated, unrelatedindividuals; they were social beings and their attitudes toward change in theworkplace were based upon (1) the personal social conditioning (values,hopes, fears, expectations, etc.) they brought to the workplace, formed fromtheir previous family or group associations, and (2) the human satisfactionthe employees derived from their social participation with coworkers andsupervisors. What the researchers learned was that an employee’sexpression of dissatisfaction may be a symptom of an underlying problem inthe workplace, at home, or in the person’s past.THEORIES X AND YAnother significant impact in the development of OB came from DouglasMcGregor (1957, 1960) when he proposed two theories by which managersview their employees: Theory X (negative/pessimistic) and Theory Y(positive/optimistic). Theories X and Y reflect polar positions and are waysof seeing and thinking about people, which, in turn, affect their behavior.Theory X states that employees are unintelligent and lazy. They dislikework, avoiding it whenever possible. In addition, employees should beclosely controlled because they have little desire for responsibility, havelittle aptitude for creativity in solving organizational problems, and willresist change. In contrast, Theory Y states that employees are creative andcompetent; they want meaningful work; they want to contribute; and theywant to participate in decision-making and leadership functions.Borrowing from Maslow’s Hierarchy of Needs, McGregor stated that theautocratic or Theory X managers were no longer effective in the workplacebecause they relied on an employee’s lower needs for motivation(physiological concerns and safety), but in modern society those needs weremostly satisfied and thus no longer acted as a motivator for the employee.For example, managers would ask, “Why aren’t people more productive? Wepay good wages, provide good working conditions, have excellent fringebenefits, and provide steady employment. Yet people do not seem to bewilling to put forth more than minimum efforts.” The answers to thesequestions were embedded in Theory X’s managerial assumptions of people.If managers believed that their employees had an inherent dislike for work

and must be coerced, controlled, and directed to achieve organizationalgoals, the resulting behavior was nothing more than self-fulfillingprophesies. The manager’s assumptions caused the staff’s “unmotivated”behavior.However, at the opposite end of the spectrum from Theory X, McGregorproposed Theory Y, where managers created opportunities, removedobstacles, and encouraged growth and learning for their employees.McGregor stated that participative or Theory Y managers supporteddecentralization and delegation of decision making, job enlargement, andparticipative management because they allowed employees degrees offreedom to direct their own activities and to assume responsibility, therebysatisfying their higher-level needs (see Figure 1–1).Figure 1–1 McGregor X-Y Theory DiagramSUMMARYSince 1960, a wealth of information has emerged within the study of OB,which will be addressed in this textbook. In Part I, the issues of diversity,perceptions, attitudes, and communication are discussed. Part II addresses

motivation and individual behaviors. Part III examines the subject ofleadership from four approaches—power and influence, behavioral,contingency, and transformational. Part IV emphasizes the importance ofintrapersonal and interpersonal issues within the context of stress andconflict management. Part V examines group dynamics, working in groups,and teams and teambuilding. Part VI provides an overview of managingorganizational change within the context of organizational development.Before we conclude this chapter, I would like to explain the differencesbetween OB and three other related fields—organization theory (OT),organizational development (OD), and human resources management(HRM). As noted previously, OB is the study of individual and groupdynamics within an organization setting and, therefore, is a micro-approach. OT analyzes the entire organization and is a macro perspective,since the organization is the unit examined. The field of OD describes aplanned process of change that is used throughout the organization, withthe goal of improving the effectiveness of the organization. Since, like OT,OD involves the entire organization, it is a macro examination. Finally,HRM can be viewed as a micro-approach to “managing” people. Thedifference between HRM and OB is that the latter studies human behaviorin various settings with an emphasis on explaining, predicting, andunderstanding behavior in organizations, whereas HRM emphasizessystems, processes, procedures, and so forth for personnel management andis usually housed in a functional unit within organizations.DISCUSSION QUESTIONS1. Define organizational behavior.2. What are some of the major challenges facing today’s and tomorrow’shealth care organizations and health care managers? Why?3. Why did the Hawthorne Studies have an impact on the study oforganizational behavior?4. Why did McGregor’s Theory X and Theory Y have an impact on thestudy of organizational behavior?5. Discuss the difference between organizational behavior, organizationtheory, organizational development, and human resourcesmanagement.X-Y THEORY QUESTIONNAIRE

What Do You Know About Organizational Behavior?QuestionTrue/False1. OB is the study of individuals, groups and organizations.______2. Under Theory Y, managers create opportunities, removeobstacles, and encourage growth and learning for theiremployees.______3. Attitudes are very individual and subjective, and thereforewe do not currently have ways to measure an employee’sattitude about their jobs.______4. Extroverts do best in quiet, non-social jobs such as computerwork, while Introverts show the best job performance whenthey must work and present in front of large groups ofpeople.______5. Motivation is described as the conscious or unconsciousstimulus, incentive, or motives for action towards a goalresulting from psychological or social factors, the factorsgiving the purpose or direction to behavior.______6. Employee motivation has a direct impact on a health servicesorganization’s performance.______7. Process theories of motivation assist managers in predictingemployees’ behavior so the behavior may be influenced, ifnecessary.______8. An employee’s degree of job satisfaction is proportionate tothe actual amount of rewards he or she is receiving.______9. Power may be defined as the influence over the beliefs,emotions, and behaviors of people.______10. A leader is a person who directs the work of employees and isresponsible for results.______11. Management and leadership are both necessary for anorganization to achieve its goals.______12. The leader who is able to respond to ever-increasing levels ofenvironmental uncertainty through the utilization of morethan one style of leadership will be most likely to increasemotivation, satisfaction, and productivity of employees.______13. Transactional leadership is all about change, innovation,improvement, and entrepreneurship through vision andinspiration.______14. Transactional and transformational leader approaches areclearly oppositional.______15. Due to stress being a complex and highly personalized

process, some individuals see a specific situation as a threat,whereas other individuals see the same situation as achallenge or opportunity.______16. Managers are under the constraints of limited time andresources, personal bias and other factors, which makerational decision-making unrealistic.______17. Conflict is inevitable and unavoidable.______18. Individuals join groups to satisfy their need for safety andsocial needs.______19. Barriers to effective teamwork fall within four categories: (1)lack of management support, (2) lack of resources, (3) lack ofleadership, and (4) lack of training.______20. The two primary forces influencing an individual’sperception, attitude, and response toward change arecumulative life experiences and social (informal group)forces.______Scoring:The correct answers to the above 20 questions are:1. False2. True3. False4. False5. True6. True7. True8. True9. False10. True11. False12. True13. True14. False15. False16. True17. True18. True19. True20. True

Interpretation:How much do you know about organizational behavior? If you scoredwell – good for you! However, the above questions only represent a verysmall part of organizational behavior. If you didn’t score high – don’t beconcern. You will learn the many theories and concepts of organizationalbehavior that will provide you with the necessary skill set to successfullymanage and lead others.REFERENCESBenjamin, M. (2003, February 24). Fads for any and all eras. U.S. News &World Report, 134, 74–75.Bureau of Labor Statistics, U.S. Department of Labor. (2013). Industryemployment and output projections to 2022. Available at:www.bls.gov/opub/mlr/2013/article/industry-employment-and-output-projections-to-2022.htmDaft, R. L. (2004). Organization theory and design (8th ed.). Mason, OH:Thomson South-Western.Homans, G. C. (1950). The human group. New York, NY: Harcourt, Braceand Company.McGregor, D. M. (1957). The human side of enterprise. ManagementReview, 46, 22–28.McGregor, D. M. (1960). The human side of enterprise. New York, NY:McGraw-Hill Book Company.Ott, J. S. (1996). Classic readings in organizational behavior (2nd ed.).Albany, NY: Wadsworth Publishing Company.Roethlisberger, F. J., & Dickson, W. J. (1939). Management and the worker.Cambridge, MA: Harvard University Press.Taylor, F. W. (1911). The principles of scientific management. New York,NY: Harper and Brothers.

CHAPTER 2Diversity and Cultural Competencyin Health CareJean Gordon, RN, DBALEARNING OUTCOMESAfter completing this chapter, the student should be able to: Define diversity. Define cultural competency. Define diversity management. Understand why changes in U.S. demographics affect the health careindustry.OVERVIEWDemographics of the U.S. population have changed dramatically in thepast three decades. These changes directly impact the health care industryin regard to the patients we serve and our workforce. By 2050, the term“minority” will take on a new meaning. According to the U.S. CensusBureau, by midcentury the white, non-Hispanic population will compriseless than 50 percent of the nation’s population. As such, the health careindustry needs to change and adopt new ways to meet the diverse needs ofour current and future patients and employees.The American Heritage Dictionary of the English Language (4th ed.)defines diversity as: “(1) the fact or quality of being diverse; difference, and(2) a point in which things differ.” Dreachslin (1998) provided us with amore specific definition of diversity. She defined diversity as “the full rangeof human similarities and differences in group affiliation including gender,race/ethnicity, social class, role within an organization, age, religion, sexualorientation, physical ability, and other group identities” (p. 813). For ourdiscussions, we will focus on the following diversity characteristics: (1)

race/ethnicity, (2) age, and (3) gender.This chapter is presented in three parts. First, we discuss the changingdemographics of the nation’s population. Second, we examine how thesechanges are affecting the delivery of health services from both the patient’sand employee’s perspectives. Because diversity challenges faced by thehealth care industry are not limited to quality-of-care and access-to-careissues, in part three of our discussions we explore how these changes willaffect the health services workforce, and more specifically the current andfuture leadership within the industry.CHANGING UNITED STATES POPULATIONThere is no doubt that the demographic profile of the U.S. population hasundergone significant changes within the past 10 years regarding age,gender, and ethnicity (see Table 2–1).Table 2–1 Population of the United States by Age, Gender, and Race/EthnicityaaPercentages do not add up to 100 percent due to rounding and because Hispanics may be of any raceand are therefore counted under more than one category.Data from U.S. Census Bureau, 2010 Census. DP-1 – United States: Profile of General Population andHousing Characteristics: 2010 Demographic Profile Data: U.S. Census Bureau 2000 Census Data asshown in the 2009 Population Estimates table; U.S. Census Bureau: National Population Estimates;Decennial Census.

Data from the 2010 Census provide insights to our racially and ethnicallydiverse nation (Humes, Jones, & Ramirez, 2011). According to the 2010Census, 308.7 million people resided in the United States on April 1, 2010—an increase of 27.3 million people, or 9.7 percent, between 2000 and 2010.The vast majority of the growth in the total population came from increasesin those who reported their race(s) as something other than White alone andthose who reported their ethnicity as Hispanic or Latino. For the first timein the 2000 Census, individuals were presented with the option to self-identify with more than one race, and this continued with the 2010 Census.Using the five race categories (White, Black/African American, AmericanIndian/Alaska Native, Asian, and Native Hawaiian/Other Pacific Islander)required by federal agencies, there are 57 possible multiple racecombinations that could have been selected by individuals in addition to“some other race.” In fact, over 7 million or 2 percent of the U.S. populationdid so in the 2010 Census by identifying with and choosing “some otherrace” or “two or more races.” It is predicted that the number of Americansreporting themselves or their children as multiracial will increase in thefuture. In addition to the changing ethnic and racial composition of America,another issue is the aging population. According to the 2010 Census, 40million people (13 percent of the U.S. population) are 65 years of age orolder. This is 12.3 million more people than in 2000 (see Figure 2–1).

Figure 2–1 Population 65 Years and Over by Age and Sex, 2000 and 2010 (numbers in thousands)Data from U.S. Census Bureau, 2010 Census. DP-1 – United States: Profile of General Population and HousingCharacteristics: 2010 Demographic Profile Data: U.S. Census Bureau 2000 Census Data as shown in the 2009 PopulationEstimates table.During the past decade, the population aged 65 and over grew at a fasterrate (15.1 percent) than the population under age 45. This trend wasexpected as the Baby Boomers (those born between 1946 and 1964) beganreaching age 65 in 2011 (see Figure 2–2).In addition to the increasingly older population, there is a declining

number of young people in America. From 1940 to 2010, the percentage ofthe American population under the age of 18 fell from 31 percent to 24percent (U.S. Census Bureau, 2012). This decline in America’s youngerpopulation will have a direct effect on the industry’s ability to recruit healthcare professionals to provide sufficient services in the future. Young peopleof all ethnicities must be attracted to the health care industry as a careerchoice in order to meet the health care needs of the country’s growingpopulation.Males and females are almost evenly divided for the total population,representing 49.2 percent and 50.8 percent, respectively; however, in thepopulation under 25 years, males dominate females, with 105 males forevery 100 females. Among older adults, the male–female ratio reverses,with women outnumbering men. However, there was an interesting changein the male–female ratios for the population aged 60 and older between2000 and 2010 (Howden & Meyer, 2011). A greater increase in the malepopulation relative to the female population for these age groups was noted.Males aged 60 to 74 increased by 35.2 percent, while their femalecounterparts increased by 29.2 percent. A narrowing of the mortality gapbetween men and women at older ages in part accounts for this difference.

Figure 2–2 Projected Population of the United States by Age, 2000–2050 (Numbers in thousands)Data from Population Division, U.S. Census Bureau.Race/EthnicityThe U.S. population has continued to diversify during the past 10 years,as minority populations continue to increase at a faster rate than the Whitepopulation. Although the White population still represents the largest group(63.7 percent) of the U.S. population, this is down from 75.1 percent in 2000(see Table 2–1).In 2010, the Hispanic population represented the largest minority in theUnited States, 16.3 percent of the population. This is up from 4.5 percent in

1970, the first census in which Hispanic origin was identified. Theremaining population is composed of 12 percent Black, 5 percent Asian andPacific Islanders, 1 percent American Indians and Alaska Natives, and 3percent those who identified themselves as belonging to another or morethan one race (see Table 2–1).The Asian population in the United States is increasing rapidly as apercentage of the total population. From 2000 to 2010, the population ofthose people who identified themselves as being Asian (either alone or incombination with another race) grew 43.3 percent, while the totalpopulation grew only 9.7 percent (see Table 2–1)Aging PopulationThe world’s population is aging. According to the United Nations (2013),slow population growth brought about by reductions in fertility leads topopulation aging; that is, it produces populations where the proportion ofolder persons increases while that of younger persons decreases. Globally,the number of persons aged 60 and over is expected to more than triple by2100, which will represent 34 percent of the world’s population, or morethan 3 billion individuals. Of this group, the number of persons aged 80 andover is projected to increase almost sevenfold by 2100, representing justunder one-third of the world’s population aged 60 and over.The United States is experiencing the same as the world’s agingpopulation. As reported by Howden and Meyer (2011), the 2010 Censusreflects that the number of people under age 18 was 74.2 million (24.0percent of the total population). The younger working-age population, ages18 to 44, represented 112.8 million persons (36.5 percent). The olderworking-age population, ages 45 to 64, made up 81.5 million persons (26.4percent). Finally, the 65 and over population was 40.3 million persons (13.0percent). Between 2000 and 2010, the population under the age of 18 grewat a rate of 2.6 percent. The growth rate was even slower for those aged 18to 44 (0.6 percent). On the opposite side, the country is experiencingsubstantially faster growth rates for older ages. For example, the populationaged 45 to 64 grew at a rate of 31.5 percent. The large growth in this agegroup is primarily attributable to the aging of the Baby Boom population. Asnoted previously, the growth rate (15.1 percent) of the 65 and overpopulation was faster than the population under age 45.One of the most striking characteristics of the older population is thechange in the ratio of men to women as people age. As Howden and Meyer(2011, p. 3) point out, this is a result of differences in mortality for men and

women, where women tend to live longer than men. As such, there are morefemales then males at older ages. However, over the past decade anincrease in the male population relative to the female population has beennoted. For example, in 2010, there were 96.7 males per 100 females,representing an increase from 2000, when the ratio was 96.3 males per 100females (Howden & Meyer, 2011). This lowering of male mortality may beattributible to technological advances, more preventive screening, andhealthier lifestyles.While the elderly population is not as racially and ethnically diverse asthe younger generations, it is projected to increase in its racial and ethnicalmakeup over the next four decades. As in the past, the highest proportion ofthe U.S. population aged 60 and over is White (78.8 percent). However,within the racial composition of the older population, White is projected todecrease by 10 percent by 2050, and all other race groups will increase intheir own populations. This change is already being seen. In 2000, the agedWhite population was 82.5 percent, a 7 percent decrease compared with2010. The remaining makeup of this population group is 8.8 percent Black,7.3 percent Hispanic, and 3.6 percent Asian, with other races forming theremainder. As noted, this population group’s racial composition will continueto change over the next 40 years.GenderAs previously noted, according to the U.S. Census Bureau, in 2010, 50.8percent of the U.S. population was female, and 49.2 percent was male—almost identical to the 2000 Census. That translates to 96 men for every100 women. However, the ratio of men to women varies significantly by agegroup. There were about 105 males for every 100 females under 25 in 2010,reflecting the fact that more boys than girls are born every year and thatboys continue to outnumber girls through early childhood and youngadulthood. However, the male–female ratio declines as people age. For menand women aged 25 to 54, the number of men for each 100 women in 2010was 99. Among older adults, the male–female ratio continued to fall aswomen increasingly outnumbered men. For people 55 to 64, the male–female ratio was 93 to 100, but for those 85 and older, there were only 48men for every 100 women. These male–female ratios reflect a new trendthat has been occurring since 1980. From 1900 to 1940, there were moremales. Beginning in 1950, there were increasingly more females due toreduced female mortality rates. This trend reversed between 1980 and 1990as male death rates declined faster than female rates and as more men

immigrated to the United States than women (United States Department ofCommerce, 2003).When we look at education, it appears that females are outpacing men.Among the population aged 25 and older, 88 percent of both men andwomen were high school graduates. But of this group, 39 percent of menhad graduated from college, as compared with 61 percent of women.However, even with college degrees, only a high minority (44 percent) ofwomen are employed in management or professional positions.Exhibit 2–1 Hofstede’s Cultural DimensionsOne of the most extensive cross-cultural surveys ever conducted is Hofstede’s (1983) study ofthe influence of national culture on organizational and managerial behaviors. National culture isdeemed to be central to organizational studies, because national cultures incorporate political,sociological, and psychological components.Hofstede’s research was conducted over an 11-year period, with more than 116,000respondents in more than 40 countries. The researcher collected data about “values” from theemployees of a multinational corporation located in more than 50 countries. On the basis of hisfindings, Hofstede proposed that there are four dimensions of national culture, within whichcountries could be positioned, that are independent of one another. Hofstede’s (1983, pp. 78–85)four dimensions of national culture were labeled and described as:• Individualism–Collectivism: Individualism–collectivism measures culture along a self-interestversus group-interest scale. Individualism stands for a preference for a loosely knit socialframework in society wherein individuals are supposed to take care of themselves and theirimmediate families only. Its opposite, collectivism, stands for a preference for a tightly knitsocial framework in which individuals can expect their relatives, clan, or other in-group to lookafter them in exchange for unquestioning loyalty. Hofstede (1983) suggested that self-interested cultures (e.g., individualism) are positively related to the wealth of a nation.• Power Distance: Power Distance is the measure of how a society deals with physical andintellectual inequalities, and how the culture applies power and wealth relative to itsinequalities. People in large Power Distance societies accept hierarchical order in whicheverybody has a place, which needs no further justification. People in small Power Distancesocieties strive for power equalization and demand justification for power inequalities.Hofstede (1983) indicated that group-interest cultures (e.g., Collectivism) have large PowerDistance.• Uncertainty Avoidance: Uncertainty Avoidance reflects the degree to which members of asociety feel uncomfortable with uncertainty and ambiguity. The scale runs from tolerance ofdifferent behaviors (i.e., a society in which there is a natural tendency to feel secure) to one inwhich the society creates institutions to create security and minimize risk. Strong UncertaintyAvoidance societies maintain rigid codes of belief and behavior and are intolerant towarddeviant personalities and ideas.• Weak Uncertainty: Avoidance societies maintain a more relaxed atmosphere in which practicecounts more than principles and deviance is more easily tolerated.• Masculinity Versus Femininity: Masculinity versus femininity measures the division of rolesbetween the genders. The masculine side of the scale is a society in which the genderdifferences are maximized (e.g., need for achievement, heroism, assertiveness, and materialsuccess). Feminine societies are ones in which there are preferences for relationships,

modesty, caring for the weak, and the quality of life.Hofstede proposed that the most important dimensions for organizational leadership areIndividualism/Collectivism and Power Distance, and the most important for decision-making arePower Distance and Uncertainty Avoidance. Uncertainty Avoidance plays an integral part in acountry’s culture regarding change. For example, Nahavandi and Malekzadeh (1999, pp. 495–496)point out that countries such as Greece, Portugal, and Japan have national cultures that do noteasily tolerate uncertainty and ambiguity. Therefore, the resultant behavior emphasizes theissue avoidance or the importance of planned and well-managed activities. Other countries, suchas Sweden, Canada, and the United States, are able to tolerate change because of the potentialfor new opportunities that may come with change.The question frequently asked is whether Hofstede’s (1983) cultural dimensions are stillapplicable today. Patel (2003) found that the characteristics of Chinese, Indian, and Australiancultures corroborated Hofstede’s study results. Patel’s study of the relationship betweenbusiness goals and culture, measured by correlating the relative importance attached to thevarious business goals with the national culture dimension scores from Hofstede’s study, foundthat although the four cultural dimension scores were nearly 20 years old, they were validated inthis large, cross-national survey. In a study that measured 1,800 managers and professionals in15 countries, statistically significant correlations with the Hofstede indices validated theapplicability of the first study’s cultural dimension findings (Hofstede et al., 2002). The findingsfrom these studies suggest that Hofstede’s cultural dimensions continue to be robust and are stillapplicable measure components of national culture differences.NOTE: Hofstede (1991) subsequently included an additional dimension based on Chinesevalues referred to “Confucian dynamism.” Hofstede renamed this dimension as a long-termversus short-term orientation in life.IMPLICATIONS FOR THE HEALTH CARE INDUSTRYThe changing demographics of America’s population affect the health careindustry twofold. First, health care professionals and organizations need tohave cultural and linguistic competence to provide effective and efficienthealth services to diverse patient populations. However, before we continueour discussion, we need to define what is meant by cultural and linguisticcompetence. Over the years, cultural competence has been defined in manyways, such as “ongoing commitment or institutionalism of appropriatepractice and policies for diverse populations” (Brach & Fraser, 2000; Weech-Maldonado et al., 2002; see Hofstede’s Cultural Dimensions, Exhibit 2–1).Linguistic competence has been defined as “the capacity of an organizationand its personnel to communicate effectively, and convey information in amanner that is easily understood by diverse audiences including persons oflimited English proficiency, those who have low literacy skills or are notliterate, and individuals with disabilities” (Goode & Jones, 2004). For ourdiscussions we adopted the definition used by the Office of Minority Health(OMH) of the U.S. Department of Health and Human Services, which

defines “cultural and linguistic competence as a set of congruent behaviors,attitudes, and policies that come together in a system, agency, or amongprofessionals and that enables effective work in cross-cultural situations.”(United States Department of Health and Human Services, 2013).Second, because of the changing demographics of the nation’s population,the health care industry needs to ensure that the health care workforcemirrors the patient population it serves, both clinically and managerially. Asnoted by Weech-Maldonado et al. (2002), health care organizations mustdevelop policies and practices aimed at recruiting, retaining, and managinga diverse workforce in order to provide both culturally appropriate care andimproved access to care for racial/ethnic minorities.DIVERSITY ISSUES WITHIN THE CLINICAL SETTINGConsider the following:Scenario One: An insulin-dependent, indigent black non-Hispanicmale was treated at a predominantly Hispanic border clinic. Later, hewas brought back to the clinic in a diabetic coma. When he awoke,the nurse who had counseled him asked whether he had beenfollowing her instructions. “Exactly!” he replied. When the nurseasked him to show her, the monolingual Spanish-speaking nurse wasstartled when the patient proceeded to inject an orange and eat it.Scenario Two: As Maria (an elderly, monolingual Hispanic female)was being prepared for surgery, which was not why she came to thehospital, her designated interpreter (a young female relative) wastold by an English-speaking nurse to tell Maria that the surgeon wasthe best in his field and she’d get through this fine. The younginterpreter translated, “the nurse says the doctor does best when he’sin the field, and when it’s over you’ll have to pay a fine!”These may seem rather humorous misunderstandings, but real-lifeexperiences such as these happen every day in the United States (Howard,Andrade, & Byrd, 2001). For example, a survey by the Commonwealth Fund(2002) found that black non-Hispanics, Asian Americans, and Hispanics aremore likely than white non-Hispanics to experience difficultycommunicating with their physician, to feel that they are treated withdisrespect when receiving health care, to experience barriers to access tocare, such as lack of insurance or not having a regular physician, and to feelthey would receive better care if they were of a different race or ethnicity.

In addition, the survey found that Hispanics were more than twice as likelyas white non-Hispanics (33 percent versus 16 percent) to cite one or morecommunication problems, such as not understanding the physician, notbeing listened to by the physician, or not asking questions they needed toask. Twenty-seven percent of Asian Americans and 23 percent of black non-Hispanics experience similar communication difficulties.Cultural differences between providers and patients affect the provider–patient relationship. For example, Fadiman (1998) related a true andpoignant story of cultural misunderstanding within the health careprofession. Fadiman described the story of a young female epileptic Hmongimmigrant whose parents believed that their daughter’s condition wascaused by spirits called “dabs,” which had caught her and made her falldown, hence the name of Fadiman’s book The Spirit Catches You and YouFall Down. The patient’s parents struggled to understand the prescribedmedical care that only recognized the scientific necessities, but ignored theirpersonal belief about the spirituality of one’s soul in relationship to theuniverse. From a unique perspective, Fadiman examined the roles of thecaregivers (physicians, nurses, and social workers) in the treatment of illchildren. She studied the way the medical care system responded to its ownperceptions that the family was refusing to comply with medical orderswithout understanding the meaning of those orders in the context of theHmong culture, language, and beliefs.Because of our increasingly diverse population, health care professionalsneed to be concerned about their cultural competency, which is more thanjust cultural awareness or sensitivity. Although formal cultural training hasbeen found to improve the cultural competence of health care practitioners,Kundhal (2003) reported that only 8 percent of U.S. medical schools and noCanadian medical schools had formal courses on cultural issues. However,changes are occurring within the industry (see Exhibit 2–2) to assist healthcare practitioners in the developing of their cultural competences as theyencounter more diverse patients. For example, in 2000 the LiaisonCommittee on Medical Education (LCME), the accrediting body of medicalschools, introduced the following accreditation standard for culturalcompetence:The faculty and students must demonstrate an understanding ofthe manner in which people of diverse cultures and belief systemsperceive health and illness and respond to various symptoms,diseases, and treatments. Medical students should learn to recognize

and appropriately address gender and cultural biases in healthcaredelivery, while considering first the health of the patient.This standard has given added impetus and emphasis to medical schoolsto introduce education in cultural competence into the undergraduatemedical curriculum (Association of American Medical Colleges, 2005, p. 1).In addition, The Joint Commission has implemented patient-centeredcommunication accreditation standards, which require hospitals to meetcertain mandates related to qualifications for language interpreters andtranslators, identifying and addressing patient communication needs,collecting patient race and ethnicity data, patient access to a supportindividual, and nondiscrimination in care (The Joint Commission, 2014).Exhibit 2–2 Unequal TreatmentA study in 2002 by the Institute of Medicine, entitled Unequal Treatment: Confronting Racialand Ethnic Disparities in Health Care, found that a consistent body of research demonstratessignificant variation in the rates of medical procedures by race, even when insurance status,income, age, and severity of conditions are comparable. This research indicated that U.S. racialand ethnic minorities receive even fewer routine medical procedures and experience a lowerquality of health services than the majority of the population. For example, minorities are lesslikely to be given appropriate cardiac medications or to undergo bypass surgery, and are lesslikely to receive kidney dialysis or transplants. By contrast, they are more likely to receivecertain less desirable procedures, such as lower-limb amputations for diabetes.The study’s recommendations for reducing racial and ethnic disparities in health care includedincreasing awareness about disparities among the general public, health care providers,insurance companies, and policy makers.Modified from unequal treatment: Confronting racial and ethnic disparities in health care (p.3), by B. D. Smedley, A. Y. Stitch, and A. R. Nelson (Eds.), 2002, Washington, DC: NationalAcademy of Sciences, Institute of Medicine Committee on Understanding and Eliminating Racialand Ethnic Disparities in Health Care.Over the past decade, the Commonwealth Fund has been a leader in theeffort “to eliminate the cultural and linguistic barriers between health careproviders and patients, which can interfere with the effective delivery ofhealth services” (Beach, Saha, & Cooper, 2006, p. vi). The CommonwealthFund (2003), in addition to funding initiatives regarding quality of care forunder-served populations, has also initiated an educational program thatassists health care practitioners in understanding the importance ofcommunication between culturally diverse patients and their physicians, thetensions between modern medicine and cultural beliefs, and the ongoing

problems of racial and ethnic discrimination. The goals of this program arefor clinicians to:1. Understand that patients and health care professionals often havedifferent perspectives, values, and beliefs about health and illnessthat can lead to conflict, especially when communication is limited bylanguage and cultural barriers.2. Become familiar with the types of issues and challenges that areparticularly important in caring for patients of different culturalbackgrounds.3. Think about each patient as an individual, with many different social,cultural, and personal influences, rather than using generalstereotypes about cultural groups.4. Understand how discrimination and mistrust affect the interaction ofpatients with physicians and the health care system.5. Develop a greater sense of curiosity, empathy, and respect towardpatients who are culturally different, and thus be encouraged todevelop better communication and negotiation skills through ongoinginstruction.Reproduced from World’s Apart, Facilitator’s Guide by Alexander Green, MD, Joseph Betancourt, MD, MPH, and J.Emilio Carrillo, MD, MPH, The Commonwealth Fund, p. 4.In addition to the Commonwealth Fund, the W. K. Kellogg Foundationhas led efforts to lessen the recognized disparity of racial and ethnicminority groups’ representation among the nation’s health professionals. Itwas the Kellogg Foundation that requested the Institute of Medicine’s(2004) study entitled In the Nation’s Compelling Interest: EnsuringDiversity in the Health Care Workforce. The Institute of Medicine found thatracial and ethnic diversity is important in the health professions because:1. Racial and minority health care professionals are significantly morelikely than their peers to serve minority and medically underservedcommunities, thereby helping to improve problems of limited minorityaccess to care.2. Minority patients who have a choice are more likely to select healthcare professionals of their own racial or ethnic background. Moreover,racial and ethnic minority patients are generally more satisfied withthe care that they receive from minority professionals, and minoritypatients’ ratings of the quality of their health care are generallyhigher in racially concordant than in racially discordant settings.

3. Diversity in health care training settings may assist in efforts toimprove the cross-cultural training and competencies of all trainees.In addition to the Commonwealth Fund and the W. K. KelloggFoundation, other organizations are active in bridging cultural differencesin an attempt to lessen health disparities. For example, in 2000 the OMHdeveloped a list of standards for Culturally and Linguistically AppropriateServices (CLAS), which health care organizations and practitioners shoulduse to ensure equal access to quality health care by diverse populations. In2013, these standards were expanded to reflect the growth in the field ofcultural and linguistic competency. There are now 15 standards under fourcategories: (1) Principal Standard, (2) Governance, Leadership, andWorkforce, (3) Communication and Language Assistance, and (4)Engagement, Continuous Improvement, and Accountability.Principal Standard1. Provide effective, equitable, understandable, and respectful qualitycare and services that are responsive to diverse cultural health beliefsand practices, preferred languages, health literacy, and othercommunication needs.Governance, Leadership, and Workforce2. Advance and sustain organizational governance and leadership thatpromotes CLAS and health equity through policy, practices, andallocated resources.3. Recruit, promote, and support a culturally and linguistically diversegovernance, leadership, and workforce that are responsive to thepopulation in the service area.4. Educate and train governance, leadership, and workforce in culturallyand linguistically appropriate policies and practices on an ongoingbasis.Communication and Language Assistance5. Offer language assistance to individuals who have limited Englishproficiency and/or other communication needs, at no cost to them, tofacilitate timely access to all health care and services.6. Inform all individuals of the availability of language assistanceservices clearly and in their preferred language, verbally and inwriting.7. Ensure the competence of individuals providing language assistance,recognizing that the use of untrained individuals and/or minors as

interpreters should be avoided.8. Provide easy-to-understand print and multimedia materials andsignage in the languages commonly used by the populations in theservice area.Engagement, Continuous Improvement, and Accountability9. Establish culturally and linguistically appropriate goals, policies, andmanagement accountability, and infuse them throughout theorganization’s planning and operations.10. Conduct ongoing assessments of the organization’s CLAS-relatedactivities and integrate CLAS-related measures into measurementand continuous quality improvement activities.11. Collect and maintain accurate and reliable demographic data tomonitor and evaluate the impact of CLAS on health equity andoutcomes and to inform service delivery.12. Conduct regular assessments of community health assets and needs,and use the results to plan and implement services that respond tothe cultural and linguistic diversity of populations in the service area.13. Partner with the community to design, implement, and evaluatepolicies, practices, and services to ensure cultural and linguisticappropriateness.14. Create conflict and grievance resolution processes that are culturallyand linguistically appropriate to identify, prevent, and resolveconflicts or complaints.15. Communicate the organization’s progress in implementing andsustaining CLAS to all stakeholders, constituents, and the generalpublic.Reproduced from the National CLAS Standards, The office of Minority Health, U.S. Department of Health and HumanServices.Another diversity area that has shown progress since 2007 is the use ofthe Healthcare Equality Index (HEI) of the Human Rights Campaign (HRC)Foundation by hospitals and other organizations. This survey is a resourcefor health care organizations seeking to provide equitable, inclusive care tolesbian, gay, bisexual, and transgender (LGBT) Americans—and for LGBTAmericans seeking health care organizations with a demonstratedcommitment to their care (HRC, 2014). In 2013, facilities in all 50 statesand most U.S. veterans hospitals participated in using the HEI, with 93percent and 87 percent reporting that sexual orientation and gender identitywere included in their patient nondiscrimination policies, respectively. These

nondiscrimination policies are required for Joint Commission accreditation.In addition, both The Joint Commission and the Centers for Medicare andMedicaid Services require that facilities allow visitation without regard tosexual orientation or gender identity. Furthermore, 96 percent and 85percent of participants reported that sexual orientation and gender identity,respectively, were also included in their employment nondiscriminationpolicies. The HEI has two sections: (1) the core four leader criteria and (2)the additional best practices checklist. The Core Four Leader Criteria arereflected in Table 2–2. The Additional Best Practices Checklist is designed tofamiliarize HEI participants with other expert recommendations for LGBTpatient-centered care, to help identify and remedy gaps.AGING POPULATIONIn addition to the changing ethnic and racial composition of America,another area of concern is the growing elderly population. Technology hasgiven us the ability to enhance longevity; the challenge now is whether ornot the health care profession can learn how to best serve this growingpopulation of patients.Table 2–2 Health Care Equality Index’s Core Four Leader CriteriaCriteriaPatient Nondiscriminationa. Patient nondiscrimination policy (or patients’ bill of rights) includes the terms “sexualorientation” and “gender identity”b. LGBT-inclusive patient nondiscrimination policy is communicated to patients in at leasttwo documented waysEqual Visitationa. Visitation policy explicitly grants equal visitation to LGBT patients and their visitorsb. Equal visitation policy is communicated to patients in at least two documented waysEmploymentNondiscriminationEmployment nondiscrimination policy (or equal employment opportunity policy) includes theterms “sexual orientation” and “gender identity”Training in LGBT Patient-Centered CareStaff receive training in LGBT patient-centered careCopyright © 2014 by the Human Rights Campaign Foundation. Reproduced with permission. No furtherreproduction or distribution is permitted without written permission from the Human Rights CampaignFoundation.As our citizens grow older, more services are required for the treatmentand management of both acute and chronic health conditions. Theprofession must devise strategies for caring for the elderly patientpopulation. America’s older citizens are often living on fixed incomes andhave small or nonexistent support groups. Although this may be consideredan American infrastructure dilemma, the reality is that medical

professionals must be able to understand and empathize with poor, sick,elderly people of all races, sexes, and creeds.The term “ageism” was coined in 1968 by Robert N. Butler, M.D., apioneer in geriatric medicine and a founding director of the NationalInstitute on Aging (NIA). Butler was among the first to identify thephenomenon of age prejudice, initially describing it as “a systematicstereotyping of and discrimination against people because they are old.”Ageism can be defined as “any attitude, action, or institutional structure,which subordinates a person or group because of age or any assignment ofroles in society purely on the basis of age” (Traxler, 1980, p. 4). Health careprofessionals often make assumptions about their older patients on the basisof age rather than functional status (Bowling, 2007). This may be due to thelimited training physicians receive in the care and management of geriatricpatients. For example, Warshaw and colleagues (2002, 2006) related thatmedical residents have only limited training in geriatric medicine. Findingsfrom Warshaw et al.’s 2006 study were compared with those from a similar2002 survey to determine whether any changes had occurred. Of theparticipating three-year residency training programs, only 9 percentrequired six weeks or more of training. As in 2002, the residency programscontinue to depend on nursing home facilities, geriatric preceptors innongeriatric clinical ambulatory settings, and outpatient geriatricassessment centers for the medical residents’ geriatrics training. A reportfrom the Alliance for Aging Research (2003) related that there continue tobe shortcomings in medical training, prevention, screening, and treatmentpatterns that disadvantage older patients. The report outlined five domainsof ageism in health care:1. Health care professionals do not receive enough training in geriatricsto properly care for many older patients.2. Older patients are less likely than younger people to receivepreventive care.3. Older patients are less likely to be tested or screened for diseases andother health problems.4. Proven medical interventions for older patients are often ignored,leading to inappropriate or incomplete treatment.5. Older people are consistently excluded from clinical trials, eventhough they are the largest users of approved drugs.On a positive note, Perry (2012) relates that progress against systematicageism in health care has begun, in part, due to the passing of the 2010

Affordable Care Act (ACA). He notes that the law’s various provisions, suchas Medicare’s increased focus on chronic disease prevention, new models ofcare for reducing re-hospitalizations, and improved care coordination, aswell as annual screening for cognitive impairment, will assist with changingattitudes toward elderly patients.Before moving to our next discussion regarding diversity management, wepause to provide a brief overview of the efforts being made regarding themeasuring and reporting of cultural competency. Measurement andreporting are needed to ensure that culturally competent care can betranslated into: (1) improved health outcomes and more patient-centeredcare, and (2) actionable initiatives for providers that result in meaningfulimprovement. Through the support of the Robert Wood Johnson Foundation(RWJF), in 2009, the National Quality Forum (NQF) endorsed acomprehensive national framework based on a set of seven interrelateddomains (and multiple subdomains) for evaluating cultural competencyacross all health care settings, as well as a set of 45 recommended practicesbased on the framework. This was followed by RAND’s development of acultural competency implementation measurement tool. This tool is anorganizational survey designed to assist health care organizations inidentifying the degree to which they are providing culturally competent careand addressing the needs of diverse populations, as well as their adherenceto 12 of the 45 NQF-endorsed cultural competency practices. In 2012, NQFendorsed 12 quality measures that address health literacy, language access,cultural competency, leadership, and workforce development (RWJF, 2014).These quality measures are the first endorsed by NQF that specificallyaddress health care disparities and cultural competency.DIVERSITY MANAGEMENTDiversity management is a challenge to all organizations. Diversitymanagement is “a strategically driven process whose emphasis is onbuilding skills and creating policies that will address the changingdemographics of the workforce and patient population” (Svehla, 1994;Weech-Maldonado et al., 2002). In 2004, the National Urban Leaguepublished its first study on employees’ perceptions regarding theeffectiveness of their companies’ diversity programs. The results of theorganization’s 2009 follow-up survey found that progress has been madeover the past five years in certain areas. However, leadership commitmentto diversity and companies clearly communicating their platform on howthey value diversity are still lagging (see Table 2–3).

As reflected in Table 2–3, organizations have improved in communicatingeffectively regarding their diversity platforms but need to focus on their (1)commitment to, (2) accountability for, (3) action on, and (4) measurement ofthese initiatives. The good news is the notable increases reflecting theintrinsic acceptance of diversity and inclusion by the American worker. Asreported by the National Urban League (2009), the playing field appearsmore level, diverse talent is being developed and retained, andcustomer/consumer diversity is being recognized.While some gains have been made in regard to increasing diversity in thefield of health care management, recent studies continue to suggest thatthere is still ample room for improvement. The Institute for Diversity inHealth Management, an affiliate of the American Hospital Association, wasformed in 1994 to address the problem that was disclosed in a 1992 studythat minorities held less than 1 percent of top management positions withinthe industry. In addition, the study revealed that African American healthcare executives made less money, held lower positions, and had less jobsatisfaction than their white counterparts. A 1997 follow-up study,expanded to include Latinos and Asians, found that although the gap hadnarrowed in some areas, not much had changed. As examples, a study byMotwani, Hodge, and Crampton (1995) found that only 27.7 percent ofhealth care workers in six Midwest hospitals felt that their institutions hada program to improve employee skills in dealing with people of differentcultures, and only 38.9 percent felt that management realized that culturalfactors were sometimes the cause of conflicts among employees. Weech-Maldonado, et al. (2002) found that hospitals in Pennsylvania had beenrelatively inactive with employing diversity management practices, andequal employment requirements were the main driver of diversitymanagement policy. Five years later, Weech-Maldonado and colleagues(Weech-Maldonado, Elliott, Schiller, Hall, Dreachslin, & Hays, 2007;Weech-Maldonado, Elliott, Schiller, Hall, & Hays, 2007) continued to findlow levels of diversity management activity within California hospitals.Since that time, the Institute for Diversity in Health Management, incollaboration with other organizations, designed several initiatives toexpand health care leadership opportunities for ethnically, culturally, andracially diverse individuals, thus increasing the number of these individualsentering and advancing in the field.

Table 2–3 American Workers’ Perception

Data from National Urban League. Diversity Practices That Work: The American Worker Speaks II, 2009Highlights.HEALTH CARE LEADERSHIPThe American College of Healthcare Executives (ACHE), the NationalAssociation of Health Services Executives (NAHSE), the Institute forDiversity in Healthcare Management (IFD), the National Forum for LatinoHealthcare Executives, and the Asian Health Care Leaders Associationreleased a study in 2009 that measured the representation of black non-Hispanics, Hispanics, women, and other minorities in health care executiveleadership roles. This study was a follow up to similar studies completed in1992, 1997, and 2002. The study, completed in 2008, was based on arandom-sample survey of 1,515 health care executives. Respondents workedin a variety of settings—hospitals, health care–provider organizations,government health agencies, and consulting and educational institutes (seeTable 2–4).Although the results of the 1997 study reflected improvements in

diversity over the 1992 study (see: www.ache.org—Race and Ethnic Study2002), the 2002 and 2008 results indicated that the health care industry didnot do as well in promoting minorities and women in chief executive officer(CEO) and chief operating officer (COO)/senior vice president positions. Inthe 2008 ACHE study, as noted by the authors of the study (p. 12) andreflected in Tables 2–4 and 2–5, 34 percent of CEOs are white men,compared to 28 percent of them being Hispanic men, 16 percent black men,and 5 percent Asian men. However, these disparities are not apparentamong women, where all racial/ethnic groups hold between 10 and 13percent of CEO positions. When all senior executive positions areconsidered, including chief executive officer and chief operatingofficer/senior vice president, the proportion of white men in such positionscontinues to exceed that of minority men. However, among women, a higherproportion of Hispanic women than others are in senior executive positions.The two factors of race/ethnicity and gender are evident especially whencomparing blacks and whites. For both blacks and whites, only about half asmany women attained CEO or COO/senior vice president posts as theirmale counterparts.In the 2013–2014 Benchmarking Survey by the Institute of Diversity, theresults highlighted that while there was some limited increase in thediversity of hospitals’ leadership and governance, more positive movement isneeded. The study reported that minorities composed:• 14 percent of hospital board members (unchanged from 2011)• 12 percent of executive leadership positions (unchanged from 12 percentin 2011)• 17 percent of first- and mid-level management positions (up from 15percent in 2011)

Table 2–4 American College of Healthcare Executives 2008 Diversity StudySOURCE: American College of Healthcare Executives. Reprinted with permission.Table 2–4 American College of Healthcare Executives 2008 Diversity Studya Responses may not total to 100 because of rounding.Reproduced from American College Of Healthcare Executives with permission.Table 2–5 American College of Healthcare Executives 2008 Diversity Studya Responses may not total to 100 because of rounding.Reproduced from American College Of Healthcare Executives with permission.Dreachslin and Curtis (2004) noted that career advancement of womenand racially/ethnically diverse individuals in health care management was

characterized by: (1) underrepresentation, especially in senior-levelmanagement positions; (2) lower compensation, even controlling foreducation and experience; and (3) more negative perceptions of equity andopportunity in the workplace. The researchers identified three areas thatare key organization-specific factors for shaping career outcomes for womenand racially/ethnically diverse individuals: (1) leadership and strategicorientation (i.e., senior management’s commitment to successfulimplementation of diversity initiatives), (2) organizational culture/climate(i.e., the depth and breadth of the organization’s strategic commitment todiversity leadership and cultural competence), and (3) human resourcespractices (i.e., establishing best practices in advancing the managementcareers of women and racially/ethnically diverse individuals, such as formalmentoring programs, professional development, work/life balances, andflexible benefits).On the basis of Dreachslin’s and others’ research, the NCHL, ACHE, IFD,and the American Hospital Association developed the Diversity and CulturalProficiency Assessment Tool for Leaders (see Exhibit 2–3). The assessmenttool begins the process of developing a cultural awareness for theorganization’s workforce. Going forward, managers will need to developmodels that establish benchmarks for cultural competence to enable theirorganizations to develop competent interventions, thereby improving thequality of health care (Betancourt, Green, & Carrillo, 2002).Exhibit 2–3 A Diversity and Cultural Proficiency Assessment Tool for LeadersCHECKLISTAs Diverse as the Community You ServeYESNO• Do you monitor at least every three years the demographics of your community totrack change in gender and racial and ethnic diversity?__________• Do you actively use these data for strategic and outreach planning?__________• Has your community relations team identified community organizations, schools,churches, businesses, and publications that serve racial and ethnic minorities foroutreach and educational purposes?__________• Do you have a strategy to partner with them to work on health issues important tothem?__________• Has a team from your hospital met with community leaders to gauge theirperceptions of the hospital and to seek their advice on how you can better servethem, in both patient care and community outreach?__________• Have you done focus groups and surveys within the past three years in yourcommunity to measure the public’s perception of your hospital as being sensitive todiversity and cultural issues?__________

• Do you compare the results among diverse groups in your community and act on theinformation?__________• Are the individuals who represent your hospital in the community reflective of thediversity of the community and your organization?__________• When your hospital partners with other organizations for community healthinitiatives or sponsors community events, do you have a strategy in place to becertain you work with organizations that relate to the diversity of your community?__________• As a purchaser of goods and services in the community, does your hospital have astrategy to ensure that businesses in the minority community have an opportunity toserve you?__________• Are your public communications, community reports, advertisements, healtheducation materials, websites, etc. accessible to and reflective of the diversecommunity you serve?__________Culturally Proficient Patient Care• Do you regularly monitor the racial and ethnic diversity of the patients you serve?__________• Do your organization’s internal and external communications stress yourcommitment to culturally proficient care and give concrete examples of what you aredoing?__________• Do your patient satisfaction surveys take into account the diversity of your patients?__________• Do you compare patient satisfaction ratings among diverse groups and act on theinformation?__________• Have your patient representatives, social workers, discharge planners, financialcounselors, and other key patient and family resources received special training indiversity issues?__________• Does your review of quality assurance data take into account the diversity of yourpatients in order to detect and eliminate disparities?__________• Has your hospital developed a “language resource,” identifying qualified people insideand outside your organization who could help your staff communicate with patientsand families from a wide variety of nationalities and ethnic backgrounds?__________• Are your written communications with patients and families available in a variety oflanguages that reflects the ethnic and cultural fabric of your community?__________• Depending on the racial and ethnic diversity of the patients you serve, do youeducate your staff at orientation and on a continuing basis on cultural issuesimportant to your patients?__________• Are core services in your hospital such as signage, food service, chaplaincy services,patient information, and communications attuned to the diversity of the patients youcare for?__________• Does your hospital account for complementary and alternative treatments inplanning care for your patients?__________Strengthening Your Workforce Diversity• Do your recruitment efforts include strategies to reach out to the racial and ethnicminorities in your community?__________• Does the team that leads your workforce recruitment initiatives reflect the diversityyou need in your organization?__________• Do your policies about time off for holidays and religious observances take intoaccount the diversity of your workforce?__________• Do you acknowledge and honor diversity in your employee communications, awardsprograms, and other internal celebrations?__________• Have you done employee surveys or focus groups to measure their perceptions ofyour hospital’s policies and practices on diversity and to surface potential problems?__________• Do you compare the results among diverse groups in your workforce? Do you

communicate and act on the information?__________• Have you made diversity awareness and sensitivity training available to youremployees?__________• Is the diversity of your workforce taken into account in your performance evaluationsystem?__________• Does your human resources department have a system in place to measure diversityprogress and report it to you and your board?__________• Do you have a mechanism in place to look at employee turnover rates for variancesaccording to diverse groups?__________• Do you ensure that changes in job design, workforce size, hours, and other changesdo not affect diverse groups disproportionately?__________Expanding the Diversity of Your Leadership Team• Has your Board of Trustees discussed the issue of the diversity of the hospital’sboard? Its workforce? Its management team?__________• Is there a Board-approved policy encouraging diversity across the organization?__________• Is your policy reflected in your mission and values statement? Is it visible ondocuments seen by your employees and the public?__________• Have you told your management team that you are personally committed toachieving and maintaining diversity across your organization?__________• Does your strategic plan emphasize the importance of diversity at all levels of yourworkforce?__________• Has your board set goals on organizational diversity, culturally proficient care, andeliminating disparities in care to diverse groups as part of your strategic plan?__________• Does your organization have a process in place to ensure diversity reflecting yourcommunity on your Board and subsidiary and advisory boards?__________• Have you designated a high-ranking member of your staff to be responsible forcoordinating and implementing your diversity strategy?__________• Have sufficient funds been allocated to achieve your diversity goals?__________• Is diversity awareness and cultural proficiency training mandatory for all seniorleadership, management, and staff?__________• Have you made diversity awareness part of your management and board retreatagendas?__________• Is your management team’s compensation linked to achieving your diversity goals?__________• Does your organization have a mentoring program in place to help develop your besttalent, regardless of gender, race, or ethnicity?__________• Do you provide tuition reimbursement to encourage employees to further theireducation?__________• Do you have a succession/advancement plan for your management team linked toyour overall diversity goals?__________• Are search firms required to present a mix of candidates reflecting your community’sdiversity?__________© Used with permission of the American Hospital Association. Strategies for Leadership: aDiversity and Cultural Proficiency Assessment Tool for Leaders. 2004.http://www.aha.org/aha/content/2004/pdf/diversitytool.pdfIn order to best serve their patient base, health care organizations andproviders must be willing to invest the time, money, and effort needed to

educate all their employees. Educating senior staff is important, but so iseducating the entire health care workforce. Wilson-Stronks and Murtha(2010), Cejka Search and Solucient (2005), and Kochan et al. (2003) havelinked the effects of diversity to business performance. Kochan andcolleagues (2003) concluded that the impact of diversity is dependent uponthe following factors: organizational culture, human resource practices, andstrategy. In other words, the impact of diversity is directly related to theorganization’s ability to walk their talk and can have a negative impact ifnot followed. For example, the Witt/Kieffer’s 2011 national survey of 454health care professionals, with 54 percent representing senior executives,provides a deeper understanding of how diversity is connected tomeasurable business benefits:• Patient satisfaction: Nearly two-thirds (62 percent) believe culturaldifferences improve patient satisfaction.• Successful decision-making: More than half (57 percent) believe thatcultural differences support successful decision-making.• Strategic goals: More than half of these respondents (54 percent)acknowledge that diversity recruiting enables the organization to reachits strategic goals.• Clinical outcomes: Nearly half (46 percent) believe diversity improvesclinical outcomes.Dreachslin (2007) reinforces the need for mass customization of diversitypractices to be inclusive of disparities that are represented within thecommunities that health care organizations serve. In order to activelysupport business strategy, organizations will need to provide employeeswith skills that are inclusive of conflict-management skills, self-awareness,understanding of cultural differences, validation of alternative points ofview, and methods to manage bias through effective human resourcetraining and development.For health care managers to transform their organizations into aninclusive culture where all employees feel the opportunity to reach their fullpotential, Guillory (2004, pp. 25–30) recommended a 10-step process:1. Development of a customized business case for diversity for yourorganization. In other words, how does diversity relate to the overallsuccess of the organization?2. Education and training for your staff to develop an understanding ofdiversity, its importance to your organization’s success, and diversity

skills to apply on a daily basis.3. Establishment of a baseline by conducting a comprehensive culturalsurvey that integrates performance, inclusion, climate, and work/lifebalance.4. Selection and prioritization of the issues that lead to the greatestbreakthrough in transforming the culture.5. Creation of a three- to five-year diversity strategic plan that is tied toorganizational strategic business objectives.6. Leadership’s endorsement of and financial commitment to the plan.7. Establishment of measurable leadership and management objectivesto hold managers accountable to top leadership for achieving theseobjectives.8. Implementation of the plan, recognizing that surprises and setbackswill occur along the way.9. Continued training in concert with the skills and competenciesnecessary to successfully achieve the diversity action plan.10. Survey one to one-and-a-half years after initiation of the plan todetermine how inclusion has changed.Reproduced from Guillory, W. A. (2004). The roadmap to diversity, inclusion, and high performance. Healthcare Executive,19(4), 24–30.Dreachslin (2007) reinforces the need for senior staff to “manage”diversity and invest in professional development so that team membershave the tools they need to navigate their differences. As Dreachslin notes,“if left unmanaged, demographic diversity will interfere with teamfunctioning.” Managers need to provide employees with training to enhancetheir conflict-management skills, self-awareness, understanding of culturaldifferences, and methods to effectively manage bias.THE FUTURE WORKFORCEFor the first time in modern history, our workforce consists of fourseparate generations working side by side—and the differences among themare one of the greatest challenges facing managers today (Wasserman,2007). Bonnie Clipper (2012, p. 45), author of The Nurse Manager’s Guide toan Intergenerational Workforce, provides a humorous example forunderstanding the generations’ differences.A nurse manager desperate for more staff, telephones four nurses toask whether they will pull an extra shift:

The first nurse says, “What time do you need me?”The second nurse says, “Call me back if you can’t find anyone else.”The third nurse says, “How much will you pay me?”The fourth nurse says, “Sorry, I have plans. Maybe next time.”Adapted from Stokowski, L. A. (2013). The 4-generation gap innursing. Medscape. Available at:www.medscape.com/viewarticle/781752These different reponses are typical of the four different generations ofnurses currently working side by side at the bedside. The first response wasfrom the traditionalist generational cohort. This generation, born between1925 and 1942, is typically characterized as dedicated, hardworking, andloyal. The second response is from the Baby Boomer generation, those bornbetween 1943 and 1960 who are viewed as optimistic, productive, andworkaholics. The third response is from Generation X, born between 1961and 1981, typically referred to as cynical, independent, and informal. Thefourth response is reflective of the Millennial generational cohort, bornbetween 1982 and 2000, which is viewed as confident, inpatient, and social.Becton, Walker, and Jones-Farmer (2014) point out that although much hasbeen written about their differences, there still remains a gap in ourunderstanding of each generational cohort’s values and beliefs. As such,generational differences may best be explained by “age, life stage, or careerstage effects” (Becton, Walker, & Farmer, 2014, p. 176).As part of diversity management, health care managers need to devisestrategies for attracting younger workers to enter the health care fieldwhile maintaining positive relationships with older workers. For example,Barney (2002, p. 83) points out that Generation X workers want “managerswho listen, consider their ideas, and treat them as peers. They want to bepart of the decision-making process and want flexibility in their workenvironment because they value their time and freedom.”What about the Millennials, sometimes referred to as Generation Y?Although this generational cohort has only recently begun to enter theworkforce, Millennials will be the fastest-growing segment of the workingpopulation—they grew from 14 percent of the workforce to 21 percent overthe past four years, to nearly 32 million workers (Armour, 2005). Althoughit is impossible to generalize about the wants and needs of millions of peoplein each generation, workplace experts tend to use the followingcharacteristics to describe the Millennials (Martin & Tulgan, 2006):

• High expectations of self: They aim to work faster and better thanother workers.• High expectations of employers: They want fair and direct managerswho are highly engaged in their professional development.• Ongoing learning: They seek out creative challenges and viewcolleagues as vast resources from whom to gain knowledge.• Immediate responsibility: They want to make an important impact onday one.• Goal oriented: They want small goals with tight deadlines so they canbuild up ownership of tasks.In addition to the younger workers, health care managers must alsoconsider the needs of older workers. For example, in a Robert Wood JohnsonFoundation study, Hatcher and colleagues (2006) suggested that hospitalsseeking to recruit and retain older nurses need to implement strategies,such as flexible work hours, increased benefits, newly created professionalroles, and an atmosphere of respect for nurses.Generational diversity poses challenges for today’s and tomorrow’semployers. Younger workers have a strong need for immediate feedback,workers now in their 30s and 40s demand greater work–life balance andflexibility, and older workers expect increased benefits and professionalism.With a multigenerational workforce, employers will need to develop age-diversity training programs for their managers so they can betterunderstand the needs and expectations of each generation (Martin &Tulgan, 2006).SUMMARYHealth care organizations need to be flexible to change and meet diversitychallenges. The greatest barrier to the industry’s success may be itsinability to understand and appreciate the increasing diversity within ourpopulation, whether relating to patients or employees. As Kochan andcolleagues (2003, p. 18) related,Diversity is a reality in labor markets and “customer” markets today.To be successful in working with and gaining value from thisdiversity requires a sustained, systemic approach and long-termcommitment. Success is facilitated by a perspective that considersdiversity to be an opportunity for everyone in an organization to learn

from each other how better to accomplish their work and an occasionthat requires a supportive and cooperative organizational culture aswell as group leadership and process skills that can facilitate effectivegroup functioning. Organizations that invest their resources in takingadvantage of the opportunities that diversity offers should outperformthose that fail to make such investments.Similarly, Dobson (2012) states that although more research is needed, itmakes good business sense for organizations to invest in leadershipdiversity. She argues that there are three interrelated strategies fororganizations to consider: (1) linking diversity with performance, (2) linkinginvestments in diversity to financial outcomes and organizational metrics ofsuccess, and (3) making organizational leadership responsible for culturalcompetence as a performance measure. When operational measures areconnected with a culturally competent organization, the results will be areduction in health disparities, increased patient satisfaction, and a moreengaged workforce.DISCUSSION QUESTIONS1. Discuss what the term “diversity” means.2. Explain the meaning of cultural competency.3. What do we mean when we say “diversity management”?4. Explain why and how changes in U.S. demographics affect the healthcare industry.EXERCISE 2–1You have been asked to join the hospital’s task force for developing a planto increase the organization’s workforce diversity from its current 20percent level to 40 percent over the next five years. How does your taskforce define diversity? What recommendations would you make as amember of the task force?EXERCISE 2–2In 2012, the Alliance of Aging Research established the HealthspanCampaign, a coalition of organizations committed to solving the challenges

brought about by the aging of the American population. With each passingyear, the percentage of people in the United States—and much of the world—over age 65 increases. This “Silver Tsunami” is expected to bring a flood ofchronic disease and disabilities due to aging that could overwhelm thehealth care systems of many nations. Watch the films The HealthspanImperative and What Is the Silver Tsunami? atwww.healthspancampaign.org. Discuss the effect of the aging population onour health system and present recommendations for how these challengescould be addressed.EXERCISE 2–3Visit the Hofstede Centre (http://geert-hofstede.com/countries.html) andreview the scores by country for the various cultural dimensions thatHofstede identified. In light of these scores, think about some interactionsyou’ve had with people (colleagues, patients, friends, etc.) born and raised inother countries. Do your interactions make more sense given this newlyfound insight?EXERCISE 2–4View the video titled Improving Patient-Provider Communication: JointCommission Standards and Federal Laws atwww.jointcommission.org/multimedia/improving-patient-provider-communication—part-1-of-4/. The video was a joint project of The JointCommission and the U.S. Department of Health & Human Services (HHS)Office for Civil Rights to support language access in health careorganizations.With diverse patient populations come language translation issues.Medical interpretation is a challenge facing most health organizations.Medical interpretation and translation services are costly. You are amember of your hospital’s task force challenged to establish customer-focused, cost-efficient communication programs. What recommendationswould you make as a member of the task force?EXERCISE 2–5

In December 2012, the American College of Healthcare Executivesreleased its fifth report in a series of research surveys designed to comparethe career attainments of men and women health care executives. View thisreport, titled A Comparison of the Career Attainments of Men and WomenHealthcare Executives: 2012, at www.ache.org. In small groups, discuss thechanges (if any) regarding women advancing to senior leadership positionsthat have occurred in the health care industry since the previous report in2006.EXERCISE 2–6In April 2013, Modern Healthcare published its fourth biennial recognitionof the Top 25 Women in Healthcare. The previous lists appeared in 2005,2007, and 2009 and can be found on ModernHealthcare.com under“Recognitions.” In small groups, discuss the changes (if any) over the pastnine years of the selected awardees population (i.e., employed in whatsectors of the health industry, what positions do/did they hold,race/ethnicity groups, and so on).REFERENCESAlliance for Aging Research. (2003). Ageism: How healthcare fails theelderly. Available at: www.agingresearch.orgAmerican College of Healthcare Executives. (2008). A race/ethniccomparison of career attainments in healthcare management, SummaryReport—2008. Available at: www.ache.orgAmerican Nurses Association, Cultural Diversity in Nursing Practice, 1991.www.nursingworld.org/MainMenuCategories/Policy-Advocacy/Positions-and-Resolutions/ANAPositionStatements/Position-Statements-Alphabetically/prtetcldv14444.htmlArmour, S. (2005, November 6). Generation Y: They arrived at work withan attitude. USA Today. Available at:www.usatoday.com/money/workplace/2005–11-06-gen-y_x.htmAssociation of American Medical Colleges. (2005). Cultural competenceeducation. Available at:www.aamc.org/download/54338/data/culturalcomped.pdfBarney, S. M. (2002). A changing workforce calls for twenty-first centurystrategies. Journal of Healthcare Management, 47(2), 61–65.

Beach, M. C., Saha, S., & Cooper, L. A. (2006). The role and relationship ofcultural competence and patient-centeredness in health care quality. TheCommonwealth Fund. Available at:http://www.commonwealthfund.org/publications/fund-reports/2006/oct/the-role-and-relationship-of-cultural-competence-and-patient-centeredness-in-health-care-qualityBecton, J. B., Walker, H. J., & Jones-Farmer, A. (2014). Generationaldifferences in workplace behavior. Journal of Applied Social Psychology,44(3), 175–189.Betancourt, J., Green, A. R., & Carrillo, E. (2002). Cultural competence inhealth care: Emerging frameworks and practical approaches. TheCommonwealth Fund. Available at:www.commonwealthfund.org/usr_doc/betancourt_culturalcompetence_576.pdf?section=4039Bowling, A. (2007). Honour your father and mother: Ageism in medicine.British Journal of General Practice, 57(538), 347–348.Brach, C., & Fraser, I. (2000). Can cultural competency reduce racial andethnic racial health disparities? A review and conceptual model. MedicalCare Review, 57(Suppl. 1), 181–217.Butler, R. (1969). Age-ism: Another form of bigotry. The Gerontologist, 9,243–246.Ceijka Search and Solucient, LLC. (2005). Hospital CEO Leadership Survey.St. Louis, MO: Ceijka Search and Solucient, LLC.Clipper, B. (2012). The nurse manager’s guide to an intergenerationalworkforce. Indianapolis, IN: Sigma Theta Tau International.Commonwealth Fund. (2002). International health policy survey of adultswith health problems. Available at: www.cmwf.orgCommonwealth Fund. (2003). Worlds apart: A film series on cross-culturalhealth care. Available at: www.cmwf.orgDobson, E. (2012). Setting the stage for a business case for leadershipdiversity in healthcare: history, research, and leverage. Journal ofHealthcare Management, 57(1), 35–46.Dreachslin, J. L. (1998). Conducting effective focus groups in the context ofdiversity: Theoretical underpinnings and practical implications.Qualitative Health Research, 8(6), 813–820.Dreachslin, J. L. (2007). Diversity management and cultural competence:Research, practice and the business case. Journal of HealthcareManagement, 52(2), 79–86.Dreachslin, J. L., & Curtis, E. F. (2004). Study of factors affecting the

career advancement of women and racially/ethnically diverse individualsin healthcare management. Journal of Health Administration Education,21(4), 441–484.Fadiman, A. (1998). The spirit catches you and you fall down. New York,NY: Farrar, Straus and Giroux.Goode, T. & Jones, W. (2004). Increasing awareness and implementation ofcultural competence principles in health professions education. Journal ofAllied Health, 29(4), 241–245.Guillory, W. A. (2004). The roadmap to diversity, inclusion, and highperformance. Healthcare Executive, 19(4), 24–30.Hatcher, B., Bleich, M. R., Connolly, C., Davis, K., O’Neill Hewlett, P., &Stokley Hill, K. (2006). Wisdom at work: The importance of the older andexperienced nurse in the workplace. Princeton, NJ: The Robert WoodJohnson Foundation. Available at:www.rwjf.org/files/publications/other/wisdomatwork.pdfHofstede, G. (1983). The cultural relativity of organizational practices andtheories. Journal of International Business Studies, 14(2), 75–89.Hofstede, G. (1991). Cultures and Organizations: Software of the Mind.London, UK: McGraw-Hill.Hofstede, G., Van Deusen, C. A., Mueller, C. B., & Charles, T. A. (2002).What goals do business leaders pursue? A study in fifteen countries.Journal of International Business Studies, 33(4), 785–803.Howard, C., Andrade, S. J., & Byrd, T. (2001). The ethical dimensions ofcultural competence in border healthcare settings. Family andCommunity Health, 23(4), 36–49.Howden, L. M., & Meyer, J. A. (2011). Age and sex composition: 2010. U.S.Department of Commerce, Economics and Statistics Administration, U.S.Census Bureau, Washington, DC.Humes, K.R., Jones, N.A. & Ramirez, R.R. (2011). Overview of race andHispanic origin: 2010. U.S. Department of Commerce, Economics andStatistics Administration, U.S. Census Bureau, Washington, DC.Human Rights Campaign (2014). Healthcare Equality Index. Available at:http://www.hrc.org/heiInstitute for Diversity in Health Management. (2014). About the Institute.Available at: www.diversityconnection.org/diversityconnection/about-us/About-the-Institute.jspInstitute of Medicine. (2004). In the nation’s compelling interest: Ensuringdiversity in the health care workforce. Washington, DC: National

Academy Press.Kochan, T., Bezrukova, R., Jackson, A., Jehn, K., Leonard, D., & Thomas,D. (2003). The effects of diversity on business performance: Report of thediversity research network. Human Resource Management, 42(5), 3–21.Kundhal, K. K. (2003). Cultural diversity: An evolving challenge tophysician-patient communication. Journal of the American MedicalAssociation, 289(1), 94.Martin, C., & Tulgan, B. (2006). Managing the generation mix (2nd ed.).Amherst, MA: HRD Press.Motwani, J., Hodge, J., & Crampton, S. (1995). Managing diversity in thehealthcare industry. Healthcare Supervisor, 13(3), 16–25.Nahavandi, A., & Malekzadeh, A. R. (1999). Organizational behavior: Theperson-organization fit. Upper Saddle River, NJ: Prentice Hall.National Urban League. (2009). Diversity practices that work: TheAmerican worker speaks II. Available at:nul.iamempowered.com/sites/nul.iamempowered.com/files/attachments/Diversity_Practices_That_work_2009.pdfPatel, C. (2003). Some cross-cultural evidence on whistle-blowing as aninternal control mechanism. Journal of International AccountingResearch, 2, 69–96.Perry, D. (2012). Entrenched ageism in healthcare isolates, ignores andimperils elders. Aging Today, 33(2), 1.Robert Wood Johnson Foundation. (2014). Improving health care bymeasuring it. Available at:www.rwjf.org/content/dam/farm/reports/program_results_reports/2014/rwjf412674Svehla, T. (1994). Diversity management: Key to future success. Frontiersof Health Services Management, 11(2), 3–33.The Joint Commision. (2014). A crosswalk of the national standards forCulturally and Linguistically Appropriate Services (CLAS) in health andhealth care to The Joint Commission Hospital Accreditation Standards.Available at: www.jointcommission.org/assets/1/6/Crosswalk-_CLAS_-20140718.pdfTraxler, A. J. (1980). Let’s get gerontologized: Developing a sensitivity toaging. The multi-purpose senior center concept: A training manual forpractitioners working with the aging. Springfield, IL: Illinois Departmentof Aging.United Nations. (2013). World population prospects: The 2012 revision—Highlights and advance tables. New York. Available at:esa.un.org/wpp/Documentation/pdf/WPP2012_HIGHLIGHTS.pdfUnited States Census Bureau. (2012). A look at the 1940 Census. Available

at: www.census.gov/newsroom/cspan/1940census/CSPAN_1940slides.pdfUnited States Department of Commerce, Bureau of the Census. (2003).Chartbook on trends in the health of Americans. Retrieved March 21,2004, from InfoTrac online database.United States Department of Commerce, Bureau of the Census. (2004). U.S.interim projections by age, sex, race, and Hispanic origin. Available at:www.census.gov/ipc/www/usinterimproj/United States Department of Health and Human Services, Office ofMinority Health [HHS OMH]. (2013). National standards for culturallyand linguistically appropriate services in health and health care: Ablueprint for advancing and sustaining CLAS Policy and Practice.Retrieved from www.thinkculturalhealth.hhs.govWarshaw, G. A. (2002). Academic geriatrics programs in US allopathic andosteopathic medical schools. Journal of the American Medical Association,288, 2313–2319.Warshaw, G. A., Bragg, E. J., Thomas, D. C., Ho, M. L., & Brewer, D. E.(2006). Are internal medicine residency programs adequately preparingphysicians to care for the Baby Boomers? A national survey from theAssociation of Directors of Geriatric Academic Programs Status ofGeriatrics Workforce Study. Journal of the American Geriatrics Society,54(1), 1603–1609.Wasserman, I. (2007). Generations working together. Entrepreneur.Available at: www.entrepreneur.com/article/183720Weech-Maldonado, R., Dreachslin, J. L., Dansky, K. H., DeSouza, G., &Gatto, M. (2002). Racial/ethnic diversity management and culturalcompetency: The case of Pennsylvania hospitals. Journal of HealthcareManagement, 47(2), 111–124.Weech-Maldonado, R., Elliott, M. N., Schiller, C., Hall, A., Dreachslin, J. L.,& Hays, R.D. (2007). Organizational and market characteristicsassociated with hospitals’ adherence to the CLAS standards. Presentationat the APHA Annual Meeting in Washington, DC, on November 5.Weech-Maldonado, R., Elliott, M. N., Schiller, C., Hall, A., & Hays, R. D.(2007). Does Hospitals’ adherence to the CLAS standards influencediverse patients’ experiences with inpatient care. Presentation at theAPHA Annual Meeting in Washington, DC, on November 5.Weil, P., & Mattis, M. (2001). Narrowing the gender gap in healthcaremanagement. Healthcare Executive 16(6), 12–17.Wilson-Stronks, A., & Mutha, S. (2010). From the perspective of CEOs:What motivates hospitals to embrace cultural competence? Journal of

Healthcare Management, 55(5), 339–351.Witt/Kieffer (2011). Building the business case. Healthcare diversityleadership: A national survey report. Institute for Diversity in HealthcareManagement, Institute Resource Center. Available at:www.diversityconnection.org/diversityconnection/membership/Institute-Resource-Center.jsp?fll=S12OTHER SUGGESTED READINGLantz, P. (2008). Gender and leadership in healthcare administration: 21stcentury progress and challenges. Journal of Healthcare Management,53(5), 291–304.Institute of Medicine. (2004). In the nation’s compelling interest: Ensuringdiversity in the healthcare workforce. Available at:www.nap.edu/catalog/10885.htmlA full list of reference texts discussing cultural beliefs and influences, issues,and how to identify/develop materials can be found on the NationalCenter for Cultural Healing, at: www.culturalhealing.com/patientedu.htmInformation relating to Anne Fadiman’s book, The Spirit Catches You andYou Fall Down, may be viewed at: www.spiritcatchesyou.comLearn more about how language and culture affect the delivery of qualityservices to ethnically diverse populations at: www.diversityrx.org

CHAPTER 3Attitudes and PerceptionsLEARNING OUTCOMESAfter completing this chapter, the student should be able to: Appreciate the importance of attitudes to understanding behavior. Understand the three components of attitude. Understand how attitudes can be changed. Understand how perceptions allow individuals to simplify their worlds. Understand the four stages of the perception process. Understand social perception and the various subgroups. Understand the importance of using objective methods for employeeselection.OVERVIEWThis chapter explains how understanding the psychology of attitudes andperceptions can help us better manage the employees of the health servicesorganizations in which we work. Psychological principles, when applied toorganizational behavior issues, can assist health care managers to deal withstaff fairly, make jobs interesting and satisfying, and motivate employees tohigher levels of productivity. By the end of this chapter, you will gain somekey insights into attitudes and perception and how they relate to humanbehavior.ATTITUDESWhat is an attitude? Gordon Allport (1935) defined an attitude as amental or neural state of readiness, organized through experience, exertinga directive or dynamic influence on the individual’s response to all objectsand situations to which it is related. A simpler definition of attitude is amind-set or a tendency to act in a particular way toward an object or entity(i.e., person, place, or thing) due to both an individual’s experience and

temperament.Typically, when we refer to a person’s attitudes, we are attempting toexplain his or her behavior. Attitudes are a complex combination of anindividual’s personality, beliefs, values, behaviors, and motivations. As anexample, we understand when someone says, “She has a positive attitudetoward work” versus “She has a poor work attitude.” When we speak ofsomeone’s attitude, we are referring to the person’s emotions and behaviors.A person’s attitude toward preventive medicine encompasses his or her pointof view about the topic (e.g., thought) and how he or she feels about thistopic (e.g., emotion), as well as the actions (e.g., behaviors) he or sheengages in as a result of attitude to preventing health problems. This is thetri-component model of attitudes (see Figure 3–1). An attitude includesthree components: an affect (a feeling), cognition (a thought or belief), andbehavior (an action).

Figure 3–1 Tri-Component Model of AttitudesAttitudes help us define how we see situations, as well as define how webehave toward the situation or object. As illustrated in the tri-componentmodel, attitudes include feelings, thoughts, and actions. Attitudes maysimply be an enduring evaluation of a person or object (e.g., “I like Johnbest of my coworkers”) or other emotional reactions to objects and to people(e.g., “I dislike working on the department’s annual budget” or “Jane makesme angry”). Attitudes also provide us with internal cognitions or beliefs andthoughts about people and objects (e.g., “Jane needs to work harder” or“Sam does not enjoy working in this department”). Attitudes cause us tobehave in a particular way toward an object or person (e.g., “I return email

messages within 24 hours because it upsets me when others do not follow upwith me in a timely fashion”). Although the feeling and belief components ofattitudes are internal to a person, we can view a person’s attitude from hisor her resulting behavior.COGNITIVE DISSONANCEAlfred Adler (1870–1937), a Viennese physician who developed the theoryof Individual Psychology, emphasized that a person’s attitude toward theenvironment had a significant influence on his or her behavior. Adlersuggested that a person’s thoughts, feelings, and behaviors weretransactions with one’s physical and social surroundings and that thedirection of influence flowed both ways—our attitudes are influenced by oursocial world and our social world is influenced by our attitudes. Theseinteractions, however, may cause a conflict between a person’s attitude andbehavior. This conflict is referred to as cognitive dissonance. Cognitivedissonance refers to any inconsistency that a person perceives between twoor more of one’s attitudes or between one’s behavior and attitudes. Festinger(1957) stated that any form of inconsistency that is uncomfortable for theperson will prompt the person to reduce the dissonance (conflict). As anexample, Harry likes two coworkers, John and Mary, but John does not likeMary (i.e., inconsistency). Harry needs to eliminate the inconsistency.Harry may: (1) try to change John’s feelings toward Mary, (2) change hisfeelings about either John or Mary, or (3) sever his relationship with eitherJohn or Mary (see Scott’s Dilemma, Case Study 3–1).Case Study 3–1 Scott’s DilemmaScott is a licensed physical therapist who works for a national rehabilitation company. Therehabilitation facility in which Scott works is located in an urban Southwest city. He hasworked at this facility for four years and, until, recently, was satisfied with his workingenvironment and the interactions he shared with his coworkers. In addition, Scott receivedpersonal fulfillment from helping his patients recover from their disabilities and seeing themreturn to productive lives.Last year the health system went through reorganization, with some new people beingbrought in and others being reassigned. Scott’s new boss, George, was transferred from one ofthe system’s Midwest facilities. Almost immediately upon taking his new position, Georgebegan finding fault with Scott’s care plans, patient interactions, and so forth. Scott beganfeeling as if he couldn’t do anything right. He was experiencing feelings of anxiety, stress, andself-blame. Although his previous performance evaluations had been above average, Scott wasshocked by his first performance review under George’s authority—it was an extremely lowrating.Scott began trying to work harder, thinking that by working harder he could exceedGeorge’s expectations. Despite the long hours and addressing George’s critiques, George

continued to find fault with Scott’s work. Staff meetings began to be a great source ofdiscomfort and stress because George would belittle Scott and single him out in front of hiscolleagues.Scott began to feel alienated from his family, friends, and colleagues at work. His eating andsleeping habits were adversely affected as well. Scott’s activities held no joy for him, and thecareer that he had once loved and been respected in became a source of pain and stress. Hebegan to call in sick more often and started visualizing himself confronting and even hurtingGeorge, which created even more guilt and anxiety for Scott.As time went on, George encouraged Scott’s coworkers to leave Scott alone to do his work.The perception of the coworkers became more sympathetic to George’s point of view. Scott’scoworkers mused that perhaps Scott really was a poor worker and that George knew betterbecause of his position as the supervisor of the rehabilitation department. Eventually, Scott’scoworkers began to distance themselves from him, in order to protect their own interests.They began to see Scott as an outsider, with whom it was unsafe to associate.In an effort to resolve the situation, Scott spoke to George directly, stating his feelings andexpressing an interest in how they might improve the situation. Rather than making thesituation better, what George perceived as Scott’s insubordination served to enrage George,and the personal attacks against Scott intensified. Feeling frustrated and helpless, Scott thendecided to take his problem to the Human Resources Department (HRD). A human resourcesmanager listened to Scott’s complaints and suggested that Scott return with documentedevidence of what Scott perceived to be George’s mistreatment. In an effort to help ease thesituation, the HRD manager discussed the issue with George, which only stirred the flames ofGeorge’s anger and his negative behavior toward Scott.As a last resort, Scott decided to go to George’s boss, Rebecca. Rebecca met with George toget his side of the story. George portrayed Scott as an unproductive employee with no respectfor authority. The result was a strong letter of reprimand in Scott’s file for insubordination.Discuss the cognitive dissonance reflected in Scott’s Dilemma.Reproduced from case discussion: Workplace bully, by J. Pinto, M. Vecchione, and L.Howard, October 2004, presented at the 12th Annual International Conference of theAssociation on Employment Practices and Principles, Ft. Lauderdale, FL.Other approaches a person may use to reduce the inconsistency are:• Eliminating his or her responsibility or control over an act or decision.• Denying, distorting, or “selectively” forgetting the information.• Minimizing the importance of the issue, decision, or act.• Selecting new information that is consonant with an attitude orbehavior.For example, why do people continue to smoke when the hazards ofsmoking are known? Using the cognitive dissonance theory, Kassarjian andCohen (1965) attempted to analyze how smokers rationalize their behavior.They found that smokers justify their continued smoking by: (1) eliminatingtheir responsibility for their behavior (“I am unable to stop” or “it takes toogreat an effort to stop”); (2) denying, distorting, misperceiving, orminimizing the degree of health hazard involved (“many smokers live a long

time” or “lots of things are hazardous”); and/or (3) selectively drawing outinformation that reduces the inconsistency of the smoker’s behavior(“smoking is better than excessive eating or drinking” or “smoking is betterthan being a nervous wreck”).Although the theory of cognitive dissonance helps us understand howindividuals try to make sense of the world they live in, it does not predictwhat an individual will do to reduce or eliminate the dissonance (asreflected in the previous Harry/John/Mary example). It only relates that theindividual will be motivated to “do something” to bring attitudes andbehaviors into balance. Cognitive dissonance theory has many practicalmanagerial applications for motivating employees and is the theoreticalbasis for what are known as the equity theories of motivation (Ott, 1996).Equity theory predicts that employees pursue a balance between theirinvestments in and the rewards gained from their work, such that their owninvestment/reward ratio is the same as that of similar others. Disturbanceof this balance results in behaviors to relieve the dissonance. For example, ifan employee perceives that another employee is paid more for the samelevel of productivity, the employee will be motivated to ask for a raise, lowerhis or her level of productivity, or seek another job.FORMATION OF ATTITUDESHow are attitudes formed? Attitude formation is a result of learning,modeling other individual’s actions and attitudes, as well as directexperiences with people and situations. Attitudes influence our decisions,guide our behavior, and impact what we selectively remember (not alwaysthe same as what we hear). Attitudes come in different strengths, and likemost things that are learned or influenced through experience, they can bemeasured, and they can be changed.

Figure 3–2 Employee Attitude SurveyMeasurement of AttitudesSince the publication of Thurstone’s procedure for attitude assessment in1929 (Thurstone & Chave, 1929), employee surveys have been widely usedin organizations to obtain information about workers’ attitudes toward theirenvironments. As Fottler and colleagues (1995, pp. 281–282) point out,“from responses to these surveys, management can learn how employeesview their jobs, their supervisors, their wages and benefits, their workingconditions, and other aspects of their employment.” As such, employeeattitude survey responses are helpful to health care managers fordetermining whether management is “doing the right things” for retainingand motivating employees. As an example, Lowe et al. (2003) found thatworkers who rated their work environments as “healthy” (in terms of taskcontent, pay, work hours, career prospects, interpersonal relationships,security, etc.) reported higher job satisfaction, morale, and organizationalcommitment and lower absenteeism and intent to quit. Employee-attitudesurveys are usually designed using five-point Likert-type (“strongly agree–strongly disagree”) or frequency (“never–very often”) response formats.

Questions typically asked are illustrated in Figure 3–2. However, asMorrel-Samuels (2002) points out, organizations need to be cautiousregarding the design of employee surveys to ensure that problem areas arenot overlooked. Morrel-Samuels provided 16 guidelines for organizations toconsider when designing an employee attitude survey (see Exhibit 3–1).Effective managers continuously survey their employees so they candetect problem areas and implement the necessary changes.Exhibit 3–1 Guidelines to Help Companies Improve Their Workplace SurveysContent• Ask questions about observable behavior rather than thoughts or motives.• Include some items that can be independently verified.• Measure only behaviors that have a recognized link to your company’s performance.Format• Keep sections of the survey unlabeled and uninterrupted by page breaks.• Design sections to contain a similar number of items, and questions with a similar number ofwords.• Place questions about respondent demographics last in employee surveys but first inperformance appraisals.Language• Avoid terms that have strong associations.• Change the wording in about one-third of questions so that the desired answer is negative.• Avoid merging two disconnected topics into one question.Measurement• Create a response scale with numbers at regularly spaced intervals and words only at eachend.• If possible, use a response scale that asks respondents to estimate a frequency.• Use only one response scale that offers an odd number of options.• Avoid questions that require rankings.Administration• Make workplace surveys individually anonymous and demonstrate that they remain so.• In large organizations, make the department the primary unit of analysis for company surveys.• Make sure that employees can complete the survey in about 20 minutes.Reproduced from Getting the truth into workplace surveys, by P. Morrel-Samuels, 2002,Harvard Business Review, 80(2), pp. 111–118.Changing AttitudesHow do you change someone’s attitude? To change a person’s attitude you

need to address the cognitive and emotional components. How would youconvince another person to start an exercise program when the individualmay say, “I don’t have enough time” or “I’m just too busy”? One approachwould be to challenge someone’s behavior by providing new information. Asan example, explain to the other person how you made time in your day andhow, as a result, both your cholesterol level and blood pressure decreased.This is a cognitive approach when a person is presented with newinformation. Providing new information is one method for changing aperson’s attitude and therefore his or her behavior. Attitude transformationtakes time, effort, and determination, but it can be done. It is important notto expect to change a person’s attitudes quickly, as illustrated by thefollowing story:“We can’t meet tomorrow morning, I’ve got to go to my doctor,” he told me.“I hope it’s nothing serious?”“Only a colonoscopy,” my friend reassured me.“Only? Do you have pain?”“No,” he replied, “my doctor said I need to have one, I’m forty-five. Don’t worry, in my family,nobody ever had colon cancer.”“It can hurt. Did your doctor tell you what the possible benefits of a colonoscopy are?”“No,” my friend said, “he just said it’s a routine test, recommended by medical organizations.”“Why don’t we find out on the Internet?”We first looked up the report of the U.S. Preventive Services Task Force. It said that there isinsufficient evidence for or against routine screening with colonoscopy. My friend is Canadianand responded that he does not bank on everything American. So we looked up the CanadianTask Force report, and it had the same result. Just to be sure, the men checked Bandolier atOxford University in the United Kingdom, and once again we found the same result. Noprofessional health association that we looked up reported that people should have a routinecolonoscopy—after all, a colonoscopy can be extremely unpleasant—but many recommended thesimpler, cheaper, and noninvasive fecal occult blood test. What did my friend do? If you thinkthat he canceled his doctor’s appointment the next day, you are as wrong as I was. Unable to bearthe evidence, he got up and left, refusing to discuss the issue any further. He wanted to trust hisdoctor.Reproduced from Gut feelings: The intelligence of the unconscious, by G. Gigerenzer, 2007, NewYork: Viking Penguin.Managers need to understand that attitude change takes time and shouldnot set unrealistic expectations for rapid change (Moore, 2003). Attitudesare formed over a lifetime through an individual’s socialization process. Anindividual’s socialization process includes his or her formation of values andbeliefs during childhood years, influenced not only by family, religion, andculture but also by socioeconomic factors. This socialization process affects a

person’s attitude toward work and his or her related behavior. (See CaseStudy 3–2: What Changed in the Housekeeping Department?)Case Study 3–2 What Changed in the Housekeeping Department?Betty Smith, the newly assigned manager of the hospital’s housekeeping department, couldnot understand why her employees never offered suggestions as to how their jobs could beperformed more effectively and efficiently. Betty was of the opinion that she shouldn’t have totell her staff how to clean a floor or a patient’s room; they should be telling her how they coulddo their jobs better. Finally, Sally, a 24-year-old recent Sierra Leone immigrant who had beenemployed in the hospital’s housekeeping department for the past five years, confided in Bettyduring her performance-evaluation conference, “I don’t offer suggestions because I’m only ahousekeeper with no formal education. I don’t want to look stupid.”Betty immediately put into place a three-month training program with the goal of giving heremployees the skills to recognize problems and the self-confidence to bring them to herattention. The training program was designed to let employees know what is expected of themregarding performance, as well as how and where they “fit” in the overall organization. Thetraining program helped the employees understand that their contributions make a differenceto the organization achieving its goals.After the employees had completed half of the training program, Betty started to hold staffmeetings on Friday afternoons to discuss any problems that were encountered during theweek. At the conclusion of a Friday’s staff meeting, Betty asked, as she always did, if anyonehad an item to discuss. Betty never received a reply, but she continued to ask the question inevery staff meeting anyway. However, this Friday was different. Sally raised her hand andrelated that she “overheard” a physician talking to the emergency department (ED) managerabout the delay of transferring his patients from the ED to the nursing floors. Sally thoughtthat part of the delay might be related to patients’ rooms not being cleaned in a timely fashionafter a patient’s discharge because the unit secretaries at the nurses’ stations did notcommunicate when the patient was being discharged. Housekeepers were told after the fact—after the patient was discharged and after the ED called the nursing station secretariesinforming them an ED patient needed to be transferred to the unit. Because of their otherduties, sometimes a housekeeper could not get to the floor for cleaning for at least an hour ormore. Sally asked, “Why can’t the nursing station secretaries communicate with us before thepatient is discharged so we can schedule our time appropriately?” Betty agreed with Sally.Why couldn’t there be better communication between the nursing units and housekeeping?Betty told the group she would look into it.Betty called the vice president of nursing, Mary Acton, and discussed her staff’sobservations regarding the turnaround time delay of a clean bed being made available for anED patient transfer. Mary concurred with Betty, stating that administration had noticed thatsometimes it took up to three hours from the time a bed became unoccupied to the time thebed was reported clean and available for patient use.A team was formed that included nurse managers, nursing supervisors, floor nurses, unitsecretaries, and housekeeping staff, including Sally, to discuss the problem and develop asolution that was workable for everyone. The solution* was simple, low-cost, and low-tech.First, the nursing supervisors would e-mail a list of anticipated room discharges for thefollowing day to housekeeping no later than midnight. The evening housekeeping staff wouldretrieve the e-mail and post the list for the morning shift so they could plan their daily jobactivities according to the anticipated discharges. Second, two jars were placed at the nurses’stations—one jar was marked for clean rooms and the other marked for dirty rooms. Third,once a patient was discharged, the nurse put a red slip of paper with the room number intothe dirty-room jar. Fourth, when housekeeping finished cleaning and preparing the room for

an incoming patient, they removed the red slip from the dirty-room jar and put a green slipwith the same room number on it in the clean-room jar. Fifth, the green slip in the jar servedas a visible reminder to the unit secretary that an open bed was available and ready to befilled when he or she received the call from the ED.Mary Acton called Sally the following month to thank her for bringing her “proactive”observations to Betty’s attention. Mary related that the new “communication” system hadreduced the bed turnaround time from three hours to 30 minutes!Betty related the news of the decreased turnaround time at her next Friday staff meeting,and she thanked Sally and everyone for participating in developing and implementing thisnew hospital procedure that had positively impacted both patient and physician satisfaction.When she asked if anyone had anything else to discuss, Sally raised her hand and said, “Barryand I noticed that an excessive amount of paper towels are being used throughout thehospital, and we have a few suggestions that may save the hospital money.” Joe interjected,“I’ve also noticed that the hospital is not taking advantage of recycling its paper waste, whichcould save money and reduce our workloads.” Tina related, “I have a few suggestionsregarding …” Betty smiled as she listened to everyone’s suggestions and recommendations.Discuss why Sally and the other housekeeping staff’s attitudes changed.Exhibit 3–2 Step-by-Step Process for Changing Attitudes in the Workplace1. Assessment of Attitudes(a) Identification—Recognize common workplace attitude problems.(b) Environment—Identify challenges in the workplace environment. Participants areintroduced to common examples of “attitude-challenged” workers. Group activitieshelp identify and role-play how to handle different types of attitude challenges. Focusis to assess the impact of negative attitudes on workers, management, andpatients/customers and identify the causes of problems.2. Adjusting Attitudes(a) How listening, coaching, and providing feedback are the tools for attitude change.(b) Role-play to practice how to use coaching and provide feedback with staff.(c) Identify payoffs and rewards.Participants learn how to use open-ended questions, active listening, and tactfulconfrontation to address attitude problems in the workplace.3. Common Management Mistakes(a) How to be realistic and patient with attitude change.(b) Why scolding employees does little to stop the problem.(c) How to stop the culture of complaining and work to positively effect attitude change.Group activities include examples of common management mistakes and exercises topractice more realistic and positive ways to provide employee feedback, facilitategroup discussion, and role-play the best methods for confronting negative attitudes.4. Resolving Conflict(a) The need to confront so that negative behaviors will not continue.(b) Expectations and coping strategies of employees to stress and management directives.(c) Recognizing personal conflict styles of workers and how to deal with them. Exercisesinclude ways to analyze communications to identify employee styles, planning themeeting, and working collaboratively to discover win/win solutions.5. How to Work with Problem Behaviors and Attitudes(a) Analyze the cause of the problem.(b) Privately confront with a calm, nondefensive professional demeanor.

In this session, participants role-play with their preferred style for handling difficultemployees. Managers and employees exchange roles and must reprimand or confrontproblem behaviors.6. The Last Resort: Employee Termination and Legal Issues(a) Legal issues of employee terminations.(b) Requirements, documentation, and procedure.Exercises use case studies to work out remedial and probationary systems and to fullydocument intervention efforts prior to the need for termination or reassignment.7. Creating a Positive Work Environment(a) Evoke a positive, collaborative team environment.(b) Top motivators include nonmonetary rewards.(c) Characteristics of managing motivation in the workplace.Exercises include engaging workers in teams, providing recognition awards for employees,and changing the climate by launching career development and advancement initiatives,leadership training, multicultural skills, and other positive incentive programs.Health care managers may use techniques employed in the counselingand conflict-resolution fields to develop a step-by-step process for changingemployees’ attitudes when necessary (see Exhibit 3–2). Attitudeassessment and change is serious business. One person with a consistently(and vocal) bad attitude can lower the morale of an entire workgroup in anotherwise “healthy” organization. Employees who demonstratecounterproductive work behaviors, also referred to as “toxic behavior,” mayseriously debilitate individuals, teams, and/or the organization over the longterm (Kusy & Holloway, 2009). For example, Rosenstein (2011) reportedbased on a survey of more than 4,500 respondents in over 100 hospitals thatthere was a strong perceived correlation between disruptive behaviors andthe occurrence of medical error and compromised quality, adverse events,compromises in patient safety, and patient mortality.Exhibit 3–3 Facilitating an Attitude Workshop for EmployeesDiscussion groups are a great way to diagnose and treat attitude problems. Begin by statingthe guidelines for the session to alleviate any anxiety and set a positive tone. Create a supportiveatmosphere so that participants feel safe to examine their attitudes and beliefs.The manager’s role should be as facilitator versus guiding a question-and-answer session. Onetask of the effective facilitator is activating the group’s resources to bring out the “best” of agroup. For example, plan activities where people interact with one another at the start. (e.g.,icebreaker type of exercise). Work with the energy of the group; use humor and laughter, andhealthy competition. These interactions build trust and help people feel comfortable to shareideas and consider new options.The second task of the facilitator is to activate participants’ internal wisdom. Ask questionsand let people discover their own answers. You can assist participants by keeping the dialoguegoing to sort out their values and priorities, explore beliefs and assumptions, and encourage

them to alter their work lives in ways that they choose.The third task is to facilitate personal reflection by asking questions to help participants testthe ideas that are developed against their own experiences. List issues, goals, problems, andsolutions that come up in the group dialogue. Write the main ideas on a board, perhaps focusingon negative attitudes and things that may cause them in the workplace. Ask people to expand onthese. Give personal examples and ask them how poor attitudes in others can make them feel.Throughout the process, the facilitator’s goal is to foster interpersonal support. Havingparticipants share ideas and experiences initiates the process of people supporting one another.Encourage team building and interpersonal support as part of creating a work atmosphere wherenegative attitudes are exposed and positive attitudes flourish.At the end of each session, it is important to provide a summary. This communicates to theparticipants that you have been actively listening and are prepared to offer a synthesis of thegroup’s observations and insights. Begin by saying “What I heard today is …” Offer participants achance to compare notes with one another for feedback. You might also ask participants to jotdown ideas and feelings about the attitude dialogue to bring to the next meeting. Always providea “take-home message” of commitment to change—everyone should leave with at least one clearidea about what they will do next.Discussions to identify negative workplace attitudes can be very effective. These discussionslead to solutions and group commitment to improved morale.Modified from Creative planning for the second half of life, by B. Kreitlow and D. Kreitlow,1997, New York: Whole Person Associates. Reprinted with permission.The first step in the change process is to identify the problem, followed byefforts to adjust attitudes, reduce conflict, and seek solutions (see Exhibit3–3). Open communication creates environments where workers safe todissent, and in which their opinions are respected. Everyone has attitudes,both positive and negative. To help workers realize their full potentialrequires ongoing efforts.PERCEPTIONPerception is closely related to attitudes. Perception is the process bywhich organisms interpret and organize sensation to produce a meaningfulexperience of the world (Lindsay & Norman, 1977). In other words, a personis confronted with a situation or stimuli. The person interprets the stimuliinto something meaningful to him or her on the basis of prior experiences.However, what an individual interprets or perceives may be substantiallydifferent from reality.The perception process follows four stages: stimulation, registration,organization, and interpretation (see Figure 3–3).A person’s awareness and acceptance of the stimuli play an important rolein the perception process. Receptiveness to the stimuli is highly selectiveand may be limited by a person’s existing beliefs, attitude, motivation, and

personality (Assael, 1995). Individuals will select the stimuli that satisfytheir immediate needs (perceptual vigilance) and may disregard stimuli thatmay cause psychological anxiety (perceptual defense).Broadbent (1958) addressed the concept of perceptual vigilance with hisfilter model. Broadbent argued that, on the one hand, because of limitedcapacity, a person must process information selectively and, therefore, whenpresented with information from two different channels (i.e., methods ofdelivery, such as visual and auditory), an individual’s perceptual systemprocesses only that which he or she believes to be most relevant. However,perceptual defense creates an internal barrier that limits the externalstimuli passing through the perception process when the stimuli is notcongruent with the person’s current beliefs, attitudes, motivation, and so on.This is referred to as selective perception. Selective perception occurs whenan individual limits the processing of external stimuli by selectivelyinterpreting what he or she sees on the basis of beliefs, experience, orattitudes (Sherif & Cantril, 1945).Figure 3–3 Perception Processing SystemBroadbent’s filter theory has been updated in recent years. A “Selection-

for-Action View” suggests that filtering is not just a consequence of capacitylimitations but also driven by goal-directed actions (Allport, 1987, 1993;Neumann, 1987; Van der Heijden, 1992). The concept is that any actionrequires the selection of certain aspects of the environment that are actionrelevant and, at the same time, filtering other aspects that are actionirrelevant. Therefore, when one is working toward a goal, one will skip overinformation that does not support one’s plan. Recent studies of the brainhave also led to new models, suggesting multiple channels of processing(Pashler, 1989) and selective perception as a result of activation of corticalmaps and neural networks (Rizzolatti & Craighero, 1998). In any case,people are selective in what they perceive and tend to filter information onthe basis of the capacity to absorb new data, combined with preconceivedthoughts.ATTRIBUTION THEORYSince the 1950s, researchers have tried to understand and explain whypeople do what they do. Attribution theory was first introduced by Heidler(1958) as “naive psychology” to help explain the behaviors of others bydescribing ways in which people make causal explanations for their actions.Heidler believed that people have two behavioral motives: (1) the need tounderstand the world around them and (2) the need to control theirenvironment. Heidler proposed that people act on the basis of their beliefswhether or not these beliefs are valid. Weiner (1979) suggested thatindividuals justify their performance decisions by cognitively constructingtheir reality in terms of internal–external, controllable–uncontrollable, andstable–unstable factors.According to Weiner (1979), when one tries to describe the processes ofexplaining events and the relating behavior, external or internalattributions can be given. An external attribution assigns causality to anoutside agent or force. An external attribution claims that some outsideforce motivated the event. By contrast, an internal attribution assignscausality to factors within the person. An internal attribution claims thatthe person was directly responsible for the event. Controllability refers towhether the person had the power to exert control over the events of thesituation. Finally, stability of the cause relates to whether the behavior isconsistent over time because of the individual’s values and beliefs or becauseof outside elements such as rules or laws that would govern a person’sbehavior in the various situations.Attribution theory is a concept from social psychology that allows people

to offer explanations for why things happen and is more concerned with theindividual’s cognitive perceptions than the underlying reality of events(Daley, 1996). As such, fundamental attribution error occurs when theinfluence of external factors is underestimated and the influence of internalfactors is overestimated in regard to making judgments about behavior.Self-serving bias is the tendency for individuals to attribute their ownsuccesses to internal factors while putting the blame for failures on externalfactors.When employees make attributions about a negative event that happenedat work, they tend to underemphasize internal (dispositional) factors suchas ability, motivation, or personality traits and overemphasize (external)situational factors. For example, some workers are “high achievers” becauseof their attributions. They approach rather than avoid tasks because theyare confident of success due to their ability and effort. These high achieverspersist when the work becomes more difficult rather than giving up becauseachieving their goals is self-rewarding and they will attribute their successto their personal drive and efforts. In contrast, the unmotivated “external”person will avoid or quit difficult tasks because he or she tends to doubt hisor her ability and attributes success to luck or other factors out of his or hercontrol. Such external persons have little drive or enthusiasm for work,because positive outcomes are not thought to be related to their directeffort.Managers are often in a position where they make causal attributionsregarding an employee’s behavior or work pattern. Kelley’s (1967, 1973)model of attribution theory incorporates three attributions: consensus,consistency, and distinctiveness (see Figure 3–4).Consensus relates to whether an employee’s performance is the same asor different from that of other employees. Consistency refers to whether theemployee’s behavior is the same in most situations, whereas distinctivenessasks the question, “Does the employee act differently in other situations?”Managers will attribute an employee’s behavior to external causes such astask difficulty if there is high consensus, low consistency, and highdistinctiveness. As an example, the regional director of an internationalpharmaceutical company attributes her top salespersons’ inabilities to reachtheir annual sales goals for a specific drug used to treat gastrointestinalconditions to recent negative media coverage of another, but similar drug’slinkage to a high number of patients suffering strokes (e.g., adverse effectsto the drug). Managers will attribute an employee’s behavior to internalfactors, such as lack of ability, if there is low consensus, high consistency,

and low distinctiveness.Figure 3–4 Kelley’s Attribution Theory ModelMitchell, Green, and Wood (1981, p. 199) gave the following example todemonstrate the preceding discussion: Suppose you are a physician, and youhave asked a nurse to administer a medication to one of your patients. Youcheck back later in the day, and you find that the medication was not given.Upon further discussions with the nurse, the supervisor, and other involvedparties, you discover that (1) this nurse has failed to administer the propermedication on other occasions (low distinctiveness), and (2) this nurse hashad difficulty on other tasks, such as charting or patient care (highconsistency), and (3) none of the other nurses have failed to carry out aphysician’s order in the past three months (low consensus). The nurse hasperformed poorly on this task before; he or she has performed poorly onother tasks; and no one else seems to have this difficulty. In this scenario,the physician will most probably make a person attribution—the cause ofthe poor performance was some characteristic or trait of that particularnurse (e.g., lack of effort or ability).Managers need to remember that many issues factor into this process(i.e., explaining events and the relating behavior) and that organizationalhistory, personal experiences, individual tendencies (toward internal versusexternal views of causality, intrinsic versus extrinsic motivations), and priorknowledge all impact perceptions of causes. Managers should avoid the“blame game” and focus on correcting workplace behavior.

SOCIAL PERCEPTIONSocial perception is how an individual “sees” others and how othersperceive an individual. This is accomplished through various means, such asclassifying an individual on the basis of a single characteristic (halo effect),evaluating a person’s characteristics by comparison to others (contrasteffect), perceiving others in ways that really reflect a perceiver’s ownattitudes and beliefs (projection), judging someone on the basis of one’sperception of the group to which that person belongs (stereotyping), causinga person to act erroneously on the basis of another person’s perception(Pygmalion effect), or controlling another person’s perception of oneself(impression management).Halo EffectThe halo effect occurs when an individual draws a general impressionabout another person based on a single characteristic, such as intelligence,sociability, or appearance. The perceiver may evaluate the other individualhigh on many traits because of his or her belief that the individual is high inone trait. For example, if an employee performs a difficult accounting taskwell because of the manager’s belief of the employee’s high intelligence, thenthe manager may also erroneously perceive the employee as havingcompetencies in other areas such as management or technology.The halo effect is applicable to individuals’ perceptions of others and oforganizations. For example, a hospital that is well known for its open-heartand cardiac programs may be perceived in the community as excellent inother clinical areas such as obstetrics or orthopedics whether that is provento be true or not.Opposite to the halo effect is the horn effect, whereby a person evaluatesanother as low on many traits because of a belief that the individual is lowon one trait that is assumed to be critical (Thorndike, 1920). A study onobesity conducted with health professionals and researchers reflects thehorn-effect concept. Study participants were asked to complete the ImplicitAssociation Test to assess overall implicit weight bias (associating “obesepeople” and “thin people” with “good” versus “bad”) and three ranges ofstereotypes: lazy–motivated, smart–stupid, and valuable–worthless. Thestudy respondents were much quicker to pair “fat” with “lazy” and othernegative traits and/or stereotypes (Schwartz et al., 2003).A challenge faced by health care managers is the halo/horn effectcognitive bias when performing workers’ evaluations. Managers need to

avoid the tendency for an employee’s positive or negative trait to “spill over”to other areas of their evaluation. For example, if an employee has been lateto work for three days, you may conclude that this person has a poorattitude and is indifferent about his or her job. There may be other externalreasons for the employee’s lateness, such as his or her car broke down, thebabysitter was late, or there was bad weather. As illustrated, because of onenegative aspect, the manager may assume that the employee is a poorworker, and this belief therefore unfairly influences his or her overallevaluation.Contrast EffectsResearch has provided evidence that perceptions are also subject to whatare termed perceptual contrast effects. Contrast effects relate to anindividual’s evaluation of another person’s characteristics based on (oraffected by) comparisons with other people who rank higher or lower on thesame characteristics. For example, Wedell, Parducci, and Geiselman (1987)found that, if compared to a highly attractive person, a target person ofaverage attractiveness is judged less attractive than he or she would havebeen if rated on his or her own. When asked to contrast a target personwith persons who were more physically attractive, ratings of attractivenessof the target were more negative, and when the target person wascompared with those less attractive, it resulted in more positive evaluations(Thornton & Moore, 1993). In other words, the contrast effect relates to howan individual is perceived in relation to others around him or her. Not onlydoes contrast effects apply to the perception of attractiveness, but it has alsobeen shown to influence self-esteem, public self-consciousness, and socialanxiety (Thornton & Moore, 1993). It stands to reason that a worker’sperformance would be judged in contrast to the workers around him or her.However, managers need to be aware of this contrast-effect bias wheninterviewing job candidates or evaluating a worker’s performance.Contrast is an important principle by which we make decisions. When wemake judgments, they are not absolute judgements. We judge an individualor object in comparison with someone else or something else. As such, byusing the perceptual contrast-effects principle, one can persuade others intheir judgements by leveraging the following comparisons(changingminds.org):Shortlists—Individuals are not good at selecting from a large group, asthere are too many contrasts to make. When faced with many

candidates for a job, we will rapidly simplify the decision by breakingthings down to a very short list.Pairwise comparison—Although we can select from a group of things, wecompare best when we have only two things from which to select. Infact, one of the reasons that we do reduce choices to a shortlist is thatwe have fewer pairs to compare. Even then, we will break things downfurther, comparing the top two or three, one against another.Polarizing—When seeking to separate two things, it is easier todifferentiate if there is a higher contrast. We hence polarize, pushingour perceptions more toward extremes in order to say “this is clearlydifferent from that,” rather than “this is a bit different from that.”Living in a black-and-white world is easier, if less accurate, and manychoose to take extreme views rather than live with uncertainty. Wepolarize by selectively amplifying those aspects that will support ourposition and downplaying or ignoring those that will not. In this way,we create selective distortion. We do this in particular when separatingourselves (and our friends) from other people, especially if values areinvolved, as we seek to ensure we are all good and we can project allbad things onto the other person.Comparing with prototypes and stereotypes—A prototype is an idealizedstereotype, both of which use polarized thinking. Sometime thestandard against which we judge other things is a prototype that wehave constructed. Thus when selecting a job candidate, we will compareeach interviewee against a nonexistent prototype that has all thewanted characteristics, traits, and so on. Prototypes are often made upof all the best parts from a wide range of experiences.Comparing with what is available—If two women are standing side byside, a man will evaluate one against the other, as the other woman ismore immediately available than a recalled prototype. Women, ofcourse, will do the same. In fact, we all will tend to use whatevercomparators are most available to us at the time of judgment. In ourusual lazy mental manner, we are more likely to use the comparatorthat is easiest to access than one that may be more appropriate. Thus,given an unattractive person and an average-looking person, we willjudge the average person to be more attractive than if we saw themalone.Comparing against other people—When evaluating ourselves, the maincomparator is other people. We decide how happy, beautiful, and so onwe are by comparing ourselves with others. In particular we tend to

look to peers and people who are “like us” to compare ourselves against.Thus rich people compare against other rich people (and often feel quitepoor as a result!). People for whom being intelligent is important willcompare themselves with other intelligent people. A result of this isthat being rich, powerful, clever, and so on is no predictor of happiness.We may strive for success, but if we change our comparators along theway, we will not seem to have achieved that much.ProjectionWhereas contrast effects are the perception of an individual based on thecomparison to others, projection is the attribution of one’s own attitudes andbeliefs onto others. All of us are guilty of unconsciously projecting our ownbeliefs onto others. Sigmund Freud (1894/1966), along with his daughterAnna Freud (1936/1967), suggested that projection was a defensivemechanism, where we attribute our own attitudes onto someone else as adefense against our feelings of anxiety or guilt. For example, if you have astrong dislike for someone, you might instead believe that he or she does notlike you. Projection works by allowing the expression of the desire orimpulse, but in a way that the ego cannot recognize, therefore reducinganxiety or guilt. Projection can mean ascribing to others the negatives thatwe find inside ourselves, thereby protecting our self-esteem. For example, aperson who is rude may constantly accuse others of being rude. This waythe person does not have to deal with the fact that he or she is rude, whichwould require acknowledging that there is something wrong with him orher, which is generally undesirable, thus making the individual feel betterabout him- or herself. Who has never blamed others for making them late towork, going off a diet, or being in a bad mood (when it was themselves atfault)? Projection is an interesting human tendency. Projection allows anindividual to perceive others in ways that really reflect oneself, because, ingeneral, people are in favor of those who are most like themselves.StereotypingIn 1798, printers invented a new way to permanently fix and reproducevisual images. This precursor to modern photographic printing processeswas called stereotyping. Over time, this word came to apply not just tovisual printed images, but also to how we fit attributes of ability, character,or behavior to groups and/or populations in order to make generalizations.As such, the term “stereotype” is defined to mean a conventional imageapplied to whole groups of people, and the treatment of groups according to

a fixed set of generalized traits or characteristics.Although stereotyping can be positive because it allows us to organize acomplex world, it may be considered negative if used as overly generalizedviews about groups of individuals. Researchers suggest that stereotypeswield a strong, covert influence on human behavior (even among those whodo not agree with stereotypes). Social researchers have revealed that it isrelatively easy for stereotypes to be activated across a wide range ofcontexts and situations, because of many factors, including race, gender,religion, physical appearance, disability, and occupation (see Bargh, Chen, &Burrows, 1996).Stereotyping regarding race and ethnicity is problematic for health careprofessionals and health service organizations. The Institute of Medicine(2003) found that “racial and ethnic minorities tend to receive a lowerquality of health care than non-minorities, even when access-related factors,such as patients’ insurance status and income are controlled … and foundevidence that stereotyping, biases, and uncertainty on the part of healthcare providers can contribute to unequal treatment” (p. 1).In addition to stereotyping racial and ethnic minorities, health careprofessionals have a tendency to stereotype other groups, such as theelderly, homeless, disabled, and those suffering from obesity. The elderly areoften stereotyped as infirm, inflexible, weak, deficient in vision and hearing,and being unable to advocate for themselves on health issues. Anotherexample is the homeless or “skid row” population. There is a tendency tostereotype this group as either the elderly alcoholic male or perhaps thedisheveled bag lady. However, homelessness affects families, children, andyoung people—groups that do not fit the typical stereotype of “homeless.”One of the most common forms of stereotyping is on the issue of genderand leadership. Women hold positions at all levels within health careorganizations, but only between 10 and 13 percent hold chief executiveofficer positions. The influence of gender stereotypes is one possibleexplanation of why it is sometimes difficult for people to accept women asleaders in the workplace. Traits often attached to leadership are “masculine”qualities such as courage, persuasiveness, and assertiveness. As such, anaggressive male leader may be viewed as “ambitious,” compared with anassertive female leader who may be viewed as “pushy.” This is, in part,because the assertive female leader’s behavior violates a gender stereotypethat women should be less authoritarian and more sensitive, gentle, andnurturing (see Exhibit 3–4).We all use stereotypes because they help us simplify our world. However,

most often we do not take the time to understand why we are perceivinggroups in a certain way. We revert to our cognitive prototypes and ignorerelevant information. These habits and biases are learned and, thus, can beunlearned. Training exercises can help to sensitize individuals to issues ofbias—racism, sexism, ageism, etc. One goal of management is to assist staffin recognizing that stereotypes are illogical by challenging these faultycognitions. The need to challenge gender and other stereotypes in theworkplace is one of the reasons so much increased attention has been placedon managing diversity in organizations. It is important to be aware of howour perception of groups can influence our behavior, including hiring andmanagement practices and interactions with workers. Stereotypes may leadto discrimination; therefore, it is important to discuss them and worktoward de-stereotyping the workplace. Negative stereotypes can beproblematic for any organization, and proper training can be effective inminimizing widely held false beliefs (see Exhibit 3–5). A recent study byDobbin and his colleagues (2007) found that mandatory diversity trainingprograms developed by companies to avoid liability in discriminationlawsuits were ineffective for increasing diversity in management. However,when diversity training is voluntary and undertaken to advance acompany’s business goals (and part of the organization’s culture), it wasassociated with increased diversity in management. According to the study,it appears that employees don’t react well when “sensitivity” training isforced on them!Exhibit 3–4 Gender StereotypingIn each culture, gender roles and gender stereotypes provide specific expectations of male andfemale behavior. When those expectations are violated (as in the case of a woman actingassertively), it results in a negative label being applied to describe the person violating theexpectation. This was at issue in Price Waterhouse v. Hopkins (1989), as cited in Lord and Maher(1991).In the case of Ann Hopkins, she was a high-performing but masculine-acting prospectivepartner at Price Waterhouse. When she was denied a partnership at Price Waterhouse, shecharged that gender stereotyping had played a role in the decision (Fiske et al., 1991). At thetime of her eligibility/consideration for promotion to partner, Hopkins was the only womanamong 88 candidates nominated for partnership. Her close colleagues submitted an evaluationnoting her “outstanding performance” and strongly urged her admission to the partnership.When she was not accepted as a partner by the promotion board, she sued.In response to the suit, Price Waterhouse countered that Ms. Hopkins had interpersonalproblems and was considered too “macho” for the position. The person responsible for explainingthe board’s decision to Ms. Hopkins advised her that in order to improve her chances forpartnership she “should walk more femininely, talk more femininely, dress more femininely,wear make-up, have her hair styled, and wear jewelry.” In addition, another board member

repeatedly commented that “he could not consider any woman seriously as a partnershipcandidate and believed that women were not even capable of functioning as partners.” Ms.Hopkins brought her gender discrimination lawsuit all the way to the Supreme Court and won.SOURCE: Leadership and information processing: Linking perceptions and performance, by R.G. Lord and K. J. Maher, 1991, Boston, MA: Unwin Hyman.Pygmalion EffectThe Pygmalion effect, or self-fulfilling prophecy, describes a person’sbehavior that is consistent with another individual’s perception whether ornot it is accurate. In other words, once an expectation is made known byanother person, an individual will have the tendency to behave in waysconsistent with the expectation. This can have negative or positive results.If a manager sets high standards for a subordinate’s performance, he or shewill respond accordingly with high performance. If a manager sets lowstandards for a subordinate’s performance because the subordinate isviewed as lacking in ability and/or motivation, the resulting workperformance will be low. Therefore, managers’ expectations directlyinfluence subordinates’ performance. In other words, what a managercommunicates as the expectation is what will result. Livingston (1969)stated that what was critical in the communication of expectations was notwhat the manager said, so much as the way the manager behaved.Indifferent and noncommittal treatment, more often than not, was the kindof treatment that communicated low expectations and led to poorperformance. Livingston related that managers were more effective atcommunicating low expectations to their subordinates than incommunicating high expectations.Exhibit 3–5 Exercise to Identify Stereotypes Within Our Organizations and ProfessionDiscussion: Have you seen any evidence of stereotypes in your workplace? Which of the following positions are filled more by MEN or by WOMEN: Physician ___________Computer Programmer ___________Medical Receptionist ___________Pharmacist ___________

Nurses Aide ___________Radiology Technician ___________Nurse ___________Chief of Staff ___________Statements:Health services administrators need to ______________________ be to be effective.The hospital cafeteria is staffed by people who are ______________________.Disabled people that I have worked with are ______________________.Closely related to the self-fulfilling prophecy is the “Galatea effect.” Thiseffect relates to the expectations we have for ourselves, rather than theexpectations others have for us. To illustrate this concept, Livingston (1969)referred to the “Sweeney’s Miracle.” James Sweeney was an industrialmanagement professor at Tulane University who wished to disprove thetheory that a certain IQ level was needed to learn how to programcomputers. Sweeney trained a poorly educated janitor whose IQ indicatedthat he would be unable to learn to type, much less program. The janitornot only learned to program, but also eventually took charge of thecomputer room along with the responsibility of training new employees toprogram and operate the computers. As Livingston pointed out, Sweeney’sexpectations were based on what he believed about his teaching ability(internal expectations), not on the janitor’s learning capabilities. Livingstonrelated that “the high expectations of superior managers are basedprimarily on what they think about themselves—about their own ability toselect, train, and motivate their subordinates. What the manager believesabout himself subtly influences what he believes about his subordinates,what he expects of them, and how he treats them” (Livingston, 1969).Therefore, managers need to understand the effects of their own self-expectations and how these expectations interact with the expectations theyhold and communicate regarding their subordinates’ performance. Managersset the tone and culture of the workplace. By understanding the Pygmalionand Galatea effects, managers can set high (but realistic) performanceexpectations for their subordinates. If a manager rates subordinates as“excellent,” they will continue their previous work behaviors. Managers canalso have workers rate their own performance. Expectations about ourselvestend to be self-sustaining.Impression Management

“You never get a second chance to make a first impression.” This classicstatement is all about impression management, where people try to shapeanother’s impression of themselves. Impression management incorporateswhat we do, how we do it, what we say, and how we say it as we try toinfluence the perceptions others have of us. Individuals will try to presentthemselves in ways that will lead to positive evaluations by others byhighlighting their achievements and avoiding the disclosure of failures.Giacalone and Rosenfeld (1989) point out that impression management isneither inherently good nor bad but rather is a fundamental part of oursocial and work lives, and we need to view it in the situations in which it isused. As an example, consider the concept of self-handicapping. Self-handicapping is where people place obstacles in their way, so if they do notsucceed they can blame the obstacles or if successful, they can bragregarding their successful performance in spite of these barriers.Schlenker and Weigold (1992) view impression management as a broadphenomenon in which we try to influence the perceptions and behaviors ofothers by controlling the information they receive. They relate that peopleactively carry out impression management in ways that help them achievetheir objectives and goals, both individually and as part of groups andorganizations. This can be done consciously and deliberately (i.e., perfectingjob-interview skills), while other times it may be unconscious. At times, theimpression that is managed serves to bolster or protect our own self-image(i.e., dressing for success); other times we manage impressions in hopes ofpleasing significant audiences. Sometimes impression management istruthful and accurate. Other times it involves “false advertising” throughthe use of exaggeration, fabrication, deception, and falsehoods (Schlenker &Weigold, 1992) (see Exhibit 3–6).Exhibit 3–6 The Liars IndexTwice a year, Jude M. Werra of Jude M. Werra & Associates, a headhunting firm in Brookfield,Wisconsin, reviews the hundreds of résumés he has seen in the previous six months—theelegant, triumphant CVs of CEOs and VPs—and he condenses them into a single statistic. “It’sthe number of people who’ve misrepresented their education divided by the number of peoplewhose education we checked,” Werra explained. Werra calls it the Liars Index—the percentageof people who invented a degree. The index, which has been published since 1995, was at itshighest in the first half of 2000: 23.3 percent. It now stands at 11.2 percent.If there is a case for regarding all résumés as adventures in narrative, it is one that should notbe made to Mr. Werra. In his view, a lie is a lie, whether it is propagated by Ronald Zarrella, thechief executive of Bausch & Lomb, who confirmed two weeks ago that he did not, after all, havean MBA from NYU, or by Quincy Troupe, California’s newly appointed poet laureate who, shortlyafter Zarrella’s announcement, acknowledged that he had never received a degree from

Grambling College in Louisiana, despite making that claim on his résumé. (Mr. Zarrella remainsat his desk, backed by the Bausch & Lomb board; Mr. Troupe’s resignation has been accepted bythe California senate, presumably on the ground that the last thing a state needs is a poet whomakes things up.) These embellished résumés, testing our taste for the legend of the self-mademan (as well as Sir Philip Sidney’s claim that “the poet…never lieth”) can now be filed alongsidethose of Kenneth Lonchar, the former chief financial officer of Veritas Software (who gavehimself a Stanford MBA), Sandy Baldwin, the former president of the U.S. Olympic Committee(doctorate in American literature), George O’Leary, the former Notre Dame football coach(master’s degree in education), David Geffen, Miss Virginia 1995, and John Holmes (the pornstar) who invented a degree in physical therapy from UCLA.Werra, who has been in the business of “retained executive searches” for 25 years, used tointerview candidates first and then do a background check. Now he checks first and interviewslater, ever since an engaging interviewee said that they had been contemporaries at MarquetteUniversity in the mid-1960s. The man claimed to remember their graduation ceremony. Werrasaid, “I was talking about how President Johnson’s daughter had attended, and about all thesecurity, the metal detectors, and how the place was ringed with police and Secret Service and soon, and he was saying, ’Yeah, yeah, wasn’t it amazing?’ And he had never been there, of course.”Werra went on, “A few years ago, I spoke with a gentleman who claimed to have a degree fromFairleigh Dickinson. Let’s call him John Martin. The university had no record of him, so Idropped him a note: ’Could you clarify this?’ He wrote me back six weeks later: ’You know, I’veaccepted a job to be director of sales and marketing of your client’s No. 1 competitor—justwanted to let you know. And, by the way, the reason you couldn’t find information on my degreeis that my name isn’t really Martin, it’s Martini, and my father was rubbed out by the Mob in NewYork years ago, and my mother got us into the witness-protection program, and when I went toFairleigh Dickinson I got my degree under another name. But I have a special phone number—you can call it and whoever answers the phone will tell you I have a degree.’” Werra did not makethat call.Reproduced from Department of Padding. Dishonorable Degrees, by I. Parker, November 4,2002. The New Yorker Magazine. © Conde NastEMPLOYEE SELECTIONBecause perceptions determine our behavior toward and can cloud ourjudgments of others, one area that clearly benefits from using psychologicalprinciples has been the area of employee selection. The goals of selectionare: (1) identify the knowledge, skills, abilities, and qualities necessary toperform a job well, (2) design tests to measure applicants’ levels on thosekey job requirements, (3) administer and score the tests, and (4) determinethe applicants most suitable for a given position, ensuring that the processis accurate and fair and does not discriminate against members of protectedgroups. The basis for this employee selection process is the ability to identifykey invariant qualities of individuals (such as skills, character, motivation,attitude, leadership potential, and personality) that match up well with thedemands of the position and the culture of the organization.Psychometrics involves the measurement of human ability, potential, and

attitude. This is most visible where employers use tests and specialinterview techniques in employee selection. Job analysis is designed toidentify the skills, abilities, and attributes needed to perform well. Context-specific tests can measure applicants’ skill levels on key job requirements,such as the operation of hardware and software. However, as with any tool,instruments used to measure human ability can be misused or misleading.Instruments that rely on self-report of personal information are subject tobias (such as impression management), and the interpretation of aptitudescores is also subject to bias (such as stereotypes and halo effects).Therefore, managers responsible for hiring and promoting should look formany sources of data from which to extract the qualities essential to thejob, such as personality (see Exhibit 3–7).One goal in this discussion is to help managers make accurate and fairassessments of staff or potential staff for various positions within theirorganizations. Who should function in positions of high contact withpatients? Who is better off working with computers? Who is most able todirect a unit to promote the best clinical care? Who is most suited tomanage the business office? How can we help those who are not ready toassume a leadership role develop the skills while still working comfortablyin their current subordinate positions? These are the questions a manageror administrator must answer in personnel decisions. To do so requires amanager to perceive the unchanging qualities of a person across situations,or their key “traits” that underlie success in a job.Exhibit 3–7 Five-Factor Model of PersonalityPersonality traits are the regularities that we observe in someone’s behavior, attitudes, andexpressions. Prior research suggests that virtually all personality measures can be reduced orcategorized under the Five-Factor Model of Personality, also known as the “Big 5.” Thedimensionality of the Big 5 has been found to be applicable across all cultures.The Big 5 is based on the concept that personality can be described and measured on five broaddimensions and/or traits: openness, conscientiousness, extraversion, agreeableness, andneuroticism.Dimensions/TraitsDescriptionsOpennessimaginative, innovative, open-mindedConscientiousnesscompetent, responsible, dependable, hardworking, goal oriented,self-disciplinedExtraversionassertive, social, positive emotionsAgreeablenesstrusting, straightforward, compliant, warmhearted, generous,modestNeuroticismemotional, insecure, self-conscious, impulsive, vulnerable

Data from An introduction to the five-factor model and its application, by R. R. McCrae and O.P. John, 1992, Journal of Personality, 60, 175–215.Many instruments used to assess personnel and management/leadershippotential, such as the Campbell Interest and Skills Inventory, are trying toidentify “constants” of personality and work style. The Campbell Interestand Skills Inventory compares employee-reported interests and skills tothose of people who describe themselves as satisfied with their careers andhighlights occupational areas to consider during career exploration. Herethe invariant is a pattern of interests and work preferences that we carryfrom one job to another.Another commonly used scale is the Myers-Briggs Type Indicator (MBTI),an instrument for measuring a person’s preferences, using four opposing-pole dimensions (extraversion/introversion, sensate/intuitive,thinking/feeling, and judging/perceiving). Based on how someone answers aseries of questions, this instrument assigns a personality “type.” Eachpersonality type is suited for specific occupations. For example, extrovertsare better suited for sales positions, and introverts do well with informationtechnology positions. There are many pros and cons to using Myers-Briggs,or any instrument, as the sole selector of occupational areas based on “type.”Nevertheless, these instruments pick up patterns (invariants) in self-reported behavioral characteristics and provide a categorization of typesthat may be useful in assessing certain qualities relevant to leadership andworkplace issues.SUMMARYIn this chapter, we reviewed several social psychology concepts that areimportant for managers to understand. These are factors that can influenceand bias our perceptions, and therefore knowledge of these biases is neededto temper and inform our perceptions. In discussing attitudes and how tochange them, we become more aware of those distinctly unique humanqualities that complicate the workplace but also make it so interesting.Likewise, by understanding how workers “see” the world, we are in a betterposition to facilitate a productive workplace. Today’s health care managershave many resources at their disposal, and this includes a wide-rangingscientific literature on organizational behavior, psychology, and humanresource issues in the workplace. Hopefully, this chapter will encourage youto develop and use your own skills as a social perceiver, and give you some

confidence that you can foster positive attitudes. We are always learning,improving, and building skills in social perception. In this way, we willcontinue to use our understanding of human behavior to create a positiveand healthy workplace.DISCUSSION QUESTIONS1. Define attitudes and provide examples.2. What is meant by cognitive dissonance?3. What are common methods to measure a person’s attitude?4. List and describe ways attitudes can be changed.5. What is the difference between the halo effect and the horn effect?6. Define the four stages of the perception process.7. How does attribution theory allow managers to “justify” workers’behaviors?8. Define social perception.9. What is the difference between contrast effect and projection?10. Is stereotyping negative or positive? Why?11. Why is stereotyping so problematic for the health care industry?12. What is the difference between the Pygmalion effect and the Galateaeffect?13. Is impression management negative or positive? Why?14. Is employee selection an unbiased process? Why?CASE STUDY AND EXERCISESEXERCISE 3–1 Gender Stereotyping in OrganizationsRole-PlayChoose a male and a female volunteer. Each member of the pair willargue over a situation in the workplace—for example, departmentsnegotiating over who gets to purchase a piece of new medical equipment(limited financial resources), or whether laptops or PCs are appropriate forthe nursing stations, or which color to paint the hospital’s hallways.Designate one of the participants as the “influencer” who should try to“win” the argument. Designate the other as the “influencee” who should

resist.The influencer has a fixed amount of time, perhaps one minute, topersuade the influencee.After you observe the interaction, break into groups for discussion of theinfluencer (i.e., leader) and make a list of adjectives used to describe theinfluencer. For example, was the leader “bossy” or “dominating” or“assertive”?Have the male and female reverse roles with a new topic and repeat thediscussion. Now discuss the two leadership influencers in both of the role-play episodes. Which one had more skill and fit your image of a “leader”?Record your responses.Break into groups again and describe the influencer with an adjective list.Continue until several male–female dyads have role-played as influencersand influencees. Record the descriptive adjectives. Rate overall leadership ofeach influencer observed. Record responses.Discussion QuestionsWere differences in leader perceptions due to gender stereotypes orbehavioral differences?What social invariants (“constants” or “traits”) can you identify asimportant for leadership positions?Why are leadership perceptions important, and can attributions aboutleadership ability impact the behaviors of followers?DebriefingResearch by Butler and Geis (1990) suggests that in role-play exercises,such as in the preceding activity, the female leader was described differentlyin terms of her personality traits and was more likely to be the recipient ofcovert gender stereotyping compared with males.EXERCISE 3–2 Implicit Association TestAn interesting approach to uncovering personal hidden biases is theImplicit Association Test (IAT). IAT is a component of Project Implicit, acollaborative research effort between researchers at Harvard University,the University of Virginia, and University of Washington. IAT may beaccessed at: implicit.harvard.edu/implicit/.This Web-based self-assessment prompts the user to link words with

images that appear on the computer screen. The links reveal the user’smental associations or automatic preferences, which are indicative of theuser’s tendency to view one identity group more positively over another.Millions of individuals have taken the IAT. An array of implicit biasassessments and answers to frequently asked questions about the IAT canbe found at implicit.harvard. edu. As the Web site cautions, the testsometimes provides some challenging personal feedback!EXERCISE 3–3 Jung Typology Test: Personality AssessmentA 72-item Web-based assessment is available at:www.humanmetrics.com. After completing the questionnaire you will obtaina description of personality type and your type formula according to the CarlJung and Isabel Myers-Briggs typology. There are no right or wronganswers; the test is only for your own self-assessment.Did the results accurately describe your personality traits? Share yourresults with a significant other. Does your significant other agree with yourresults? (Note: Short questionnaires/tests/assessments can be unreliable incertain situations.) This Web-based assessment is designed to stimulateyour thinking about yourself.Case Study 3–3 Only 15 Weeks to Thanksgiving!SCENE I:“I just hate the thought of going back to work,” Mary told her brother Tom. It was the last night ofher vacation, and Mary thought it had been much too short. “It’s 15 weeks until Thanksgiving.”“Mary, I know you’re miserable,” Tom replied. “You’ve been increasingly unhappy in that job forthe past five years. You’re a totally different person when you’re on vacation. I know we’ve discussedthis a thousand times, but isn’t there something else you can do?”“Don’t you think I’d do something else if I could?” Mary replied angrily. “I’m sorry, I know you’reonly trying to help, but I really think I’m trapped in this situation. With my diabetes and high bloodpressure I can’t afford to retire early because I need the health insurance. I could get Social Securityat 62, but the health care coverage doesn’t start until 65. A supplemental policy would be much tooexpensive, even if I could get one. I know that as soon as I go back to work my blood pressure andsugar will go up from the stress.”“Yes,” commented Tom. “And you’ll start counting the days until the weekend. You’ve alreadyfigured out how long it is until Thanksgiving! There’s got to be some other solution to this, Mary.”“Sure! The Lottery!” Mary answered. “That’s all I can think of!”SCENE II:Dan, the manager of the health information department of a large health system in South Florida,sighed as he finished his coffee. … “Mary will be back from vacation tomorrow. I keep hoping thatshe’ll be less stressed out when she gets back, but it always seems to be the same. She has so much

experience and she could be a great role model for the younger people at work, but I just can’t seemto get her attitude turned around. I’ve tried everything I can think of—special projects outside thedepartment, adjusted work schedule, more responsibility and authority on day-to-day stuff,advanced computer training—but she’s my big failure as a boss.”“Oh, I think she’s just jealous of you,” his wife Sonia replied. “You’ve really worked hard on the oldwitch. I just don’t think she’s worth the effort. Why doesn’t she just retire?”“It’s a good thing the Human Resources people didn’t hear that!” Dan laughed. “Sonia, you’re justplain wrong about Mary. She knows everything about the department. Without her help I couldn’thave managed at all when I started there. I can’t believe she’s jealous of me; she’s really been a lot ofhelp. I just wish she weren’t so unhappy. You know, I talked to Jean about her the other day. Theystarted in the company together about 20 years ago. Jean said she wasn’t sure what was going onwith Mary because they haven’t been very close lately, but she said that Mary’s always been reallyindependent. Stubborn, even. And quite outspoken about things she disagrees with. She’s usuallyright, but sometimes it’s tough for people to listen to her because of the way she puts things. I don’tthink she’s kidding when she says that’s part of her New England upbringing. Did you know she gotthrown out of college for objecting to some policy? And then she forced them to reinstate her becausethey hadn’t followed due process?”“Oh, so she’s always been a witch? From Salem, perhaps?” Sonia replied. “Come on, Dan, give it arest. You don’t need to figure Mary out until tomorrow! Don’t you want to watch the Miami Dolphinsbeat the Tampa Bay Bucs? Can you imagine? They favor the Bucs to win!”In Scene I, what is Mary’s attitude? Are you able to identify the three elements of an attitude inwhat she says?In Scene II, Dan and Sonia have very different perceptions about Mary. Why?REFERENCESAllport, D. A. (1987). Selection for action: Some behavioral andneurophysiological considerations of attention and action. In H. Heuer &F. Sanders (Eds.), Perspectives on perception and action. Hillsdale, NJ:Erlbaum.Allport, D. A. (1993). Attention and control: Have we been asking the wrongquestions? A critical review of twenty-five years. In D. E. Meyer & S.Kornblum (Eds.), Attention and performance XIV (pp. 183–218).Cambridge, MA: MIT Press.Allport, G. W. (1935). Attitudes. In Murchison, C. (Ed.), Handbook of socialpsychology (pp. 798–844). Worcester, MA: Clark University Press.Assael, H. (1995). Consumer behavior & marketing action (5th ed.). London,UK: PWS-Kent Publishing Company.Bargh, J. A., Chen, M., & Burrows, L. (1996). Automaticity of socialbehavior: Direct effects of trait construct and stereotype activation onaction. Journal of Personality and Social Psychology, 71(2), 230.Broadbent, D. E. (1958). Perception and communication. New York, NY:Pergamon Press.

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Kelley, H. H. (1973). The process of causal attribution. AmericanPsychologist, 28, 107–128.Kusy, M. & Holloway, E. (2009). Toxic workplace!: Managing toxicpersonalities and their systems of power. Indianapolis, IN: Jossey-Bass/Wiley.Lindsay, P., & Norman, D. A. (1977). Human information processing: Anintroduction to psychology. New York, NY: Harcourt Brace Jovanovich.Livingston, J. S. (1969). Pygmalion in management. Harvard BusinessReview, 81(1), 97–106.Lord, R. G., & Maher, K. J. (1991). Leadership and information processing:Linking perceptions and performance. Boston, MA: Unwin Hyman.Lowe, G., Schellenberg, G., & Shannon, H. (2003). Correlates of employees’perceptions of a healthy work environment. American Journal of HealthPromotion, 17(6), 390–399.Mitchell, T. R., Green, S. G., & Wood, R. E. (1981). An attributional modelof leadership and the poor performing subordinate. Research inOrganizational Behavior, 3, 197–234.Moore, M. (2003). How to improve staff morale using humor, appreciationand praise—Practical strategies to help you turn your workplace into a“Thank God it’s Monday” type of organization. Retrieved January 18,2004, from www.motivationalplus.comMorrel-Samuels, P. (2002). Getting the truth into workplace surveys.Harvard Business Review, 80(2), 111–118.Neumann, O. (1987). Beyond capacity: A functional view of attention. In H.Heuer & A. F. Sanders (Eds.), Perspectives on perception and action (pp.361–394). Hillsdale, NJ: Erlbaum.Ott, J. S. (1996). Classic readings in organizational behavior (2nd ed.).Albany, NY: Wadsworth Publishing Company.Pashler, H. (1989). Dissociations and dependencies between speed andaccuracy: Evidence for a two-component theory of divided attention insimple tasks. Cognitive Psychology, 21, 469–514.Price Waterhouse v. Hopkins, 109 S. Court 1775 (1989).Rizzolatti, G., & Craighero, L. (1998). Spatial attention: Mechanisms andtheories. In M. Sabourin, F. Craik, & M. Robert (Eds.), Advances inpsychological science: Vol. 2. Biological and cognitive aspects (pp. 171–198). Hove, UK: Psychology Press.Rosentein, A.H. (2011). The quality and economic impact of disruptivebehaviors on clinical outcomes of patient care. American Journal of

Medical Quality, 26(5), 372–379.Schlenker, B. R., & Weigold, M. F. (1992). Interpersonal processes involvingimpression regulation and management. Annual Review of Psychology,43, 133–168.Schwartz, M. B., Chambliss, H. O., Brownell, K. D., Blair, S. N., &Billington C. (2003). Weight bias among health professionals specializingin obesity. Obesity Research, 11(9), 1033–1039.Sherif, M., & Cantril, H. (1945). The psychology of attitudes: I. PsychologyReview, 52, 295–319.Thorndike, E. L. (1920). A constant error on psychological rating. Journal ofApplied Psychology, IV, 25–29.Thornton, B., & Moore, S. (1993). Physical attractiveness contrast effect:Implications for self-esteem and evaluations of the social self. Personalityand Social Psychology Bulletin, 19, 474–480.Thurstone, L. L., & Chave, E. J. (1929). The measurement of attitude.Chicago: University of Chicago Press.Van der Heijden, A. H. C. (1992). Selective attention in vision. London, UK:Routledge.Wedell, D. H., Parducci, A., & Geiselman, R. E. (1987). A formal analysis ofratings of physical attractiveness: Successive contrast and simultaneousassimilation. Journal of Experimental Social Psychology, 23, 230–249.Weiner, B. (1979). A theory of motivation for some classroom experiences.Journal of Educational Psychology, 71, 3–25.OTHER SUGGESTED READINGAllport, G. W. (1937). Personality: A psychological interpretation. New York,NY: Holt Rinehart & Winston.Brief, A. P. (1998). Attitudes in and around organizations. Thousand Oaks,CA: Sage.Barnes-Farrell, J. L., & Ratz, J. M. (1997). Accommodation in theworkplace. Human Resource Management Review, 7, 77–107.Briggs-Myers, I., & Briggs, K. C. (1980). Myers-Briggs Type Indicator(MBTI): Gifts differing. Palo Alto, CA: Consulting Psychologists Press.Briggs-Myers, I., & McCaulley, M. H. (1985). Manual: A guide to thedevelopment and use of the Myers Briggs Type Indicator. Palo Alto, CA:Consulting Psychologists Press.Butler, D., & Geis, F. L. (1990). Nonverbal affect responses to male and

female leaders: Implications for leadership evaluations. Journal ofPersonality and Social Psychology, 58, 48–59.Campbell, D. P. (1970). Campbell Interest and Skill Survey–CISS. UpperSaddle River, NJ: Pearson Assessments, Pearson Education. Last accessedDecember 28, 2003, at: www.pearsonassessments.comDella-Giustina, J. L., & Della-Giustina, D. E. (1989). Quality of work lifeprograms and employee motivation. Professional Safety, 34(5), 24.Denton, D. K., & Boyd, C. (1990). Employee complaint handling testedtechniques for human resources managers. Westport, CT: Quorum Books.Eagly, A., & Chaiken, S. (1993). Psychology of attitudes. New York:Harcourt, Brace Jovanovich.Feingold, A. (1998). Gender stereotyping for sociability, dominance,character, and mental health: A meta-analysis of findings from the bogusstranger paradigm. Genetic, Social, and General Psychology Monographs,124(3), 253–271.Feingold, A. (1992). Good-looking people are not what we think.Psychological Bulletin, 111(2), 304.Gibson, J. J. (1966). The senses considered as perceptual systems. Boston,MA: Houghton Mifflin.Hirsch, S. K. (1985). Using the Myers-Briggs Type Indicator inorganizations. Palo Alto, CA: Consulting Psychological Press.Kouzes, J. M., & Posner, B. (1997). The leadership challenge: How to keepgetting extraordinary things done in organizations. San Francisco, CA:Jossey-Bass.Kouzes, J. M., & Posner, B. (1999). Encouraging the heart: A leader’s guideto rewarding and recognizing others. San Francisco, CA: Jossey-Bass.McGuire, W. J. (1985). Attitudes and attitude change. In G. Lindzey & E.Aronson (Eds.), Handbook of social psychology (3rd ed., Vol. 2, pp. 136–314). Reading, MA: AddisonWesley.Stern, M., & Karraker, K. H. (1992). Modifying the prematurity stereotypein mothers of premature and ill full-term infants. Journal of ClinicalChild Psychology, 21(1), 76.Sternberg, R. J., & Lubart, T. I. (1995). Defying the crowd: Cultivatingcreativity in a culture of conformity. New York, NY: Free Press.Stone, E. F., Stone, D. L., & Dipboye, R. L. (1992). Stigmas inorganizations: Race, handicaps, and physical unattractiveness. In K. Kelly(Ed.), Issues, theory, and research in industrial and organizationalpsychology (pp. 385–457). New York, NY: Elsevier Science.

Van Ryn, M., & Burke, J. (2000). The effect of patient race and socio-economic status on physicians’ perceptions of patients. Social SciencesMedicine, 50(6), 813–828.Walsh, V., & Kulikowski, J. J. (1998). Perceptual constancy: Why thingslook as they do. Cambridge, UK: Cambridge University Press.* Portions of the solution were reported as being implemented by University Hospital ofUniversity Health System. See Blueprint at the Seams: Improving Patient Flow to Help America’sEmergency Department. Available from the Robert Wood Johnson Foundation Urgent MattersProgram. Reprinted with permission.

CHAPTER 4Workplace CommunicationLEARNING OUTCOMESAfter completing this chapter, the student should be able to: Describe the communication process. Understand the importance of feedback in the communication process. Identify various verbal and nonverbal methods of communication. Explain the common barriers to communication and apply strategies toovercome these barriers. Discuss the elements of effective communication for knowledgemanagement. Describe the various components of effective strategic communication. Understand the flow of intraorganizational communication. Comprehend the challenges of cross-cultural communication. Understand the flow of communication with external stakeholders andthe public sector.OVERVIEW“Communication is perhaps one of the greatest challenges facingmanagers and leaders today” (Hicks, 2011, p. 86). Fundamental and vital toall health care managerial functions, communication is a means oftransmitting information and making oneself understood by others. Aspreviously noted, communication is a major challenge for managers becausethey are responsible for providing information, which results in efficient andeffective performance in organizations. Every managerial function andactivity involves some form of communication. For a manager to plan,organize, direct, or lead, he or she must communicate with and throughothers. Managerial decisions are effective only if they are communicatedand understood by those responsible for enacting them. Furthermore,employee motivation and satisfaction are dependent on effectivecommunication. Communication is essential to building and maintaining

relationships in the workplace. Communication is the creation or exchangeof thoughts, ideas, emotions, and understanding between sender(s) andreceiver(s). Managers who understand this exchange can better analyzetheir communication patterns, resulting in more effective communicationwithin the workplace.Although managers spend most of their time communicating (e.g.,sending or receiving information), one cannot assume that meaningfulcommunication occurs in all exchanges (Dunn, 2006). Once a memorandum,letter, fax, or e-mail has been sent, many are inclined to believe thatcommunication has taken place. However, communication does not occuruntil information and understanding have passed between sender and theintended receiver. For example, a receiver may hear a sender but may nothave comprehended the sender’s actual meaning. Effective communicationoccurs when the message received is the same as the one intended.Communication enables one to establish and maintain positive interactionsin the workplace. An effective communicator overcomes barriers to engagein more meaningful and successful communication.COMMUNICATION PROCESSCommunication is a complex and dynamic process. Figure 4–1 illustratesthe S-M-C-R model of the communication process. Information originatesfrom the sender (S), which is encoded into a message (M) that is forwardedthrough a selected channel (C) to the designated receiver (R). Messages arereceived and decoded or interpreted by the receiver. Decoding is affected bythe receiver’s prior experiences and frames of reference. Accurate decodingof the message by the receiver is critical to effective communication. Thecloser the decoded message gets to the intent of the sender, the moreeffective the communication. However, environmental and personal barrierscan hamper the communication process which are described in a latersection of this chapter. For ensuring that messages are received as intended,feedback is a necessary component of the communication process. Thereceiver creates feedback to a message and encodes it before transmitting itback to the sender. The sender receives and decodes the feedback. Feedbackis the destination’s reaction to a message (Certo, 1992). It is an importantelement of communication since it allows for information to be sharedbetween the receiver and sender in a two-way communication.

Figure 4–1 The Communication ProcessReproduced from Organizational behavior: Emerging realities for the workplace revolution (2nd ed., 324), by S. L. McShaneand M. A. Von Glinow, 2003, Boston, MA: McGraw-Hill Book Company.FEEDBACKEffective communication takes place when a sender’s message is fullyunderstood by the receiver. As such, feedback is a response (i.e., signal)from the receiver indicating whether a message has been received in itsintended form. The response or signal may take the form of an oralcomment, a written message, a smile, a sigh, raised eybrows, or some otheraction. Even a lack of response by the receiver may be interpreted as a formof feedback. Without feedback, the sender cannot confirm that the receiverhas interpreted the message correctly. Feedback is a key component in thecommunication process because it allows the sender to evaluate whether themessage was decoded as intended or if a corrective action is needed toclarify the intended message. For instance, a manager needs feedback todetermine staff acceptance of his or her new policy requiring employees tocall and verbally confirm all patients’ appointments 48 hours in advance.Through the feedback process, both senders and receivers may need toadjust their outputs as related to the transmitted information. In theabsence of feedback, or in a case where the communication process does notallow for sufficient feedback to develop or feedback is ignored, a certain

amount of feedback will occur spontaneously and tends to take a negativeform.In one-way communication, a person sends a one-directional messagewithout interaction. For example, after reviewing a patient’s lab results, aphysician orders a medical test for the patient. He instructs the medicalassistant to arrange the appointment within the week and notify thepatient. The physician’s order is an example of one-way communication thatdoes not provide the opportunity for the patient to pose questions directly tothe physician. Negative feedback may occur if the patient expressesfrustration or anger at the physician for not directly explaining thenecessity of the medical test. However, the same patient could expresssatisfaction and appreciation toward the medical assistant who explains thepurpose of the medical test based on the patient’s lab results. In this case,the opportunity for feedback results in two-way communication between thepatient and the medical assistant. Two-way communication is moreaccurate and information-rich when the message is complex, although one-way communication is more efficient, as in the case of the physician’swritten order.To be effective, communication must allow opportunities for feedback.Feedback can take several forms, each with a different intent. Keyton(2002) describes three different forms of feedback: descriptive, evaluative,and prescriptive.• Descriptive Feedback: Feedback that identifies or describes how aperson communicates. For instance, Manager A invites her friend andfellow Manager B to attend her staff meeting and comment on her formof communication. After the meeting, B told A that she was very clearand instructive as she introduced her staff to the new computerdatabase for managing patient accounts. In this example, B provideddescriptive feedback of A’s communication with her staff.• Evaluative Feedback: Feedback that provides an assessment of theperson who communicates. In the preceding case, if Manager Bevaluates Manager A’s form of communication and concludes that shewas instructive and helpful, which enabled her staff to feel comfortablewhen going to her for advice, then B has provided positive evaluativefeedback of A’s interaction with her staff.• Prescriptive Feedback: Feedback that provides advice about how oneshould behave or communicate. For example, Manager A asks ManagerB how she could have made changes to better communicate her message

to her staff. B suggests for A to be friendlier and more cooperative bygiving the staff specific times that A is available for help with the newcomputer database. This type of advice is prescriptive feedback.In addition to forms and intent, there are also four levels of feedback.Feedback can focus on a group or an individual working with specific tasksor procedures. It can also provide information about relationships within thegroup or individual behavior within a group (Keyton, 2002).• Task or Procedural Feedback: Feedback at this level involves issues ofeffectiveness and appropriateness. Specific issues that relate to taskfeedback include the quantity or quality of a group’s output. Forinstance, are patients satisfied with the new outpatient clinic? Did thegroup complete the project on time? Procedural feedback refers towhether a correct procedure was used appropriately at the time by thegroup.• Relational Feedback: Feedback that provides information aboutinterpersonal dynamics within a group. This level of feedbackemphasizes how a group gets along while working together. It iseffective when combined with descriptive and prescriptive forms offeedback.• Individual Feedback: Feedback that focuses on a particular individualin a group. For example, is an individual in the group knowledgeable?Does he or she have the skills helpful to this group? What attitudes doeshe or she have toward the group as they work together to accomplishtheir tasks? Is the individual able to plan and organize within aschedule that contributes to the group’s goal attainment?• Group Feedback: Feedback that focuses on how well the group isperforming. Like the questions raised at the individual feedback level,similar questions are asked of the group. Do team members within thegroup have adequate knowledge to complete a task? Have theydeveloped a communication network to facilitate their objectives?Feedback can be in the form of questionnaires, surveys, and audio orvideo recordings of group interaction. It can also occur in activities such asmarket research, client surveys, accreditation, and employee evaluations(Liebler & McConnell, 2008). Feedback should be used to help a groupcommunicate more effectively by making group members identify with thegroup and increase its efficacy. Feedback should not be viewed as a negativeprocess. O’Hair, Stewart, and Rubenstein (2006) point out that negative

feedback does not imply “bad,” and positive feedback does not imply “good.”Negative feedback indicates that you should do less of what you are doing orchange to something else. Positive feedback encourages you to increasewhat you are doing. As such, managers should use feedback as a strategy toenhance goals, awareness, and learning.Feedback, as a managerial tool, enables managers to anticipate andrespond to changes. Structured feedback enhances managerial planning andcontrolling functions. Because of the value of feedback, managers shouldencourage feedback and evaluate it systematically.The Johari WindowThe process of feedback can also be illustrated by the Johari Window, auseful communication model to improve understanding between individuals.It was created by Joe Luft and Harry Ingham in 1955 (hence the name“Johari”) (Luft, 1984). The Johari Window model has two key concepts: (1)you can build trust with others by disclosing information about yourself, and(2) with the help of feedback from others, you can learn about yourself andcome to terms with personal issues.As shown in Exhibit 4–1, windowpane 1 is considered the open area inwhich information about you is known both to you and to others. Thisincludes your behavior, knowledge, skills, attitudes, and “public” history.Tubbs (2001) described this area as the general cocktail party conversationin which an individual willingly shares personal information with others.For instance, at an office picnic, you reveal to your coworkers that you are avegetarian to support your desire for a healthier lifestyle. Windowpane 2refers to a blind area in which others know information about you that youare either unaware of or that you do unknowingly. As an example, yourcolleagues know that although you are a nice and caring person, youchronically interrupt and talk over others in conversation.Exhibit 4–1 The Johari Window

Modified from Group processes: An introduction to group dynamics (3rd ed.), by J. Luft, 1984,Palo Alto, CA: Mayfield.The third windowpane is the hidden area in which you have likes anddislikes that you are unwilling to share with others. This area includes yourvalues, beliefs, fears, and past experiences that you would not wish toreveal. The last windowpane is the unknown—things that are unknown byyou, and are unknown by others. This is an area of potential growth or self-actualization. It represents all the things that you have never tried,participated in, or experienced.Increasing mutual understanding through feedback and disclosure allowsan individual to increase the open area and reduce the blind, hidden, andunknown areas of oneself (McShane & Von Glinow, 2003). In the JohariWindow, Luft (1984) argues for increasing the open area so that you andyour coworkers are aware of your limitations. This is done by receivingmore feedback from others and decreasing one’s blind area (windowpane 2),and reducing the hidden area (windowpane 3) through disclosing more aboutoneself. The combination of feedback and disclosure may also help toproduce more information in the unknown area (windowpane 4).The Johari Window can be used for opening channels of communication.Open communication is important for improving employee morale and

increasing worker productivity. Open communication allows supervisors andsubordinates to openly discuss organization-related issues such as goals andconflicts. Nevertheless, Luft (1984) is cautious on the use of the JohariWindow for all situations. He offers several guidelines for theappropriateness of self-disclosure. He recommends that self-disclosure is afunction of an ongoing relationship. Timing and extent of disclosure arecritical. A competent communicator knows when, with whom, and howmuch to disclose.COMMUNICATION CHANNELSAnother important component of the communication process is selectingan appropriate communication channel. This is the means by whichmessages are transmitted. As noted by Mazurenko and Hearld (2014, p. 2),“Individuals may have different attitudes toward [these] differentcommunication channels, often varying as a function of different personaland contextual factors, which can result in recipients responding differentlyto the same message received via different channels.”There are two types of channels: verbal and nonverbal. Various channelsof communication and the amount of information transmitted through eachtype are illustrated in Figure 4–2.Verbal CommunicationVerbal communication relies on spoken or written words to shareinformation with others. Dialogue, a form of verbal communication, is adiscussion or conversation between people. It is a process by whichparticipants are exposed to new information. The process involves a series ofmeetings of organizational members that represent different views on issuesof mutual interest. According to Edgley and Robinson (1991), in order fordialogue to be successful, there are several fundamental principles: engagemotivated people; use a facilitator and recorder to manage the process; havethe group develop procedures and live by them; ensure confidentiality; andlet the process move at its own pace. Adhering to these principles willimprove dialogue and result in more effective communication.

Figure 4–2 Communication ChannelsReproduced from Information richness: A new approach to managerial behavior and organizational design, by R. L. Daft andR. H. Lengel, 1984, in B. Staw and L. Cummings (Eds.), Research in organizational behavior (vol. 6, pp. 191–233),Greenwich, CT: JAI Press.There are different forms of verbal communication, which should be usedfor different situations. Face-to-face meetings are information-rich, sincethey allow for emotions to be transmitted and immediate feedback to takeplace. Written communication is more appropriate for describing details,especially of a technical nature, as in the example of monitoring a patient’scomplex medical condition. Although traditional written communication hadbeen considered slow, with the development of electronic mail andcomputer-aided communication, written communication through thesechannels has now dramatically improved efficiency (see Case Study 4–1:Are We Getting the Message Across?).

Case Study 4–1 Are We Getting the Message Across?James Warick, director of physical plant at Southern Hospital, e-mailed Diane Curtis,director of nursing, informing her of a leak in Operating Room 1, which would need to be shutdown for repairs early next morning. Curtis forwarded the message to Joanne Messing, theoperating room nurse supervisor on duty for the night shift. Messing, tired from a long night’swork, handwrote a message to the nurse supervisor in the day shift to switch the 8:00 a.m.operation from Room 1 to Room 8 and taped it on the bulletin board. David Swanson, the day-shift nurse supervisor, arrived at 7:30 a.m. and found Dr. Roberts shouting that his patientwas ready for surgery, but no rooms were available because Dr. Jones had already taken Room8.Discussion Questions1. What were the channels of communication used by each person?2. Should a different channel of communication have been used instead?3. What can be done to resolve the problem?4. What future policies should be put in place to prevent this from occurring again?Computer-Aided CommunicationThe use of computers and information technology is dramatically affectingthe way we communicate. Consider the following:When Mohandas Gandhi wanted to inform the world of injusticescommitted by imperialist Great Britain toward South Africa andIndia in the 20th century, he relied on the written word. His journalsand those of his colleagues, as well as firsthand observations byjournalists, provided details of wrongdoing. Looking through the lensof the 21st century, Gandhi’s message traveled slowly and only tolimited parts of the world. Fast-forward to a century later, whencitizens protesting a planned petro chemical plant near the Chinesecity of Xiamen organized their forces by using cell phones, textmessaging, e-mails, and blogs. Images of the protest were virtuallyavailable to the world in real time. In response to this negativepublicity, the Chinese government postponed construction of the petrochemical plant, acceding to the protestors’ demands that anenvironmental impact study be completed. (Heraty, 2014, p. 111)The Internet is a global network of interconnected, yet independentlyoperated computers. An intranet is an organization’s private Internet.Especially in the case of health care organizations, the intranet helps toprotect privacy and confidentiality of company records, such as patients’medical records. An extranet is an extended intranet that enables employeesto stay connected with selected customers, clients, suppliers, and other

partners, such as health care insurance companies and health care vendors.The Internet, intranets, and extranets enable employees to access, manage,and distribute information. These systems can enhance communication ifproperly set up and managed effectively. On the other hand, ineffectivemanagement can hinder communication and result in decreasedproductivity.Electronic mail uses the Internet or intranet to send computer-generatedtext and documents. E-mail has revolutionized the communication process.E-mail allows messages to be rapidly created, changed, saved, and sent tomany people at the same time. One can select any part of the message toread and skip to important parts of the message. E-mail is a preferredchannel for coordinating work and schedules. Messages can be clearlydefined through concrete and specific instructions rather than abstractwords or generalization. For example, an e-mail can be sent to all physiciansto inform them that a meeting starts promptly at 10:00 a.m.Electronic mail has several problems and limitations. The most obvious isinformation overload. E-mail users are overwhelmed by the number ofmessages received on a daily basis, of which many are unnecessary to thereceiver. Moreover, e-mail messages frequently carry computer viruses,which have caused major damage to computers and interruptions in workflow. Another problem with e-mail is its ineffectiveness to communicateemotion. Tones of messages are easily misinterpreted, causingmisunderstandings between sender and receiver. Therefore, icons have beendeveloped to represent emotions (emoticons) in e-mail messages. Forinstance, the symbol 🙂 or 🙂 means happy (Peck, 1997). E-mail also reducespoliteness and respect for others. Flaming is the act of sending anemotionally charged message to others, especially before emotions subside.This common problem occurs frequently over e-mail, whereas a traditionalletter provides time for one to cool down and develop second thoughts. Toreduce these communication problems, some have recommended training forcommunication on the Internet, called netiquette (Extejt, 1998). Netiquetterules include keeping e-mail messages to fewer than 25 lines and notsending sensitive issues through e-mail.There are also key benefits to using e-mail. E-mail reduces time and costof distributing information to employees. Furthermore, e-mail has increasedthe potential for more employee collaboration and teamwork. Rather thanusing the telephone, letters, or memos, employees can use e-mail to rapidlysend and receive messages. For instance, if a hospital ethics committee iscomposed of physicians, nurses, and administrators, staff who are

responsible for setting up monthly meetings find that the most efficient andeffective way to confirm a meeting date and time is through e-mail. Anotheradvantage of e-mail is its flexibility. This is especially so for employees withmobile devices like smartphones and tablets. These technologies aremultifunctional—that is, they can accomplish many tasks, includingmanaging appointments, sending and receiving e-mail, and watching videoclips. These handheld devices have contributed to the increased demand foraccess to information.Other Computer-Aided CommunicationIn addition to e-mail technology, other forms of technology have enteredhealth care organizations and directly enhanced and impacted thecommunication process. Coile (2002) describes several such technologicaladvancements that can be used to bridge the communications gap betweenclinicians and administrators. Computer-aided drug discovery is expected todouble the number of new medications. High-speed, high-definition imagesare created for rapid access via telemedicine. Wireless, handheld digitalelectronic medical records are capable of voice recognition. Telepresencesurgery with minimally invasive, remotely guided instruments extendsbeyond the precision of humans. Medical applications of artificialintelligence are designed for diagnosis, treatment planning, and continuousmonitoring of the chronically ill (Coile, 2002).Nonverbal CommunicationNonverbal communication is sharing information without using words toencode messages. Mehrabian (1980) demonstrated that only 7 percent ofany message is conveyed through words, 38 percent by the way that thewords are said, and 55 percent through nonverbal elements, such as facialexpressions, gestures, posture, and so on.There are four basic forms of nonverbal communication: proxemics,kinesics, facial and eye behavior, and paralanguage (Nelson & Quick, 2003).Proxemics is the study of an individual’s perception and use of space.Territorial space and seating arrangement are two examples. For instance,to encourage cooperation, coworkers working together on a patient safetyreport should sit next to each other. To facilitate communication, a managershould seat a subordinate at a 90 degree angle in order to discuss resolvingstaff complaints.Kinesics refers to body language, which is used to convey meaning andmessages. Pacing and drumming fingers are signs of nervousness. Wringing

of the hands and rubbing temples signal stress. Facial and eye behavior isanother example of nonverbal communication. For example, when a healthcare manager interviews a candidate for a position as a clinical carecoordinator, the manager attaches meaning to frowns and eye contact.Avoiding eye contact tends to close communication. However, cultural andindividual differences influence appropriate eye contact. Moderate direct eyecontact communicates openness, while too much direct eye contact can beintimidating.Paralanguage consists of voice quality, volume, speech rate, and pitch.Rapid and loud speech may be taken as signs of anger or nervousness. Thecommunication process is impeded by negative nonverbal cues. For example,arriving late for an interview with the vice president of finance, talkingvery fast, avoiding eye contact, and getting too close during a conversationor in a seating arrangement for a committee meeting serve as negativefactors in the communication process.To determine the most appropriate channel of communication for sendingmessages, one needs to identify whether verbal or nonverbal communicationshould be used. At the same time, ideal channels of communications can beselected through an examination of the information richness and symbolicmeaning of messages (Daft & Lengel, 1984). Information richness refers tothe volume and variety of information that can be transmitted. As shown inFigure 4–2, face-to-face meetings have the highest information-carryingcapability, because the sender can use verbal and nonverbal communicationchannels and the receiver can provide instant feedback. When a wrongchannel of communication is used, this creates a waste of time and leads tomore misunderstanding. When communication is nonroutine or unclear,information-rich channels are required for more effective communication.As an example, a gunshot victim is brought into a trauma center.Coordinating the care of this patient requires face-to-face instructions toquickly coordinate work flow and minimize the risk of confusion amongvarious care providers. However, for routine communications, lessinformation-rich channels can be used.Choosing one communication channel over another lends meaning to themessage. That is to say, there is symbolic meaning to the selection of aparticular channel of communication beyond the message content. Forexample, when a manager tells an employee that they must have a face-to-face meeting, this symbolizes that the issue is important, compared with abrief e-mail message with instructions.In summary, one essential part of the communication process is selecting

an ideal channel of communication. The use of different channels leads todifferences in the amount and variety of information transmitted. Choosingan appropriate channel of communication involves understanding symbolicmeanings and the information richness of messages.BARRIERS TO COMMUNICATIONAs shown in Table 4–1, several forms of barriers can impede thecommunication process. Longest, Rakich, and Darr (2000) classify thesebarriers into two categories: environmental and personal. Environmentalbarriers are characteristic of the organization and its environmental setting.Personal barriers arise from the nature of individuals and their interactionswith others. Both barriers can block, filter, or distort the messages whensent and received.Table 4–1 Overcoming Barriers to CommunicationBarriers to CommunicationOvercoming Barriers to CommunicationEnvironmental Barriers1. Competition for time and attention1. Devote adequate time and attention to listening2. Multiple levels of hierarchy2. Reduce the number of links or levels of hierarchy3. Managerial philosophy3. Change philosophy to encourage the free flow of communication4. Power/status relationships4. Consciously tailor words and symbols and reinforce words withactions so that messages are understandable5. Organizational complexity5. Use multiple channels of community to reinforce complexmessages6. Specific terminology6. Consciously define and tailor words and symbols and reinforcewords with actions so that messages are understandablePersonal Barriers1. Frame of reference2. Beliefs3. Values4. Prejudices5. Selective perception6. Jealousy7. Fear8. Evaluate the source (sender)9. Status quo10. Lack of empathy1. Consciously engage in efforts to be cognizant of other’s frame ofreference and beliefs2. Recognize that others will engage in selective perception,jealousy, fear, and prejudices to help diminish the barriers3. Engage in empathyModified from Managing health services organizations (6th ed., pp. 678–681), by B. B. Longest, and K.Darr, 2014, Baltimore, MD: Health Professions Press.Environmental BarriersExamples of environmental barriers include competition for attention andtime between senders and receivers. Multiple and simultaneous demands

cause messages to be incorrectly decoded. The receiver hears the message,but does not understand it. As a result of inadequate attention paid to themessage, the receiver is not really “listening.” Listening is a process thatintegrates physical, emotional, and intellectual inputs into the quest formeaning and understanding. Listening is effective only when the receiverunderstands the sender’s messages as intended. Thus, without engaging inactive listening, the receiver fails to comprehend the message. Time isanother barrier. Lack of time prevents the sender from carefully thinkingthrough and thoroughly structuring messages accordingly, and limits thereceiver’s ability to decipher messages and determine their meaning.Other environmental barriers include the organization’s managerialphilosophy, multiple levels of hierarchy, and power or status relationshipsbetween senders and receivers. Managerial philosophy can promote orinhibit effective communication. Managers who are not interested in or failto promote intra-organizational communication upward or disseminateinformation downward will create procedural and organizational blockages.By requiring that all communication follow the chain of command, lack ofattention and concern toward employees is a sign of a managerialphilosophy that restricts communication flow. Furthermore, whensubordinates encounter managers who fail to act, they are unwilling tocommunicate upward in the future, because communications are not takenseriously.Managerial philosophy not only affects communication within theorganization, but also impacts the organization’s communications withexternal stakeholders. For instance, when the chief executive officer (CEO)of one hospital becomes aware that patients might have been exposed to adangerous infection while hospitalized, he immediately decides to cover upthe incident and communicates that message down to his managers.However, another hospital CEO deals with this incident in a very differentmanner. She uses public media as a channel of communication to encouragepatients to come forward and be tested. These reactions to similar eventsreflect different managerial philosophies about communication.Multiple levels of hierarchy and complexities such as the size and degreeof activity conducted in an organization tend to cause message distortion. Asmessages are transmitted up or down, they may be interpreted according toan individual’s personal frame of reference. When multiple links exist in thecommunication chain, information could be misinterpreted. As a result, amessage sent through many levels is likely to be distorted or even totallyblocked. As an example, the CEO asked department administrators to relay

his message of sincere congratulations and appreciation to the staff for theirhard work to obtain their institutional re-accreditation from The JointCommission. This message was transmitted through several layers in theorganization and was received in a more nonchalant manner than originallyintended. In another scenario, a report generated by the managementinformation system analyst was given to his supervisor, who went onvacation and left it on his desk without giving it to the vice president, whohad requested it a week ago. In this case, the message did not reach itsdestination.Power or status relationships can also affect transmission of a message.An inharmonious supervisor–subordinate relationship can interfere with theflow and content of information. Moreover, a staff member’s previousexperiences in the workplace may prevent open communication because offear of negative sanctions as a result. For instance, a poor supervisor–subordinate relationship inhibits the subordinate from reporting that theproject is not working as planned. A subordinate who is fearful of the powerand status of the manager prevents effective communication from takingplace. Another environmental barrier that may lead to miscommunication isthe use of specific terminology unfamiliar to the receiver or when messagesare especially complex. Managers and clinical staff in health careorganizations use medical terminology, which may be unfamiliar to externalstakeholders. Communication between people who use different terminologycan be unproductive simply because people attach different meanings to thesame words. Thus, misunderstandings can occur as a result of unfamiliarterminology.Personal BarriersPersonal barriers arise because of an individual’s frame of reference orbeliefs and values. These barriers are based on one’s socioeconomicbackground and prior experiences and shape how messages are encoded anddecoded. One may also consciously or unconsciously engage in selectiveperception or be influenced by fear or jealousy. For example, some culturesbelieve in “don’t speak unless spoken to” or “never question elders” (Longest,Rakich, & Darr, 2000). These beliefs inhibit communication. Others acceptall communication at face value without filtering out erroneous information.Still others provide self-promotion information, intentionally transmittingand distorting messages for personal gain. Unless one has had the sameexperiences as another individual, it may be difficult to completelyunderstand the sender’s message. In addition to frame of reference, one’s

beliefs, values, and prejudices also can alter and block messages.Preconceived opinions and prejudices are formed on the basis of varyingpersonalities and backgrounds. Selective perception is a tendency forretaining positive parts of the message and filtering out negative portions.Two additional personal barriers are status quo and evaluating the source(or the sender) to determine whether the receiver should retain or filter outmessages. For instance, a manager always ignores complaints from Melissa,the medical receptionist, because Melissa tends to exaggerate issues andevents. However, one must be careful to evaluate and distinguishexaggerations from legitimate messages. Status quo is when individualsprefer the present situation. They intentionally filter out information that isunpleasant. For example, a manager refuses to tell staff and patients thattheir favorite physician, Dr. Ames, has decided to leave the practice. Toprevent patients from switching to another physician, the managerpostpones the communication to retain status quo.A final personal barrier is lack of empathy—in other words, insensitivityto the emotional states of senders and receivers. In the case where aphysician shouts for his assistants to hurry with preparing clean roomsbecause 50 patients are in the waiting room, his assistants shouldempathize with the physician and understand that he is under stress andpressure to see his patients who are complaining that they have beenwaiting over three hours. At the same time, the physician should alsoempathize with his assistants because they are understaffed as a result ofone of the three assistants calling in sick.OVERCOMING BARRIERS TO IMPROVECOMMUNICATIONRecognizing that environmental and personal barriers exist is the firststep to effective communication. By becoming cognizant of their existence,one can consciously minimize their impact. However, positive actions areneeded to overcome these barriers (see Table 4–1).Longest, Rakich, and Darr (2000) provide us with several guidelines forovercoming barriers:1. Environmental barriers are reduced if receivers and senders ensurethat attention is given to their messages and that adequate time isdevoted to listening to what is being communicated.2. A management philosophy that encourages the free flow ofcommunication is constructive.

3. Reducing the number of links (levels in the organizational hierarchyor steps between the sender in the health care organization and thereceiver, who is an external stakeholder) diminishes opportunities fordistortion.4. The power/status barrier can be removed by consciously tailoringwords and symbols so that messages are understandable; reinforcingwords with actions significantly improves communication amongdifferent power/status levels.5. Using multiple channels to reinforce complex messages decreases thelikelihood of misunderstanding.Personal barriers to effective communication are reduced by consciousefforts of senders and receivers to understand each other’s values andbeliefs. One must recognize that people engage in selective perception andare prone to jealousy and fear. Sharing empathy with those to whommessages are directed is the best way to increase effective communication.Communicating effectively among a complex, multisite health caresystem is challenging. Barriers may be difficult to overcome. Porter (1985)offers several approaches for achieving effective linkages among businessunits in a diversified corporation and suggests ways in which managers canovercome some of these barriers.1. Use techniques that extend beyond traditional organizational lines tofacilitate communication. For instance, the use of diagonalcommunication that flows through task forces or committeesenhances communication throughout the organization.2. Use management processes that are cross-organizational rather thanconfined to functional or department procedures. Implementingmanagement processes in the areas of planning, controlling, andmanaging information systems facilitates communication.3. Use human resources policies and procedures (job training and jobrotation) to enhance cooperation among members in organizations.4. Use management processes to resolve conflicts in an equitablemanner to produce effective communication.EFFECTIVE COMMUNICATION FOR KNOWLEDGEMANAGEMENTCommunication plays an important role in knowledge management.Employees are the organization’s brain cells, and communication represents

the nervous system that carries information and shared meaning to vitalparts of the organizational body. Effective communication brings knowledgeinto the organization and disseminates it to employees who require thatinformation. Agarwal, Sands, and Schneider (2010) attempted to quantifythe economic waste associated with communication inefficiencies in hospitalsettings at a national level. They found that U.S. hospitals waste more than$12 billion annually as a result of communication inefficiency among careproviders.Effective communication minimizes the “silos of knowledge” problem thatundermines an organization’s potential and, in turn, allows employees tomake more informed decisions about corporate actions. Effectivecommunication is one of the most critical goals of organizations (Spillan,Mino, & Rowles, 2002). Research suggests that an effective manager is onewho spends considerable time on staffing, motivating, and reinforcingactivities (Luthans, Welsh, & Taylor, 1988).Shortell (1991) identified multiple key elements to effectivecommunication in a model developed for physicians and hospitaladministration to improve their communication abilities to disseminateknowledge within the organization. The following summarizes these keyelements:• An effective communicator must have a desire to communicate, whichis influenced both by one’s personal values and the expectation that thecommunication will be received in a meaningful way.• An effective communicator must have an understanding of how otherslearn, which includes consideration of differences in how others perceiveand process information (e.g., analytic versus intuitive, abstract versusconcrete, verbal versus written).• The receiver of the message should be cued as to the purpose of themessage—that is, whether the message is to provide information, elicita response or reaction, or arrive at a decision.• The content, importance, and complexity of the message should beconsidered in determining the manner in which the message iscommunicated.• The credibility of the sender affects how the message will be received.• The time frame associated with the content of the message (long versusshort) needs to be considered in choosing the manner in which themessage is communicated. More precise cues are needed with shortertime frames (see Figure 4–3).

A formula to evaluate an individual’s effectiveness in communicating toothers can be calculated as shown in Exhibit 4–2.The index of communication effectiveness (ICE) is a percentage of thereaction to the intended message over the total number of messages sent. Ifmanagers find that their ICE is low over time, they should evaluate theircommunication processes to identify ways to make improvements (Certo,1992). Research suggests that to improve health care organizationalcommunication and cohesion, exchanges between employees and leadersshould involve leaders’ direct support and encouragement of employees’constructive expressions of dissatisfaction and innovative ideas (Sobo &Sadler, 2002) (see Case Study 4–2: What Should We Do Now?).Figure 4–3 Interrelationships of Effective Knowledge-Management CommunicationReproduced from Effective hospital-physician relationship (p. 87), by S. M. Shortell, 1991, Ann Arbor, MI: HealthAdministration Press.Exhibit 4–2 An Index of Communication Effectiveness

Reproduced from Modern management: Quality, ethics, and the global environment (5th ed.), byS. C. Certo, 1992, Boston, MA: Allyn and Bacon.Case Study 4–2 What Should We Do Now?Jenny Taylor, receptionist at Caring Physicians Clinic, was responsible for calling patients toremind them of their appointments. Dr. Ann Ryan, medical director of the clinic, found Jenny to behardworking and pleasant to the patients. One morning, Dr. Ryan arrived and found Jenny crying inthe supply room. When she questioned Jenny, Jenny sobbed that for the past three months she hadforgotten to order supplies. Jenny had been borrowing supplies from the pediatrics office next door.Now, they were unwilling to lend her more. Jenny confessed that she had called the supply centeronce and faxed a list of supplies over, but had not followed through. This morning, Jenny called thesupply center again and found out that they were out of business. Jenny told her immediatesupervisor, Barbara Lakes, patient care coordinator for the clinic. Lakes fired Jenny forincompetence. In the meantime, patients were waiting and there were no clean sheets, gloves, orgowns.Discussion Questions1. What was the beginning of the problem?2. What should Jenny have done?3. Using the elements of effective communication, discuss what Dr. Ryan and Barbara Lakesshould do now.Strategic CommunicationStrategic communication is an intentional process of presenting ideas in aclear, concise, and persuasive way. A manager must make an intentionaleffort to master communication skills and use them strategically—that is,consistently with the organization’s values, mission, and strategy. To planstrategic communication, managers must develop a methodology forthinking through and effectively communicating with superiors, staff, andpeers. Sperry and Whiteman (2003) provide us with a strategiccommunication plan, which consists of five components.1. Outcome: The specific result that an individual wants to achieve.2. Context: The organizational importance of the communication.3. Messages: The key information that staff need to know.4. Tactical Reinforcement: Tactics or methods used to reinforce themessage.5. Feedback: The way the message is received and its impact on theindividual, team, unit, or organization.Strategic communication requires forethought about the purpose and

outcome of the message. Managers must be able to link the needs of thestaff to the organization’s mission and deadlines.FLOWS OF INTRAORGANIZATIONAL COMMUNICATIONCommunication can flow upward, downward, horizontally, and diagonallywithin organizations. Upward communication occurs between supervisorsand subordinates. Downward communication primarily involves passing oninformation from supervisors to subordinates. Horizontal flow is frommanager to manager or from coworker to coworker. Diagonal flow occursbetween different levels of different departments. Longest, Rakich, andDarr (2000) provides us with several forms of intraorganizationalcommunication for health care organizations, which are described in thefollowing paragraphs.Upward FlowThe purpose of upward communication flow is to provide managers withinformation to make decisions, identify problem areas, collect data forperformance assessments, determine staff morale, and reveal employeethoughts and feelings about the organization. Upward flow becomesespecially important with increased organizational complexity. For example,as noted by Adelman (2012, p. 133), the Institute of Medicine’s 2004 reporttitled Keeping Patients Safe: Transforming the Work Environment of Nursesrelated that “a lack of critical upward feedback in the hospital setting hasadverse effects on direct patient care and health outcomes.” Therefore,managers must rely on effective upward communication and encourage it asan integral part of the organizational culture. Upward communication flowhelps employees meet their personal needs, by allowing those in positions oflesser authority to express opinions and perceptions to those with higherauthority. As a result, they make contributions to the organization, andparticipate in the decision-making process. Adelman (2012) found thataward-winning high-performance hospitals’ leaders have four key areas thatpromote effective upward communication:1. Establishing a culture of excellence—in which employees feelcomfortable voicing their concerns for improvement.2. Creating employee voice opportunity—through leaders’ visibility andapproachability and the use of both formal and informalcommunication channels.3. Reinforcing employee voice instrumentality—whereby leaders

interact with employees often to actively solicit comments and providefeedback on decisions.4. Removing of risks and costs—a climate of safety (i.e., trust) thatallows employees to take interpersonal risks with regard tocommunicating improvement ideas to the leaders of the organization.The hierarchical structure (chain of command) is the main channel forupward communications in health care organizations. To increase theeffectiveness of upward communication, Luthans (1984) recommends theuse of grievance procedures, open-door policies, counseling, employeequestionnaires, exit interviews, participative decision-making techniques,and the use of an ombudsperson.• Grievance Procedure: The grievance procedure allows employees tomake an appeal upward beyond their immediate supervisor. It protectsindividuals from arbitrary action by their direct supervisor andencourages communication about complaints.• Open-Door Policy: The supervisor’s door is always open to subordinates.It is an invitation for subordinates to come in and talk to the supervisorabout problems that trouble them, seek advice, or to share information.• Counseling, Questionnaires, and Exit Interviews: The department ofhuman resources in a health care organization can facilitatesubordinate-initiated communication by conducting confidentialcounseling, administering attitude questionnaires, and holding exitinterviews for those leaving the organization. Information gained fromthese forms of communication can be used to make improvements.• Participative Decision-Making Techniques: Through the use of informalinvolvement of subordinates or formal participation programs such asquality-improvement teams, union–management committees, andsuggestion boxes, participative techniques can improve employeeperformance and satisfaction. Since employees can participate in thedecision-making process, they feel that they can make valuablecontributions to the organization.• Ombudsperson: The use of an ombudsperson provides an outlet forpersons who feel they have been treated unfairly.In upward communication, subordinates can provide two types ofinformation to supervisors: (1) personal information about ideas, attitudes,and performance and (2) technical information to provide feedback.Managers who encourage feedback enhance upward flow of communication.

Downward FlowDownward communication involves passing information from supervisorsto subordinates. This includes verbal and nonverbal communication, such asinstructions for completing tasks, as well as communications on a one-to-onebasis. Downward communications include meeting with employees, writtenmemos, newsletters, bulletin boards, procedural manuals, and clinical andadministration information systems.Horizontal FlowRelying only on upward and downward communication is inadequate foreffective organizational performance. In complex health care organizations,horizontal flow or lateral communication must also occur. The purpose oflateral communication is the sharing of information among peers at similarlevels to keep organizational staff informed of all current practices, policies,and procedures (Spillan, Mino, & Rowles, 2002). For example, coordinatingthe continuum of patient care requires communication among multipleunits. Committees, task forces, and cross-functional project teams are alluseful forms of horizontal communication.Diagonal FlowThe least-used channel of communication in health care organizations isdiagonal flow, although it is growing in importance. While diagonal flowdoes not follow the typical hierarchical chain of command, diagonal flow isespecially useful in health care for efficient communication and coordinationof patient care. For example, diagonal communication occurs when thedirector of nursing asks the data analyst in the medical records departmentto generate a monthly report for all patients in the intensive care unit (seeCase Study 4–3: Communication Flows).Case Study 4–3 Communication FlowsSara Lang is a charge nurse at Sunny Nursing Home and has worked under the same president,Lisa Davis, for five years. In fact, the two have become good friends. They frequently socialize afterhours. Rick Walters, director of nursing, is a capable person who has been working there for threeyears. Four nurses (Anna, Barbara, Charles, and Dan) report directly to Sara.Anna, one of the nurses, was having personal difficulties. She asked Sara whether she couldchange her work schedule from the usual eight-hour shift of four days with three consecutive daysoff to 16-hour shifts for two days and five consecutive days off. Sara thought that was not a problemand told Anna that she would enter that information into the computerized scheduling system andthat she would tell Lisa Davis of the change, since they were getting together for a drink after work.Barbara overheard the conversation between Sara and Anna, and she immediately went to see

Rick Walters and complained that Anna was getting preferential treatment and she wanted thesame schedule. Rick, who always wanted to make sure that the nursing staff were happy and gotalong, approved Barbara’s change in schedule. He made this change through the computerizedschedule and did not tell anyone else. Barbara, who is good friends with Charles, told him of her newschedule. Charles, who works closely with the chief of staff, Dr. Goodman, told Dr. Goodman of thechange in Barbara’s schedule and asked Dr. Goodman to change his. Dr. Goodman thought it was agood idea and e-mailed Charles’s new schedule to his assistant, Susan Stevens, to enter it into thescheduling system.On the next Monday morning, changes were implemented to Anna’s, Barbara’s, and Charles’schedules. Yet, no one had discussed these changes with anyone else. When the schedule wasprinted out and posted, it showed that Anna, Barbara, and Charles were all off for five days thatweek, from Monday to Friday, and all three began work on Saturday. In the meantime, the onlynurse left working was Dan.Discussion Questions1. What are the different forms of communication flow taking place?2. What changes should have been implemented?3. What should be done now?COMMUNICATION NETWORKSFlows of communication can be combined into patterns calledcommunication networks. These networks are interconnected bycommunication channels. A communication network is the interactionpattern between and among group members. A network creates structurefor the group because it controls who can and should talk to whom (Keyton,2002). Groups generally develop two types of communication networks:centralized and decentralized (Figure 4–4).Decentralized networks allow each group member to talk to every othergroup member without restrictions. An open, all-channel, or decentralizednetwork is best used for group discussions, decision making, and problemsolving. The all-channel network tends to be fast and accurate comparedwith the centralized network, such as the chain or Y-pattern network(Longest et al., 2000). Nevertheless, a decentralized network can createcommunication overload, in which too much information or too complexcommunication may occur (Keyton, 2002). When communication overload isproduced, messages may conflict with one another and result in confusion ordisagreement. To reduce communication overload, a facilitator should beused to monitor group discussions.A centralized network restricts the number of individuals in thecommunication chain. In a group setting where a dominant leader takesover group discussions by controlling the number of messages and amountof information being passed, group members do not interact except through

the leader. Such a network can create communication underload, in whichtoo few or simple messages are transmitted. In this type of network, groupmembers feel isolated from group discussions and generally feel dissatisfied.In the chain network, communication occurs upward and downward andfollows line authority relationships. An example is a staff nurse who reportsto the charge nurse, who reports to the director of nursing, who reports tothe vice president for clinical services, who finally reports to the CEO of alarge hospital. This network delineates the chain of command and showsclear lines of authority.

Figure 4–4 Two Types of Communication Networks: Centralized and DecentralizedReproduced from Managing health services organizations (6th ed., p. 684), by B. B. Longest, and K. Darr, 2014, Baltimore,MD: Health Professionals Press.Other types of centralized networks include the Y-pattern, the wheelpattern, and the circle network. The Y-pattern is similar to the chain

network, with its hierarchical structure, except it shows two employees atthe same level who then follow the chain. An example is of two medicalassistants in the organ transplant division who report to the clinicaladministrator for the division, who reports to the clinical administrator forthe department of surgery, who reports to the vice president of clinicalservices, who finally reports to the CEO of the hospital.The wheel pattern shows four subordinates reporting to one supervisor.Subordinates do not interact, and all communications are channeledthrough the manager at the center of the wheel. This pattern is rare inhealth care organizations and systems, although elements of it can be foundin the example where four vice presidents report to a president if the vicepresidents have little interaction. Even though this network pattern is notroutinely used, it may be used when urgency or secrecy is required. Forexample, the president with an organizational emergency mightcommunicate with the vice presidents in a wheel pattern because time doesnot permit using other modes. Similarly, if secrecy is important, such aswhen investigating possible embezzlement, then the president may requirethat all relevant communication with the vice presidents be keptconfidential. The wheel pattern works well when there is pressure for time,secrecy, and accuracy.The circle pattern allows communicators in the network to communicatedirectly only with two others. Since each communicates with another in thenetwork, there is no central authority or leader. The circle network workswell when there are open channels of communication among all parties;however, it can also slow down the communication process to enableeveryone access to information.Although there are different communication networks, there is not onethat works for all situations. Different forms can be applied under varyingcircumstances. To be effective, health care managers must be able to selectappropriate flows of communication for specific situations. Identifying anideal communication network is critical to successful communication. Sincehealth problems range from simple to complex, simple problems can beeasily resolved using simple networks. As an example, scheduling patientappointments for Dr. Davis can be easily accomplished through thesuperior–subordinate chain network. However, complex problems requiremany levels of decision making. For instance, whether Horizons Hospitalshould merge with its major competitor to gain more market share at therisk of making a major capital investment can be accomplished through theall-channel network, which is more useful and effective for tackling complex

problems. Hellriegel and Slocum (2004) compared the five communicationnetworks using four assessment criteria. Figure 4–5 shows the specificcriteria when making a selection among the different types of networks.1. Degree of Centralization: Degree of centralization is the extent towhich team members have access to more communication thanothers. In the case of the wheel network, because communicationflows from and to only one member, this is the most centralizednetwork. However, the allchannel network provides everyone in thenetwork with the same opportunity for communication; thus, it is theleast centralized network.2. Leadership Predictability: Leadership predictability is the ability toanticipate which member of the communication network is likely toemerge as the leader. In the case of the Y- and wheel patterns, themost centrally positioned individual is the most likely person.3. Average Group Satisfaction: Average group satisfaction reflects thelevel of satisfaction of members in the communication network. In thewheel network, average member satisfaction is the lowest comparedwith other networks, since the most centrally positioned person playsthe most crucial roles and leaves less important decision-makingresponsibilities for those around the wheel.4. Range of Individual Member Satisfaction: The range of anindividual’s satisfaction within the communication network shows aninverse relationship with the average group satisfaction. Again, in thewheel, although average member satisfaction is low, the range ofindividual member satisfaction is high, because they are highlydependent on the individual in the middle. In the case of the all-channel network, average group satisfaction is high since there isgreater participation by all members of the communication network;yet, individual satisfaction tends to be low.

Figure 4–5 Effects of Five Communication NetworksReproduced from Organizational behavior (10th ed., p. 301), by D. Hellriegel and J. W. Slocum, 2004, Mason, OH: South-Western.INFORMAL COMMUNICATIONIn addition to formal communication flows and networks within healthcare organizations, there are informal communication flows, which havetheir own networks. Employees have always relied on the oldestcommunication channel—the corporate grapevine. The grapevine is anunstructured and informal network founded on social relationships ratherthan organizational charts or job descriptions. According to some estimates,75 percent of employees typically receive news from the grapevine beforethey hear about it through formal channels (McShane & Von Glinow, 2003).Early research identified several unique features of the grapevine. Ittransmits information rapidly in all directions (Newstrom & Davis, 1993).Figure 4–6 illustrates four common patterns that the grapevine can take.

Figure 4–6 Grapevine NetworksThe typical pattern is a cluster chain, whereby a few people activelytransmit rumors to many others. The grapevine works through informalsocial networks, so it is more active for employees who have similarbackgrounds and are able to communicate easily. Many rumors seem to

have at least a little bit of truth, possibly because rumors are transmittedthrough information-rich communication channels, and employees aremotivated to communicate effectively. Nevertheless, the grapevine distortsinformation by deleting fine details and exaggerating key points of themessage.In this era of information technology, e-mail and instant messaging havereplaced the traditional watercooler site of grapevine gossip. Instead,networks have expanded as employees communicate with one another insideand outside of the organization instantly through computer-aidedcommunication. Furthermore, public Web sites have become virtualwatercoolers for posting anonymous comments about specific companies forall to view. This technology extends gossip to anyone, not just employeesconnected to the social networks. A manager’s responsibility is to utilize theinformal network selectively to benefit the organization’s goals (see CaseStudy 4–4: Did You Hear the Latest?).Case Study 4–4 Did You Hear the Latest?Sally Reeds, a medical secretary for the department of neurology at Western Heights Hospital inColorado, turned on her computer and found an e-mail from her friend and coworker Justin Zeels, asocial worker in the same hospital. Justin wrote that Dr. Sites, medical director of neurology, hadbeen found under a bench outside the emergency. The hospital security allegedly reported that Dr.Sites was completely intoxicated, and he was rushed home. Sally spiced up the tale and immediatelye-mailed 10 of her friends. This morning, Sally looked up and saw Dr. Sites seeing his patients as ifnothing had happened. She confronted him and asked him how he could possibly face everyone afterwhat happened last night. Dr. Sites looked confused until a copy of Zeels’s e-mail was thrust into Dr.Sites’s hands by another staff member. After reading it, Dr. Sites became livid and fired Justin forspreading such a malicious rumor. Meanwhile, Maria Hummingshire, another medical secretary,who saw the entire incident, ran to her computer to e-mail the latest to her friends.Discussion Questions1. What did Sally do wrong?2. What should Justin have done?3. What should the organization do to prevent the spread of gossip through the grapevine?CROSS-CULTURAL COMMUNICATIONIncreasing information technology, globalization, and cultural diversitypresent a number of communication opportunities and challenges fororganizations. Organizational personnel must be sensitive and competent incross-cultural communication. While ethnic and racial diversity enriches theenvironment, it can also cause communication barriers and impede efficient

and effective service delivery. Communication difficulties arise fromdifferences in cultural values, languages, and points of view. For instance,in the health care industry, one major barrier is language, because as manyas 20 languages may be encountered among staff and patients. In theUnited States, more than 25 percent of the population is foreign-born, and15 percent speak a language at home other than English (Thiederman,1996). Since language is the most obvious cross-cultural barrier, words canbe easily misunderstood in verbal communication (Dutton, 1998). Althoughthe English language is relied on as the common business language, Englishwords may have different meanings in different cultures.Voice intonation varies by country. For instance, in Japan,communicating softly is an expression of politeness, whereas in the MiddleEast, the louder the voice, the more one is believed to be sincere (Mead,1993). To achieve effective communication, health care professionals canapply several strategies to reduce communication barriers. Thiederman(1996) provides us with several verbal and nonverbal techniques to improvecross-cultural communication.• Write down in simple English the issues that have been agreed upon inorder to obtain feedback on accuracy.• Repeat a message when there is doubt.• Watch for nonverbal signs of a lack of understanding.• Listen carefully to an entire message, especially when there is a foreignaccent involved in the communication.• Create a relaxed atmosphere so that tension is reduced to increase theflow of communication.• Phrase questions in different ways to make it easier for the receiver tounderstand.Opportunities for working with individuals from other cultures haveincreased dramatically. As U.S. industries branch into world marketsthrough the interconnectedness of the Internet, e-mail, fax machines, voicemessaging, electronic bulletin boards, and smart phones, organizations areable to conduct business without ever meeting face to face. To be effective incross-cultural communication, several guidelines are important.• Understand one’s own identity. To develop sensitivity to other cultures,you must first understand your own culture and identity. Your personalidentity encompasses who you are and who you want to be. That is, youchoose your lifestyle, goals, occupation or profession, and friends. The

choices that you make or pursue are affected by racial, cultural, gender,and social class factors.• Enhance personal and social interactions. With globalization, we haveincreased opportunities to associate and develop close interactions withindividuals who are different from us. The conscious decisions we maketo become more accommodating, flexible, and tolerant of others broadenour views of the world and enrich our perspectives. Our relationshipswith those of different cultures help us to learn more about the worldand to break typical stereotypes. These interactions also enable us todevelop new skills for communicating with others and to learn fromthem.• Solve misunderstandings, miscommunications, and mistrust. Take thetime and make the effort to study, understand, and appreciateindividuals of different cultures. Through open, honest, and positivecommunication, this will resolve misunderstandings,miscommunications, and mistrust.• Enhance and enrich the quality of the work environment. Recognizingand respecting ethnic and cultural diversity through more opencommunication are the first steps toward valuing diversity andenriching the quality of the work environment (Hybels & Weaver,2007).COMMUNICATING WITH EXTERNAL STAKEHOLDERSIn health care organizations, managers must be competentcommunicators, because they spend most of their time and energycommunicating with large numbers of external stakeholders, individuals,groups, and organizations that are interested in the health careorganization’s actions and decisions. A competent communicator is anindividual who has the ability to identify appropriate communicationpatterns in a given situation and to achieve goals by applying thatknowledge. Competent communicators quickly learn the meaning thatlisteners take from certain words and symbols, and they know whichcommunication channel is preferred in a particular situation. Moreover,competent communicators use this knowledge to communicate in ways toachieve personal, team, and organizational objectives. A manager with highcommunication competence would be better than others at determiningwhether an e-mail, telephone call, or personal visit would be the bestapproach to convey a message to an employee.To competently communicate with external stakeholders, organizations

and their managers are responsible for assessing the environment to gaininformation in order to make strategic decisions. Managers must utilizetheir roles as liaisons and monitors to scan the environment foropportunities and minimize threats. Furthermore, managers must utilizetheir strategist role to formulate and implement policies that are consistentwith their organization’s strategic goals and plans (Guo, 2003). Exhibit 4–3shows steps for analyzing stakeholders to increase the acquisition of usefulinformation.First, scanning the macro- and microenvironments results in informationabout stakeholders. In the case of one state’s department of health, shownin Figure 4–7, the diversity of stakeholders is illustrated (Ginter, Swayne,& Duncan, 1998).Relationships between the organization and its external stakeholders arecomplex and affect communication since the organization is a dynamic, opensystem operating in a turbulent external environment. The size and varietyof external stakeholders make communication complex, especially sincestakeholders attempt to influence the decision making of organizations.Fottler et al. (1989) examined communication between a large hospital andits stakeholders and found different relationships. While some relationshipsare positive, others are neutral or negative. Positive relationships withexternal stakeholders are easier to manage, and communication tends to bemore effective than negative relationships.Exhibit 4–3 Stakeholder Analysis1. Scan the environment of the organization (macroenvironment: economic, regulatory,social/cultural, political, demographics, competitive, technology) (microenvironment:health care industry)2. Identify strategically important issues (i.e., identify important stakeholders)3. Monitor these issues (track stakeholders’ views and positions)4. Forecast trends (project trends in stakeholders’ views and positions)5. Assess their importance (assess the implications of stakeholders’ views and positions)6. Diffuse information (diffuse stakeholder information to those who need it)Reproduced from Managing health services organizations (6th ed., p. 687–688), B. B. Longest,and K. Darr, 2014, Baltimore, MD: Health Professions Press.In the stakeholder analysis, important issues and stakeholders areidentified through the environmental scan. Next, monitoring the activitiesof stakeholders is crucial. Managers must be able to take the views of

stakeholders and use that information to incorporate trends into theirdecision-making process. Finally, managers must evaluate the value of theinformation, and take the information gathered and transmit it to thosewho need the information.Figure 4–7 Grapevine NetworksReproduced from Ginter, P. M., Swayne, L. M., & Duncan, W. J. (1998). Strategic Management of Health Care Organizations,3rd ed. Malden, MA, Blackwell, p. 458.Another way to describe communication with external stakeholders iscalled boundary spanning. Boundary spanning, or external communicationlinks, provides opportunities for organizational learning in areas such asstrategic planning or marketing (Johnson & Chang, 2000). Communicatingwith all external stakeholders is essential; however, each may be viewed forits unique position and benefits to the organization. For instance, ininteractions with the public sector, health care organizations are affected bypublic policies. Government is a major stakeholder because of its legislativeand regulatory powers and as one of the largest purchasers of healthservices. For example, issues such as access to care, cost containment, and

quality concerns have driven federal government debate, reforms, andinvolvement in health care. Thus, health care organizations cannot beinsulated from public policies and must make strategic responses to reflectthe needs of the public sector. A health care organization holds a specialrelationship with the geographical community where the organization islocated. Meeting the particular needs of the community is a primary goal ofhealth care organizations. For effective communication to take place,realistic expectations must be formed by both parties. There are six areas ofresponsibility toward their communities for health care organizations(Longest, Rakich, & Darr, 2000). They include:1. Engaging in the core, health-enhancing activities in the community.2. Providing economic benefits to the community.3. Offering unique benefits or a niche to the community.4. Pursuing philanthropic activities in a broad and generous manner.5. Being in full compliance with legal requirements.6. Meeting ethical and fiduciary obligations.SUMMARYCommunication in the workplace is critical to establishing andmaintaining quality working relationships in organizations. Communicationis the creation or exchange of thoughts, ideas, emotions, and understandingbetween sender(s) and receiver(s). Feedback is information that individualsreceive about their behavior. Feedback can be used to promote moreeffective communication. The Johari Window is a model to improve anindividual’s communication skills through identifying one’s capabilities andlimitations. The channels of communication are the means by whichmessages are transmitted. Verbal communication relies on spoken orwritten words to share information with others. Computer-aidedcommunication, such as electronic mail, has greatly enhanced thecommunication process. Especially in health care, other forms of technology(such as high-speed, high-definition images; telemedicine; and wireless,handheld digital electronic medical records) can be used to bridgecommunication gaps between clinicians and administrators. Nonverbalcommunication is the sharing of information without using words to encodemessages. This includes proxemics, kinesics, facial and eye behavior, andparalanguage.There are two types of barriers to communication: environmental and

personal. Barriers can be overcome by conscious efforts to devote time andattention to communication, reduce hierarchical levels, tailor words andsymbols, reinforce words with action, use multiple channels ofcommunication, and understand one another’s frame of reference andbeliefs.Key elements of effective communication include the desire tocommunicate; understanding how others learn; the intent; the content; thesender’s credibility; and the time frame. Strategic communication is anintentional process of presenting ideas in a clear, concise, and persuasiveway. Five components of strategic communication are outcome, context,messages, tactical reinforcement, and feedback.Intraorganizational communication flows upward, downward,horizontally, and diagonally. Various flows of communication can becombined to form communication networks, such as the chain, Y, wheel,circle, and all-channel. Certain networks work better than others in varyingsituations. A manager’s role is to determine the best network to use forsimple or complex communications. Informal communication results frominterpersonal relationships developed in the workplace. Although informalnetworks can be useful, they can also be misused.Cross-cultural communication can be challenging. Communicationdifficulties arise from differences in cultural values, languages, and points ofview. Organizational personnel must be sensitive and competent in cross-cultural communication. Several techniques and guidelines for improvingcross-cultural communication are provided.Health care organizations must manage relationships with large numbersof external stakeholders made up of individuals, groups, and organizationsthat are interested in the organization’s actions and decisions. Effectivecommunication with external stakeholders involves environmentalassessments to enable managers to identify and make strategic decisions fortheir organizations.DISCUSSION QUESTIONS1. What are the various components of the communication process?2. What are the three forms and four levels of feedback?3. What is the Johari Window? How is it used in communication?4. What is verbal communication? Give an example.5. What are the different types of nonverbal communication?6. What are the appropriate uses of verbal and nonverbal

communication channels?7. What are the two types of barriers to effective communication?8. What methods are available to overcome these barriers?9. What are the elements of effective communication?10. What are the five components of a strategic communication plan?11. What are the different forms of intraorganizational flows ofcommunication?12. What are the various networks available for formal and informalcommunication?13. Why is cross-cultural communication important to today’s healthservices organizations?14. What competencies are needed by managers for communicating withexternal stakeholders?CASE STUDIESCase Study 4–5 Now We Can Finally TalkComfort Zone is a 60-bed, for-profit intermediate care facility in northern California. Therehabilitative department manager, Jamie Richards, has been working at Comfort Zone for only sixmonths. She holds monthly staff meetings, as well as additional individual meetings with staff toaddress specific patient-related issues. On most days, she eats lunch in a quiet corner of thecafeteria so that she can catch up on her paperwork at the same time.Catherine Williams, one of her staff members who has been working at the facility for more than25 years, spotted her in the cafeteria one day and sat down uninvited. Catherine has never attendedany of the monthly meetings and always has an excuse for not attending. Catherine said, “I’ve beenwaiting to tell you this ever since you began working here, but I wanted you to get adjusted first.Now we can finally talk. I have been here for a long time and have seen all kinds of comings andgoings.”Catherine proceeded to tell Jamie about her staff who were constantly tardy or absent. She alsotold Jamie about the things the staff had been doing behind her back, such as using the Internet forpersonal matters, going shopping during lunch hour and coming back late, and going home earlywithout permission. Catherine concluded with, “At your monthly meetings, the staff show up to tellyou that everything’s just fine, when I know differently. I’m too busy working to attend thesemeetings. If you want my opinion, I would fire them all since they are incompetent.”Discussion Questions1. How should Jamie deal with the information that Catherine provided?2. What do you think of Jamie’s methods of communicating with her staff?3. Do you think that she should use a different form of communication with Catherine?Case Study 4–6 It’s Not My Job

In the medical unit of the Northeastern Medical Center, Leah Hernandez is an insurance claimsspecialist who works with one nurse, one certified nursing assistant, and one medicalassistant/receptionist. The physician and administrator are located in a separate building of themedical center. The administrator, Dan Jules, spends three hours a day in the clinic, from 9:00 to10:30 every morning, and 2:00 to 3:30 every afternoon. He never varies the times that he is in theclinic.One morning at 9:00 a.m., Dan was in the clinic with nurse Kate Williams, addressing the concernsof the patient in room 2, when the phone rang. A second phone line rang a few seconds later, and thiswas followed by a third line ringing. The nursing assistant was in room 1 with the physician, and themedical assistant was in room 3 with another patient. The only available staff member to answer thephone was Leah, who was holding on the line with an insurance company. She yelled, “Anybody?Somebody, pick up the phone already! It’s driving me crazy!” Everyone in the clinic, including thepatients, heard her shouting. Nurse Kate rolled her eyes and told Dan that it was like this everyday. Dan excused himself and rushed into the reception area to pick up the phone. Later on, Danasked Leah why she couldn’t pick up the phone. Leah answered, “It’s not my job. I’m too busy withthe insurance company.”Discussion Questions1. What should Dan do to address the problem?2. Should Dan meet with Leah individually or communicate with all staff?3. Because Dan works in a different building, who should have communicated this ongoingproblem to Dan?REFERENCESAdelman, K. (2012). Promoting employee voice and upward communicationin healthcare: The CEO’s influence. Journal of Healthcare Management,57(2), 133–148.Agarwal, R., Sands, D. Z., & Schneider, J. D. (2010). Quantifying theeconomic impact of communication inefficiencies in U.S. hospitals.Journal of Healthcare Management, 55(4), 265–282.Certo, S. C. (1992). Modern management: Quality, ethics, and the globalenvironment (5th ed.). Boston, MA: Allyn and Bacon.Coile, R. C., Jr. (2002). Physician executives explore “New Science” frontier:Bridging the communications gap between medical staff andadministration. Physician Executive, 28(1), 81–83.Daft, R. L., & Lengel, R. H. (1984). Information richness: A new approach tomanagerial behavior and organizational design. In B. Staw & L.Cummings (Eds.), Research in organizational behavior (pp. 191–233).Greenwich, CT: JAI Press.Dunn, R. (2006). Haimann’s healthcare management (8th ed.). Chicago, IL:Health Administration Press.Dutton, G. (1998). One workforce, many languages. Management Review,

87, 42–47.Edgley, G., & Robinson, J. (1991). The dialogue process. AssociationManagement, 43(10), 37–40.Extejt, M. M. (1998). Teaching students to correspond effectivelyelectronically: Tips for using electronic mail properly. BusinessCommunication Quarterly, 61, 57.Fottler, M. D., Blair, J. D., Whitehead, C. J., Laus, M. D., & Savage, G. T.(1989). Assessing key stakeholders: Who matters to hospitals and why?Hospital & Health Services Administration, 34, 530.Ginter, P. M., Swayne, L. M., & Duncan, W. J. (1998). Strategicmanagement of healthcare organizations (3rd ed.). Malden, MA:Blackwell.Guo, K. L. (2003). A study of the skills and roles of senior level healthcaremanagers. Healthcare Manager, 22(2), 152–158.Hellriegel, D., & Slocum, J. W. (2004). Organizational behavior (10th ed.).Mason, OH: South-Western.Heraty, P. (2014). Transparency: How leaders create a culture of candor. InJ. L. Pierce & J. W. Newstrom (Eds.), The manager’s bookshelf: A mosaicof contemporary views (10th ed., pp. 111–115). Upper Saddle River, NJ:Pearson Education.Hicks, J. M. (2011). Leader communication styles and organizational health.Health Care Manager, 30(1), 86–91.Hybels, S., & Weaver II, R. L. (2007). Communicating effectively (8th ed.).Boston, MA: McGraw-Hill Book Company.Institute of Medicine. (2004). Keeping patients safe: Transforming the workenvironment of nurses. Washington, DC: National Academies Press.Johnson, J. D., & Chang, H. J. (2000). Internal and externalcommunication, boundary spanning and innovation adoption: An over-time comparison of three explanations of internal and external innovationcommunication in a new organizational form. Journal of BusinessCommunication, 37(3), 238.Keyton, J. (2002). Communicating in groups: Building relationships foreffective decision making (2nd ed.). Boston, MA: McGraw-Hill BookCompany.Liebler, J. G., & McConnell, C. R. (2008). Management principles for healthprofessionals (5th ed.). Sudbury, MA: Jones and Bartlett Publishers.Longest, B. B., Rakich, J. S., & Darr, K. (2000). Managing health servicesorganizations (4th ed.). Baltimore, MD: Health Professions Press.

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messages through effective lateral communication. CommunicationQuarterly, 50(2): Research Library Core, Q96.Thiederman, S. (1996). Improving communication in a diverse healthcareenvironment. Healthcare Financial Management, 50(11), 72–74.Tubbs, S. L. (2001). A systems approach to small group interaction (7th ed.).Boston, MA: McGraw-Hill Book Company.We wish to acknowledge and thank Dr. Kristina L. Guo, who was a contributing author of theearlier versions of this chapter, which appeared in the previous editions of Organizational Behaviorin Health Care, Jones and Bartlett Publishers.

PART IIUnderstanding Individual Behaviors“What conditions of work, what kinds of work, what kinds ofmanagement, and what kinds of reward or pay will help motivate humans?”(Maslow, in Motivation and Personality, 1954). In Part II, we answer thequestions posed by Maslow with three chapters dedicated to the discussionof motivation.In Chapter 5, we describe and explain four content theories of motivation:(1) Maslow’s Hierarchy of Needs, (2) Alderfer’s ERG Theory, (3) Herzberg’sTwo-Factor Theory, and (4) McClelland’s Three-Needs Theory. Each of thesetheories contains some parts of the others, as they attempt to explain whatmotivates employees.In Chapter 6, we examine five process theories of motivation: (1)Expectancy Theory, (2) Equity Theory, (3) Satisfaction–PerformanceTheory, (4) Goal-Setting Theory, and (5) Reinforcement Theory. AlthoughReinforcement Theory is not usually included with process theories ofmotivation, it does assist managers with understanding whatreinforcements control an individual’s behavior. Process theories containsome components of the content theories and vice versa.In Chapter 7, we examine attribution theory. The discussion of attributiontheory and its relevancy in the workplace provides managers with a betterunderstanding of the highly cognitive and psychological mechanisms thatinfluence individuals’ motivation levels.

CHAPTER 5Content Theories of MotivationLEARNING OUTCOMESAfter completing this chapter, the student should be able to understand: The definition of motivation. The difference between content theories and process theories ofmotivation. Maslow’s Hierarchy of Needs Theory and its criticisms. Alderfer’s ERG Theory. Herzberg’s Two-Factor Theory and how it relates to job design. Hackman and Oldham’s Job Characteristics Model. McClelland’s Three-Needs Theory.OVERVIEWWe will begin by defining motivation before we explore two groups ofmotivation theories—content and process. Motivation is described as theconscious or unconscious stimulus, incentive, or motives for action toward agoal resulting from psychological or social factors, the factors giving thepurpose or direction to behavior (see Figure 5–1). In other words,motivation is the psychological process through which unsatisfied needs orwants lead to drives that are aimed at goals or incentives. The purpose of anindividual’s behavior is to satisfy needs or wants. A need is anything aperson requires or desires. A want is the conscious recognition of a need.The presence of an unsatisfied need or want creates an internal tension,from which an individual seeks relief.In organizational behavior the concept of motivation has been researchedover many years. Through this research, we have identified and categorizedmotivation theories into two groups: (1) content and (2) process.Content theories of motivation (also referred to as needs theories) explainthe specific factors that motivate people. The content approach focuses onthe assumption that individuals are motivated by the desire to satisfy their

inner needs. Content theories answer the question “what drives behavior?”Content theories help managers understand what arouses, energizes, orinitiates employee behavior.Figure 5–1 Process of MotivationProcess theories of motivation (also referred to as cognitive theories) focuson the cognitive processes underlying an individual’s level of motivation.This approach provides a description and analysis of how behavior isenergized, directed, sustained, and stopped. Process theories help explainhow an employee’s behavior is initiated, redirected, and halted.Employee motivation has a direct impact on a health serviceorganization’s performance; therefore, managers need to understand whatmotivates employees. By understanding what motivates employees,managers can assist them in reaching their fullest potential. There are somefactors the manager can control (e.g., extrinsic factors such as salary,working conditions, interpersonal relationships). For the motivating factorsthat are intrinsic to the employee (e.g., need for recognition, achievement),managers can be influential by providing a work environment that allowsemployees the opportunity to satisfy their personal needs and,simultaneously, the organization’s goals.Motivating staff is not about hanging posters with cute sayings in theoffice. Motivating is something managers do by establishing anorganizational structure and environment that provide the opportunity foremployees to satisfy both their intrinsic and extrinsic needs. Remember,motivation is an individual’s voluntary drive to satisfy a need or want!MASLOW’S HIERARCHY OF NEEDS THEORYThe most popular and widely cited human motivation theorist is AbrahamMaslow. Maslow (1954) is considered the father of humanistic psychology.As a brief background, humanistic psychology incorporates aspects of both

behavioral and psychoanalytic psychology. Behaviorists believe that humanbehavior is controlled by external environmental factors, whereaspsychoanalytic psychology is based on the idea that human behavior iscontrolled by internal unconscious forces. Early in his career, Maslowconcluded that human behavior is not controlled only by internal or externalfactors (e.g., needs), but by both, and that some factors have precedenceover others. From this concept, Maslow created his five-tier Hierarchy ofNeeds (see Figure 5–2).According to Maslow, humans have five levels of needs and are driven tofulfill these needs. The most basic needs are physiological, such as the needfor air, water, and food. After the basic physiological needs are achieved, anindividual moves toward satisfying safety and security needs. At this lowerlevel of the hierarchy, individuals are interested in having a home in a safeneighborhood, job security, a retirement plan, and health/medical insurance.Because employees are concerned about satisfying these external or“extrinsic” needs, these motivators need to be addressed by employers, suchas by providing employees with an adequate benefits package.The next three levels in Maslow’s Hierarchy of Needs Theory aresomewhat less tangible and more psychological. The third level in thehierarchy is a desire to be loved, to belong, and to be approved of by others.Humans have a drive to feel needed and loved. Within the workplace,employees seek a sense of community and belonging. As such, they seek theapproval and acceptance of their peers and supervisors. Managers, byhelping staff feel connected to the organization and its mission, can providethis sense of belonging and community.After an individual’s physiological, safety, and belonging needs aresatisfied, the next tier in the hierarchy is self-esteem. Maslow noted twoversions of esteem needs—a lower one (external) and a higher one(internal). External esteem is satisfied by achieving the respect of others,social and professional status, recognition, and appreciation. The higherform of esteem, internal esteem, involves the need for self-respect, a feelingof confidence, achievement, and autonomy. Individuals want to becompetent in what they do, and self-esteem grows when one receivesattention and recognition from others for one’s accomplishments. Therefore,careful use of praise and of positive feedback to staff is an important meansof motivating employees. A pat on the back or other forms of positivefeedback go a long way toward motivating staff to perform. Managersshould also provide employees with opportunities to demonstrate theircompetence. Staff participation in continuing education and other

professional development activities and providing opportunities forchallenging and meaningful work are effective motivators. Theseopportunities allow employees to achieve feelings of self-esteem andaccomplishment.Figure 5–2 Maslow’s Hierarchy of NeedsReproduced from Motivation and personality, by A. H. Maslow, 1954, New York: Harper & Row.Maslow described the preceding four levels (physiological, safety,belonging, and self-esteem) as deficiency needs (D-needs) because if any ofthese motivators are not satisfied, they create an inner tension within the

individual that must be relieved (see Case Study 5–1: Poor Cindy, WhatShould She Do?). However, if an individual has satisfied his or her needs,those needs cease to motivate the individual, and the person moves to thenext level in the hierarchy. Individuals must satisfy their lower-level needs,at least to an acceptable state, before they can be motivated to achieve thehigher levels in the hierarchy.Case Study 5–1 Poor Cindy, What Should She Do?Cindy has been employed by Memorial Health System for the past 25 years, working her way upthe organization’s hierarchy. She started working for the health system as a medical coder afterobtaining her bachelor’s degree. After 10 years, Cindy returned to school to earn an MHSA degree soshe could qualify for management positions. After many years of hard work, she became the system’sdirector of compliance. However, she has recently been hearing rumors that the organization is notdoing well because of the national health reform changes and that layoffs may be announced in thenear future. This is causing Cindy stress and worry; Memorial is the only organization she hasworked for! She has tried to stay focused, but it is extremely difficult for her to do so, especially aftertalking with Harry last week.Harry and Cindy went to school together and have kept in touch over the years since Harry movedto another state to work for a larger health system. Harry told Cindy that he was laid off threemonths earlier and has not been able to even secure an interview with other provider organizationsbecause of the uncertainty in the marketplace due to the reform changes. Harry’s current experiencefurther stressed Cindy as she thought about how this could be her situation soon. She tried to getreassurance from her boss about her job security, but he just seemed to give her the runaround. Dueto her preoccupation with her job security, Cindy’s quality of work began slipping and she becameforgetful of project deadlines. She now spends most of her time worrying and has had to call in sick afew times over the past four weeks due to stomach cramps and headaches.Discuss Cindy’s situation using Maslow’s Hierarchy of Needs.The highest level of need is an individual’s desire to become all that he orshe can be. Although Maslow used a variety of terms to refer to this level, itis most commonly referred to as self-actualization. Self-actualization is thedesire to become more of what we are, and to become everything that one iscapable of becoming. It is referred to as a “being need” (B-need) because it ismotivating without deficiency, as with the D-needs. In Maslow’s view, self-actualization is not an endpoint, but rather an ongoing process that involvesmany growth choices that entail risk and require courage (O’Connor &Yballe, 2007). In addition to describing what is meant by self-actualizationin his theory, Maslow (1970) identified key characteristics of a self-actualized person:• Acceptance and Realism: Self-actualized people have realisticperceptions of themselves, others, and the world around them. Theyeasily accept themselves and others as they are.

• Problem-Centering: Self-actualized individuals are concerned withsolving problems outside of themselves. They often dedicate themselvesto a larger purpose in life based on ethics or a sense of personalresponsibility.• Spontaneity: Self-actualized people are spontaneous, natural, and openin their behavior and thoughts. However, they can easily conform toconventional rules and expectations when situations demand suchbehavior.• Autonomy and Solitude: Although they accept and enjoy other people,self-actualized individuals have a strong need for privacy andindependence. They focus on their own potential and developmentrather than on the opinions of others.• Continued Freshness of Appreciation: Self-actualized people continue toappreciate the simple pleasures of life with awe and wonder.• Peak Experiences: Self-actualized people commonly have peakexperiences, or moments of intense ecstasy, wonder, and awe duringwhich their sense of self is lost or transcended. The self-actualizedperson may feel transformed and strengthened by these peakexperiences.Although progress to self-actualization is often interrupted by failure tomeet lower-level needs due to things such as illness (lack of physiologicalwell-being), loss of job (lack of security), or divorce (lack of sense of beingloved), individuals can learn that satisfying basic needs becomes anintegrated, consciously managed aspect of a whole life and is not compulsiveor dominating of all other concerns. As O’Connor and Yballe (2007, p. 749)point out, “a paradigm shift takes place. An individual becomes a personwho has needs, not a needy person.”Managers need to ask themselves, “How can I motivate my employees?”When answering this question, managers need to be conscious of the factthat all employees are not driven by the same needs, nor is any employeedriven by the same need at the same time. For example, right now as youread this book, you may have several needs operating simultaneously—curiosity, need for new knowledge, thirst, and so forth. Managers need torecognize the needs of each employee, individually. Managers whosimultaneously address each employee’s lower level of needs will benefitfrom workers who are motivated to achieve the higher levels in Maslow’sHierarchy of Needs (see Figure 5–3).

Figure 5–3 How Managers Can Satisfy Employees’ Needs at Different Levels of Maslow’s Hierarchyof Needs

Although Maslow introduced his Hierarchy of Needs Theory more than 60years ago, there have been only a limited number of studies that support histheory, and those published have reported mixed findings (Alderfer, 1972).In fact, some research contradicts Maslow’s specific “ordering” of needs. Forexample, Huizinga, as cited in Griffin (1991), attempted to validate thetheory in the workplace.Because of its scope and different cultural setting, Huizinga’s study is oneof the more ambitious attempts to verify the principles of the hierarchy. Hesurveyed over 600 managers drawn from five industries in the Netherlands.His sample included people from production, personnel, research anddevelopment, finance, and top management. They ranged in age from 20 to65, and their educational backgrounds extended from the Dutch equivalentof grade school to university graduates. Huizinga found that no matter howmany ways he analyzed the data, there was simply no evidence thatworkers had a single dominant need, much less that the need diminished instrength when gratified (Griffin, 1991 p. 131).In addition, Maslow’s needs theory also had difficulty explainingindividuals such as Mother Teresa, who neglected her lower-level needs inpursuit of her spiritual calling to serve the poor in India. Maslow himselfused the example of a starving artist pursuing his creativity needs (e.g.,self-actualization) while ignoring physiological needs. Despite the gap inempirical research to support Maslow’s Hierarchy of Needs Theory, itremains “popular with managers because (1) its core elements are simple topresent, (2) it accords with the values held by many managers, and (3) itdraws a parallel between organizational hierarchies and needs hierarchies”(Dolea & Adams, 2005, p. X).ALDERFER’S ERG THEORYTo address the criticisms of Maslow’s Hierarchy of Needs, in the late1960s, Clayton Alderfer (1972) introduced an alternative needs hierarchy,referred to as the ERG Theory. Alderfer’s hierarchy relates to threeidentified categories of needs: existence, relatedness, and growth (see Table5–1).• Existence refers to an individual’s concern with basic material andphysiological existence requirements, such as food, water, pay, fringebenefits, and working conditions.• Relatedness refers to the need for developing and sustaininginterpersonal relationships such as relations with family, friends,

supervisors, coworkers, subordinates, and other significant groups.• Growth refers to an individual’s intrinsic need to be creative, and tomake useful and productive contributions, including personaldevelopment with opportunities for personal growth.When compared with Maslow’s Hierarchy of Needs, Alderfer’s ERGTheory differs on three points. First, the ERG Theory allows for anindividual to seek satisfaction of higher-level needs before lower-level needsare satisfied. In other words, the ERG Theory does not require an individualto satisfy a lower-level need for a higher-level need to become the driver ofthe person’s behavior. Although the ERG Theory retains the concept of aneeds hierarchy, it does not require a strict ordering, as compared toMaslow.Second, the ERG Theory accounts for differences in need preferencesbetween cultures; therefore, the order of needs can be different for differentpeople. This flexibility allows the ERG Theory to account for a wider rangeof observed behaviors. For example, it can explain Mother Teresa’s behaviorof placing spiritual needs above existence needs.Table 5–1 Alderfer’s ERG TheoryLevel of NeedDefinitionPropertiesGrowthImpel a person to make creative orproductive effects on himself orherself and the environment.Satisfied through a person using his or her capabilitiesfully (and developing additional ones) in problemsolving; creates a greater sense of wholeness andfullness as a human being.RelatednessInvolves relationships with significantother people.Satisfied by mutually sharing their thoughts and feelings;acceptance, confirmation, understanding, and influenceare elements of the relatedness process.ExistenceIncludes all of the various forms ofpsychological and material desires.When divided among people, one person’s gain isanother’s loss when resources are limited.Third, which may be the most important aspect of the ERG Theory, is thefrustration–regression principle. The frustration–regression principleexplains that when a barrier prevents an individual from obtaining ahigher-level need, a person may “regress” to a lower-level need (or viceversa) to achieve satisfaction. For example, a person wants existence-related objects when his or her relatedness needs are not satisfied; a personwants relationships with significant others when growth needs are notbeing met.Managers must recognize that an employee may have multiple needs tosatisfy simultaneously; focusing exclusively on one need will not effectively

motivate an employee. In addition, the frustration–regression principleimpacts workplace motivation. For example, if growth opportunities are notprovided to employees, they may regress to relatedness needs and socializemore with coworkers, or even look to other types of organizations forsatisfaction of this need—for example, a union. If the work environmentdoes not satisfy an employee’s need for social interaction, an increaseddesire for more money or better working conditions may occur. If a manageris able to recognize these conditions, steps can be taken to satisfy theemployee’s frustrated needs until the employee is able to pursue growthagain. (See Case Study 5–2: I Get by with a Little Help from My Friends.)Case Study 5–2 I Get by with a Little Help from My FriendsJennifer Smith, RN, has worked at St. Joe’s Medical Center for the past five years as an operatingroom nurse. She enjoys her work and the interaction it provides with patients, physicians, andespecially her coworkers. In fact, she has developed strong friendships with her coworkers. Almostevery day, they eat lunch together. They have monthly dinner parties at one another’s homes andfrequently go on vacations together. Helen Jones, the director of surgical services, has remarkedabout the cohesiveness of the group and how well they work together, creating a well-functioningteam. However, during the past year, Jennifer has made frequent remarks to her coworkers that shefelt her nursing career was at a stalemate, and that she was getting bored with “doing the samething every day.” Jennifer questioned why she went back to school to earn her MSN degree, whenHelen never gave her an opportunity to apply what she had learned. Jennifer started to think aboutlooking for a new position at a different hospital that would give her the opportunity to growprofessionally. Jennifer’s coworkers empathized with her, and when a vacancy was posted on thehospital’s job bulletin board for an assistant clinical manager position in her department, theyencouraged her to apply. After reviewing the job description, Jennifer agreed that with her clinicalexperience and graduate degree, she was the perfect candidate for the job. She submitted herapplication, fully confident that Helen would offer her the position. Jennifer was very excited andlooked forward to the challenges she would face when promoted.However, when Jennifer was informed by Helen that another staff member with more“management” experience was offered the position, Jennifer could not disguise her disappointment.She wondered what she should do now. Should she quit and seek a new position at a differenthospital? But what about her friends at St. Joe’s?Jennifer’s coworkers knew how upset she was and made special efforts to ease her disappointmentby scheduling more outings together. They told her that other opportunities would come and that,with a little more experience, she would be promoted. Being with her coworkers was like grouptherapy for Jennifer.After a few weeks, Jennifer returned to the level of enjoyment she obtained from her work beforethis episode. In addition, Helen approached Jennifer to discuss her enrolling in a mentorshipprogram that the hospital had recently established. The mentorship program, similar to aninternship, would provide clinical staff with hands-on management experience. Jennifer did nothesitate; she enrolled in the program the following week. Jennifer was confident that she would beready when the next opportunity presented itself.Discuss how Jennifer displayed the frustration–regression principle of Alderfer’s ERG Theory.

HERZBERG’S TWO-FACTOR THEORYFrederick Herzberg developed his Two-Factor Theory, also known as theMotivation–Hygiene Theory, from a study designed to test the concept thatpeople have two sets of needs: (1) avoidance of unpleasantness and (2)personal growth. In Herzberg’s original study (1959), 200 engineers andaccountants were asked about events they had experienced at work, whichhad resulted in either a marked improvement in job satisfaction or amarked reduction in job dissatisfaction. From Herzberg’s research (1966),five factors stood out as strong determiners of job satisfaction (i.e.,motivator factors) and are related to job content: (1) achievement, (2)recognition, (3) work itself, (4) responsibility, and (5) advancement. Thedeterminants of job dissatisfaction (i.e., hygiene factors) that are related tojob context were found to be: (1) company policies, (2) administrativepolicies, (3) supervision, (4) salary, (5) interpersonal relations, and (6)working conditions. It is important to note that Herzberg used the term“hygiene” to describe factors that are necessary to avoid dissatisfaction, butthat by themselves do not provide satisfaction or motivation (see Exhibit 5–1).Herzberg’s research findings are significant to managers because thefactors involved in producing job satisfaction are separate and distinct fromthe factors that lead to job dissatisfaction. As illustrated in Exhibit 5–1,these two factors are not opposites of each other. As Herzberg pointed out,the opposite of job satisfaction is not job dissatisfaction, but rather no jobsatisfaction; similarly, the opposite of job dissatisfaction is no jobdissatisfaction, not satisfaction with one’s job.In a practical sense, this means that dissatisfiers, referred to as hygienefactors, support and maintain the structure of the job (job context), whilethe satisfiers, referred to as motivators, assist employees with increasingtheir motivation to do their work (job content). Unfortunately, Timmreck’s(2001) study of 99 health service midmanagers found that only a minorityactually believed in and used motivators to stimulate subordinates’behavior.Exhibit 5–1 Job Satisfaction

One of the criticisms of Herzberg’s Two-Factor Theory is that a singlefactor may be a motivator for one person, but cause job dissatisfaction foranother. As an example, increased responsibility may be welcomed by oneemployee, but avoided by another. Another criticism has been Herzberg’splacement of salary/pay in the dissatisfier category, which has caused someto believe that Herzberg did not value money as a motivator. However,what Herzberg meant was that if pay did not meet expectations, employeeswere dissatisfied, but if pay met employees’ expectations, salary was not aneed to achieve satisfaction. This view is reititerated in Daniel Pink’s (2011)book Drive: The Surprising Truth About What Motivates Us. He refers to anemployee’s salary as a “baseline reward.” If this baseline reward is notadequate, then employees will focus on the inadequacy of theirremuneration, which will lead to anxiety about their financialcircumstances, resulting in very little motivation. Herzberg believed thatthe absence of good hygiene factors, including money, would lead todissatisfaction and thus potentially block any attempt to motivate theworker (see Exhibit 5–2).

Exhibit 5–2 Stop Demotivating, Before You Start MotivatingWhen people think about motivating employees, they’re usually thinking about ways to rewardthem. What carrots can be offered to get employees to work harder; what can we dangle in frontof them to encourage them to take the actions we desire? There are entire books written on waysto reward our employees, and multimillion-dollar consulting engagements built on those books.They include issues big and small, like money, pay-for-performance plans, flexible shifts, thank-you notes, gift cards, extra days off, promotions, educational opportunities, public recognition,and private pats on the back.Although rewarding employees is important, it misses a hugely important point. If someone ishitting your foot with a hammer, you can’t stop the pain with a backrub. This is an odd bit of folkwisdom, but here’s the lesson. In one of our recent studies, 76 percent of employees said that inthe past 12 months, their managers had done things that made them want to quit. And 89 percentof employees said that their organization had done something that made them want to quit.Every day, employees face various demotivators, things that cause them to lose their passionfor their jobs and even cause them to consider quitting. And before we can try to “motivate” them,we’ve got to stop “demotivating” them. To make this concept a little easier, instead of talkingabout demotivators and motivators, we’re going to talk about Shoves and Tugs. Shoves are thoseissues that cause people to lose their passion, enthusiasm, and even consider quitting. Tugs arethose issues that get people excited, ignite their passion, and make them committed to stayingwith an organization or boss.This tends to be a radical concept for most leaders, so let’s walk through an example.Pat is a nurse at a major teaching hospital. She’s worked there for eight years and thinks it’s agreat place to work. She loves doing research, and this organization has hundreds of ongoingstudies in which she can participate, and even publish. Her major Tug is doing intellectuallychallenging work with really smart people. But two weeks ago, the hospital instituted flexiblework schedules and changed all the shifts. This is causing Pat serious difficulty because she hadtimed her kids’ schedules around her old shift start/end times, and this change disruptseverything. For Pat, this scheduling change is a Shove.Now, here’s the radical part. Before Pat’s manager can address her Tugs, they will have to fixher Shoves. When you see Pat’s issues described separately as Shoves and Tugs, it becomespretty clear that she’s going to be much less excited about the opportunity to publish as long asher schedule is causing her problems. But because most leaders don’t initially separate Shovesand Tugs into two distinct issues, the typical leader will ignore the scheduling issue and just tryto give Pat more research work. Or try to buy her compliance with money.Shoves are often focused on basic issues like working conditions, schedules, compensation, anacceptable relationship with the boss, and so on. Tugs often encompass higher-order issues likeenjoying the work, career advancement, working with interesting people, organizational culture,and so on.If we had only asked Pat what excited her about her job, what really made her love thishospital, we’d have gotten an answer about doing intellectually stimulating work. And if we hadonly asked Pat what could make her life sufficiently miserable to cause her resignation, we’dhave gotten an answer about her schedule and her outside-of-work obligations. It’s only when weask about both issues that we get the complete picture.When you’re working with low performers, when you’re working terrible hours, or you’ve got aterrible working environment, you could be so frustrated that you feel like you’re being Shovedout the door. You could feel so frustrated that you no longer notice all of the other good thingsabout your job that Tug at you to stay—the autonomy, the ability to have control over an entireprocess, the ability to work on innovative projects and teams. If your organization is like theorganizations in our studies, as much as 35 percent of your workforce could feel this way. Andthese people are huge retention risks.

On the other hand, you could have a working environment that is free from Shoves, but alsolacking in any significant Tugs. You’re not being Shoved out the door by frustration, but neitherare you being Tugged to remain at the company. And once again, if yours is anything like theorganizations in our studies, as much as 50 percent of your workforce could feel this way. Thegood news is that these people probably aren’t spending their days on Monster.com activelyapplying for jobs. The bad news is that if the economy changes, or one of your competitors makesa play for them, or they just happen across another opportunity, they will leave.To get someone really truly committed to your organization, you must first eliminate anyShoves and fulfill at least some Tugs. In essence, you’ve got to meet their basic needs and affordsome opportunity to address their higher-order needs.Reproduced from Murphy, M. (2008). Stop Demotivating, Before You Start Motivating.Leadership IQ, available at: https://www.leadershipiq.com/stop-demotivating-before-you-start-motivatingDent (2002) relates that when Herzberg first presented his work it wasvery controversial in the academic community, but very popular in industrybecause it helped to answer employers’ questions as to “why doesn’t thelevel of an employee’s productivity equate to the compensation received bytheir workers?”In the late 1950s, the U.S. economy was in a tremendous economicupswing. The issue of motivation was critical for retaining good people, whooften had several other opportunities. The primary advice coming fromindustrial psychologists was to motivate through compensation packages. Asa result, employers were paying higher and higher salaries, but felt thatthey were not getting higher amounts of performance. Herzberg’s workvalidated what the employers were feeling. Herzberg suggested that higherperformance levels would come not from higher salaries but by givingemployees the opportunity to create and impact their environments (Dent,2002, p. 276).Although managers need to provide employees with a reasonable salary, adegree of job security, and safe and comfortable working conditions (hygienefactors), focusing on these matters will not contribute to an employee’smotivation or performance improvement (Sashkin, 1996). Herzbergpromoted the concept that if the work one does is significant, it willultimately lead to satisfaction with the work itself. In other words,employees will be motivated to do work that they perceive to be significant(see Case Study 5–3: Why Don’t I Just Quit!).Case Study 5–3 Why Don’t I Just Quit!Robin Williams sat at her desk, going through her mail, and asked herself the same question she

had asked herself a hundred times before: “Why don’t I just quit!” Robin thought to herself, “I don’tneed this job; I have enough money in my savings account to last a year, and with my degree andexperience, I could go anywhere.” Robin graduated from one of the top schools in the country with anMSW and has been a social worker for the Alpine Medical Center for the past four years. Althoughshe loves her interaction with her clients, with the ability and freedom to help them through the“system” satisfying all their social and medical needs, she is unhappy with the required 60-hourwork week, for a salary far less than what her friends who graduate with an AS/Nursing are earning.In addition, Robin believes her boss is trying to set her up to be fired just because she told him thathe was an incompetent administrator. “Well, he is,” thought Robin. He hasn’t been able to find themoney in the department budget to purchase a new computer that she desperately needs to help herclients. To make matters worse, her coworkers, who “live in their own worlds,” never extend thecourtesy of asking her to join them for lunch. “Not that I would go with them,” Robin thought. “Theyare just as useless as the director; and didn’t they forget yesterday was my birthday?!”As she thought the issues over in her mind, she opened a thank-you letter from a client she helpedlast month. He just wanted to tell her how much he appreciated her help through his illness and tellher that without her assistance, he would not have known all the community services available tohim so he could remain at home versus being admitted into a nursing home.Robin smiled and put the card aside; she was still trying to figure out why she didn’t quit her job.She wished she knew the answer.Using Herzberg’s Two-Factor Theory, discuss why Robin has not resigned from her position.Building on this concept, jobs should be designed with special attention foropportunities relating to achievement, responsibility, meaningfulness, andrecognition. Pink (2011) relates that organizations need to focus onindividuals’ intrinsic needs for autonomy (providing employees with thecontrol over some or all of their work), mastery (allowing employees tobecome better at something that matters to them), and purpose (fulfilingemployees’ natural desire to contribute to a cause greater and moreenduring than themselves).According to Herzberg, motivation comes from job content. Therefore, it isimportant for managers to consider the nature of the jobs they ask theiremployees to do. Herzberg’s approach can be summarized by “if you wantpeople to do a good job for you, then you must give them a good job to do.”Managers need to be concerned with job-design characteristics, including jobenrichment. Job enrichment is the vertical expansion of the job as opposedto a horizontal expansion (job enlargement) (see Table 5–2).JOB DESIGNJob-design research in the past three decades has generated manyinsights into the relationship between job characteristics and jobsatisfaction. The well-known and widely researched Job CharacteristicsModel was developed by Hackman and Oldham (1976, 1980) (see Figure 5–4).

Hackman and Oldham (1980) listed five core motivational jobcharacteristics:• Skill Variety: The degree to which a job requires a variety of differentactivities in carrying out the work, involving the use of a number ofdifferent skills and talents of the person.• Task Identity: The degree to which a job requires completion of a“whole” and identifiable piece of work—that is, doing a job frombeginning to end with a visible outcome.• Task Significance: The degree to which the job has a substantial impacton the lives of other people, whether those people are in the immediateorganization or in the world at large.Table 5–2 Herzberg’s Principles of Vertical Job LoadingPrincipleMotivators InvolvedRemoving some controls while retaining accountabilityResponsibility and personalachievementIncreasing the accountability of individuals for own workResponsibility and recognitionGiving a person a complete natural unit of work (module, division, area, and soon)Responsibility, achievement, andrecognitionGranting additional authority to an employee in his or her activity; job freedomResponsibility, achievement, andrecognitionMaking periodic reports directly available to the worker himself or herself ratherthan to the supervisorInternal recognitionIntroducing new and more difficult tasks not previously handledGrowth and learningAssigning individuals specific or specialized tasks, enabling them to becomeexpertsResponsibility, growth, andachievementReproduced from: One more time: How do you motivate employees? by F. Herzberg, Harvard BusinessReview, 81(1), p. 93, 1983.• Autonomy: The degree to which the job provides substantial freedom,independence, and discretion to the individual in scheduling the workand in determining the procedures to be used in carrying it out.• Feedback: The degree to which the work activities required by the jobprovide the individual with direct and clear information about theeffectiveness of his or her performance (pp. 78–80).As reflected in Figure 5–4, each core job characteristic, or combination offactors, leads to critical psychological states for an employee. Hackman andOldham (1980) relate that the combination of skill variety, task identity,and task significance leads to the psychological state of experiencedmeaningfulness, where the worker perceives that the job is significant.

Autonomy leads to the psychological state of experienced responsibility foroutcomes (i.e., the employee feels individual responsibility for the work),and feedback leads to the psychological state of knowledge of the actualresults of work activities. These critical psychological states lead to anemployee’s high levels of internal motivation, growth and job satisfaction,and work effectiveness (quality and quantity).Using the moderators in the Job Characteristics Model, Hackman andOldham (1980, pp. 82–88) attempted to explain why some employees “takeoff” on jobs that are high in motivating potential and others are “turned off.”The first moderator is knowledge and skills. If people have sufficientknowledge and skills to perform their job well, they will experience positivefeelings as a result of their work activities. However, people who are notcompetent to perform their tasks well will experience unhappiness andfrustration at work.

Figure 5–4 The Job Characteristics Model of Work MotivationSource: Work redesign (p. 90), by J. R. Hackman and G. R. Oldham, 1980, Reading, MA: Addison-Wesley.The second moderator is growth-needs strength. Some people have strongneeds for personal accomplishment, for learning, and for developingthemselves beyond where they currently are. These people are said to havestrong “growth needs.” Others have less strong needs for growth or personalaccomplishment. Therefore, individuals with strong growth needs respondpositively to the opportunities provided by enriched work. However,individuals with low growth needs may not recognize the existence of

enriching opportunities, or may not value them, or may find themthreatening and complain about being pushed or stretched too far at work.The third moderator is satisfaction with the work context. Employees whoare relatively satisfied with their job context (pay, job security, coworkers,etc.) will respond more positively to enriched and challenging jobs thanemployees who are dissatisfied with their job context.Managers need to pay close attention to the moderators. If an employee isfully competent to carry out the work required by a complex, challengingtask, and has strong needs for personal growth and is well satisfied with thework context, then the manager should expect the employee to exhibit highpersonal satisfaction and high work motivation and performance. If anemployee lacks any of these moderators, the opposite results would occur.To assist managers in designing jobs that will increase motivation foremployees, Hackman and Oldham (1975) developed the Job DiagnosticSurvey (JDS). The JDS measures the degree to which the various jobcharacteristics are included in the job. The job characteristics can then bealtered to enrich the job and increase its motivational potential (Lunenburg,2011). The JDS generates a summary score reflecting the overall“motivating potential” of a job in terms of the core job dimensions(Hackman and Oldham, 1975). The MPS is calculated as follows:The core job characteristics of skill variety, task identity, and tasksignificance are combined and divided by three, whereas the jobcharacteristics of autonomy and feedback stand alone. Because of theadditive and multiplicative relationships of the job characteristics in theMPS formula, one or more of skill variety, task identity, and tasksignificance could be missing or measured as zero, and the employee couldstill experience meaningfulness of the work. However, if either autonomy orfeedback were missing, the job would offer no motivating potential (MPS =0) because of the multiplier effect (Lunenburg, 2011, p. 5).In a recent study, Grant, Fried, and Juillerat (2010) found that jobredesign for bank tellers increased both job performance and job satisfactionwith positive effects lasting up to four years. Grant and his colleagues’ worksupports that careful job redesign that increases performance andsatisfaction is an important factor not only for employees but fororganizations as well. Grant’s research was conducted at a large bankwhere managers, using a research survey, found that bank tellers were very

dissatisfied with their jobs, stating that they were “just glorified clerks”—micromanaged with boring jobs and no decision-making responsibilities. Thebank managers decided to redesign the teller jobs. New tasks were added toprovide variety requiring a broad range of skills. The tellers were also givenmore autonomy in their roles as well as decision-making responsibilities.Job satisfaction increased, and when a survey was administered six monthslater, it showed that not only were the tellers more satisfied with theirroles, but they were also more committed to the organization (Grant, Fried,& Juillerat, 2010).MCCLELLAND’S THREE-NEEDS THEORYDavid McClelland (1985) experimented with individuals’ responses topictures of various groups of persons gathered together. On the basis of theparticipants’ responses, McClelland identified three types of motivationalneeds: achievement, power, and affiliation.• Achievement (n-Ach) is described as the need to excel or succeed. Ingeneral, high achievers tend to seek moderately challenging tasks, takepersonal responsibility for their performance, and require feedback toconfirm their successes.• Power (n-Pow) is described as an individual’s need to influence others.This can be positive or negative, as we will discuss later.• Affiliation (n-Aff) is described as an individual’s need to be liked andapproved of by others. As such, n-Aff people have a strong need forinterpersonal relationships.McClelland (1985) believed that most persons have a combination of thesemotivational needs, with some exhibiting a stronger tendency to oneparticular motivational need (e.g., a high power need versus a highachievement need). This tendency affects a person’s behavior andmanagement style. For example, McClelland suggested that a highaffiliation need weakens a manager’s objectivity and decision-makingcapability, because of the need to be liked by his or her subordinates,colleagues, and supervisors. Although persons with high power needs areattracted to leadership roles, they may not have the required flexibility andhuman relations skills necessary to be effective. McClelland argues thatpersons with strong achievement needs make the best leaders, althoughthey can have a tendency to demand too much of their staff in the beliefthat they are all similarly and highly focused on achievement (i.e., results

driven). One interesting aspect of McClelland’s theory is that individualscan learn or acquire a need for achievement by being associated withsuccess and failure in the past (and the effect that accompanies success andfailure).AchievementA significant part of McClelland’s research focused on the achievementmotivational need (n-Ach). Through his research, McClelland concluded thatwhile most persons do not possess a strong n-Ach motivation, those who dodisplay a consistent behavior of moderate risk-taking. To support his theory,McClelland (1985) performed the now famous ring-toss experiment.Participants played a ring-toss game where the subjects determined howclose or far away they would stand from the peg. One group of participantsstood very close to the peg to ensure they would never miss. Another groupstood so far away that if they actually did place the ring on the peg, it wasdue to chance, not ability. The third group calculated their distance from thepeg. They didn’t stand too far away to make the task impossible, nor didthey stand too close to make it too easy. If they missed the first toss, theywould move closer; if they made the toss, they would take a step back forthe next toss. McClelland referred to the third group as moderate risk-takers—individuals who desired a challenge, but whose success was basedon their abilities, not chance, as with the second group.McClelland (1961) relates that n-Ach persons have various attributes.First, n-Ach persons are not high risk-takers as compared to a gambler whohas no control over the outcomes. High achievers are moderate risk-takers.Achievement-motivated individuals set difficult goals, but goals they believeto be achievable through their efforts and abilities. High achievers workharder and more efficiently when the task is challenging and requirescreativity, such as designing new systems or just a better way of doingthings. Second, n-Ach persons view goal achievement as their reward andrequire feedback that is quantifiable and factual. As such, they equate moremoney and/or higher profits as the measurement or feedback of theirsuccess. Job security is not an important issue for n-Ach people. They preferoccupations that allow them the flexibility and the opportunity to set theirown goals, such as in sales, business, or entrepreneurial roles. Althoughhigh achievers can work in groups, they receive their satisfaction byknowing that they initiated an action that contributed to the group’ssuccess.McClelland (1961) believed that n-Ach persons are the ones who make

things happen and get results in an organization. They are successful inobtaining the resources, including employee “buy-in” to achieveorganizational goals. However, high achievers may be viewed as demandingof staff and insensitive to the needs of others, because of their results-drivenattitude.PowerMcClelland (1985) relates that a high need for power may be expressed aspersonalized power or socialized power. Those with a high need forpersonalized power have tendencies to display impulsive aggressive actions,abuse alcohol, and collect prestige “toys” such as fancy cars. They seek tocontrol others for their own benefit. Their attitude is “I win, you lose.”Individuals with a high need for personalized power demand personalloyalty from staff versus loyalty to the organization. Yukl (2001) points outthat when a high personalized power leader leaves an organization, itusually results in chaos, loss of direction, and low morale.Socialized power need is associated with effective leadership. Theseleaders direct their power in ways that benefit others and the organizationversus their own personal gain. As McClelland (1985) and Yukl (2001)relate, they are more interested in seeking power because it is throughpower that they can influence others to accomplish tasks. They empowerothers who use that power to enact and further the leader’s vision for theorganization.AffiliationIndividuals with a high need for affiliation seek to be with and interactwith others. McClelland (1985) relates that they are concerned withestablishing, maintaining, or restoring positive relationships with others.High affiliation individuals want to please others and engage in moredialogue with others. Individuals are very important to persons in n-Aff.They prefer friends over experts when working in groups (n-Ach preferexperts over friends as working partners), and prefer feedback on how wellthe group is getting along rather than how well they are performing on thetask. They avoid conflict and criticism, and have a fear of rejection byothers. As such, individuals with a high need for affiliation do not makegood managers (see Case Study 5–4: The Office Manager’s Dilemma).Case Study 5–4 The Office Manager’s Dilemma

When Karen Lewis was promoted to office manager for Dr. Green’s orthopedic practice, she wasthrilled. She had worked for Dr. Green for almost six years and considered it her home away fromhome and her coworkers as her extended family. Karen was the office organizer for picnics, Fridaynight get-togethers, and holiday parties. She always made sure that staff ‘s birthdays andanniversaries were recognized and celebrated. She was very concerned that everyone was happy andwas always available to help other coworkers with any problems.In addition, Karen was competent in all areas of the office operations. Although originally hired asan X-ray technician, she had performed, at one time or another, the duties of all the positions withinthe practice. She had covered the receptionist, medical records, and billing staff ’s positions whenthey were on vacation or ill, or when there was an unfilled vacancy. Not only was she responsible forrunning the X-ray area of the practice, but also over the years she had assumed the responsibilitiesfor ordering supplies and scheduling surgeries.Karen thought making the transition to office manager would be easy. The first few months wentwell. But in her fourth month, other staff members came to her complaining about Suzie, the newappointment-scheduling clerk. Karen was surprised to hear that Suzie was not doing her job welland that her errors were affecting the entire office operations. Suzie was scheduling patients tocome to the office when Dr. Green was at the hospital performing surgery, and during the staff’slunch periods. In addition, she was overscheduling, causing patients to wait for hours. Karen toldthe office staff that she would discuss the matter with Suzie as soon as possible.However, Karen found it very difficult to schedule a meeting with Suzie to discuss the problems.Every time Karen approached Suzie about the subject, she found that her stomach tightened and shebegan to sweat. The best she could do was to ask Suzie, “How is everything going?” Suzie replied,“Everything is great and I love working in such a warm and friendly office.”A week later, the staff approached Karen again and asked if she had spoken with Suzie becausethe problems were getting worse. Karen lied and said that last week was so busy, she did not get anopportunity but that she would talk with Suzie this week. Again, Karen found it difficult to discussthe matter with Suzie. She didn’t want to hurt Suzie’s feelings because Suzie thought she was doing agood job. However, if she didn’t speak with Suzie soon, Karen knew Dr. Green would start toquestion whether she was capable of handling the duties of the office manager position. She couldn’tbear to think that she let Dr. Green down and that he might be displeased with her work. Inaddition, there were rumors circulating through the office grapevine that if the “appointment-scheduling” problem was not fixed soon, a few staff members were thinking about quitting becausethe mistakes caused their workload to increase 20 percent.Karen decided that she would discuss the matter with Suzie the following day. Karen asked Suzieto come in 10 minutes before office hours started so they could have a chat. Karen had a restlessnight’s sleep. When she awoke, she noticed that she had developed a rash over her entire body! Shehad no choice; she called the answering service to tell Dr. Green and the staff that she was too ill tocome to work.Using McClelland’s Three-Needs Theory, discuss if Dr. Green made the right decision promotingKaren Lewis to office manager. Why?SUMMARYWhen a comparison is made of the content theories of motivation, thereare noted similarities (see Table 5–3). Each theory describes an individual’svarious needs in similar terms. Herzberg’s hygiene factors parallel Maslow’sphysiological, security, and belongingness needs, and Alderfer’s existenceand relatedness needs. Maslow’s self-esteem and self-actualization needs are

similar to Herzberg’s motivators and Alderfer’s growth requirement.McClelland’s achievement is closely related to Herzberg’s motivators, andhis power and affiliation can be related to Alderfer’s relatedness needsbecause of an individual’s need to influence (power) or satisfy a need forwarm feelings (affiliation) (Alderfer, 1972). It is clear that Maslow’sHierarchy of Needs Theory has had a great influence on the study oforganizational behavior and continues to do so after 60 years (Latham &Pinder, 2005).Table 5–3 Comparisons of Content Theories of MotivationDISCUSSION QUESTIONS1. Define motivation.2. Explain the connection of the five tiers of Maslow’s Hierarchy ofNeeds to the workplace.3. Discuss how Alderfer’s ERG Theory satisfied the criticisms ofMaslow’s Hierarchy of Needs.4. Explain Herzberg’s Two-Factor Theory as it relates to job design.5. Explain the various components of Hackman and Oldham’s JobCharacteristics Model.6. Discuss McClelland’s Three-Needs Theory as it relates to a manager’ssuccess in the workplace.7. Discuss the relationship between the various content theories ofmotivation.CASE STUDIES AND EXERCISE

Case Study 5–5 All in a Day’s WorkSarah Goodman, senior manager of network development for Holy Managed Care Company,looked over her calendar for the day and sighed deeply. It seemed as if there would be no time at allto work on the project she’d been putting off for most of the week. Circumstances seemed to be suchthat she simply didn’t have any control over her own time anymore.Well, first things first, she determined. At 9:00 she was due at a meeting of senior managers whowere involved in trying to devise a strategy for counteracting a threatened unionization drive by thecompany’s nonexempt employees. As Sarah thought about the people working for her, she began towonder exactly what they wanted. They had a pleasant working space, good benefits package, andsecure employment. She heard the laughter and chatter drifting into her office as people came intowork and thought what a pleasant and congenial group they were. What more could they want?Then at 10:30 there was another meeting. This one could be very exciting! In six months Sarah’soffice was scheduled to be moved to a new industrial park on the west side of town. The plans she’dseen so far had all kinds of great perks for employees: on-site day-care center, fitness center, ampleparking, great facilities for training. The company was certainly spending a lot of money on this newsite. Sarah certainly hoped it would help increase productivity; it certainly would make theemployees happier and make recruitment easier.She’d have to hurry to her lunch meeting with the adviser for the MHA program at Saint ThomasUniversity. Sarah had decided as a part of her New Year’s resolution that she was finally going tobegin her graduate degree. She felt she was simply stagnating in her job and, after looking around atpositions in her company that looked interesting, she realized she needed a graduate degree if shewere going to progress. The only problem was that she wasn’t sure how enthusiastic Richard, herhusband, would be about the whole idea. And her mother certainly wouldn’t be happy! The hintsabout grandchildren had become an outright discussion over the holidays.Discuss the various motivation theories reflected in this case study.Reproduced from Pidge Diehl, EdD.Case Study 5–6 Develop a Motivation PlanJane Couch is the director of nursing for a 400-bed nonprofit hospital in the Southwest. SusanSmith joined the hospital as a staff nurse three years ago after relocating from the northeast. She is30 years old and has been a staff nurse since graduating from a two-year college nursing program 10years ago. She is married to a lawyer, and they have two children, ages 6 and 8.The hospital’s inpatient census has been extremely high because of another hospital’s closing. Thetension on the nursing floors has been running pretty high because of time pressures to dischargepatients early, lack of professional staff, and an upcoming accreditation visit from The JointCommission. Because of time restraints, Jane was unable to complete the staff’s annual performanceevaluations. However, all nurses received a 5 percent pay increase. With this increase, the hospitalstaff is now the highest paid as compared with other hospitals within the region. Jane believes thehigher pay compensates the nursing staff for their increased workload and related stress levels.Until recently, Jane had been pleased with Susan’s performance. Susan had demonstrated herwillingness to work hard and had made very few, if any, patient-care errors. However, over the pastthree months, Jane has noticed that Susan is not performing at her same productivity level andappears to argue frequently with the treating physicians and other nurses about the patients’treatment plans. Jane frequently hears Susan complaining that “no one listens to me,” “no one wantsto hear my opinion,” and “they don’t pay me enough to do this job.”Susan was once a highly motivated, productive member of the nursing staff. Jane understands that

everyone is experiencing more stress than usual because of the increased workload, but what can bedone to motivate Susan to her prior “self”?Within the principles of the content theories of Maslow, Herzberg, and Alderfer, explain to thedirector of nursing why Susan is behaving the way she has over the past three months.Case Study 5–7 Employees’ Motivation NeedsAlthough cash bonuses can improve physician executive job performance, money isn’t too helpfulwhen it comes to improving job satisfaction, a recent survey found.According to the survey of physician executives, personal growth, personal development, life/workbalance, effective communications, and personal relationships are the true keys to improvingsatisfaction. The informal survey questioned 104 physician leaders and included CEOs, vicepresidents of medical affairs, medical directors, department chairs, and consultants. It examinedboth individual and organizational views of job satisfaction. When asked to describe successfulmethods of improving job satisfaction for their staff:• 46 percent of respondents described improving communications and personal relationships.• 9 percent mentioned improving leadership quality.• Only 3 percent of respondents stated that bonuses successfully could be used to improvesatisfaction at the staff level.When it comes to dealing with staff, “listen to them and treat them with respect,” one surveyrespondent said. “Give them credit for their help and ideas whenever there is an opportunity,especially in front of my bosses or in a large group. Ask them what they need to do their job betterand then try to give it to them. If we can’t give it to them, be honest and ask for other suggestions.”Another participant said more money is certainly not the answer. “Added pay for addedresponsibility does not work if they really did not want the responsibility in the first place.”Using Herzberg’s Two-Factor Theory, explain the informal survey’s results regarding employees’motivation needs.Reproduced from Matheny, G. L. (2008). Money not key to happiness, survey finds. PhysicianExecutive, 34(6), 14–15.Case Study 5–8 We Only Wanted to “Scare” Management into Making Changes!A small group of nurses, employed at a large community hospital, were unhappy about their workenvironment and would meet daily during lunch to discuss the situation. There had been a recentchange in the hospital’s senior management, which caused a high level of uncertainty and anxietyamong the nursing staff. The nurses felt overworked. They were being asked to forgo their breaktimes, work overtime, and take extra on-call work because of the hospital’s hiring freeze (whichincluded nursing positions) and the high daily occupancy rate with sicker patients. Their wages andbenefits had been stagnant, with no salary increases for the past two years; and the cost of living intheir community had increased by 10 percent during this period. They felt that they were fallingbehind economically. In fact, a few nurses complained that they could no longer afford to send theirchildren to private schools.The nurses saw the situation as management requiring them to do more work with fewerresources, with no appreciation or recognition of their efforts. Due to recent layoffs of support staff,each day the nurses lost precious time caring for their patients due to hunting for neededmedications and supplies. They felt that these “hunting and gathering” activities threatened patient

safety because it kept the nurses away from the bedside. They also had enough of the physicians’verbal abuse and disruptive behaviors. Whenever the nurses approached management with theirconcerns, they perceived them as falling on deaf ears since no changes were made.Feeling like they had no other choice, the nurses contacted a labor union. The labor union beganan organizing effort in the hospital shortly thereafter, holding an aggressive campaign over a six-week period. There was tremendous peer pressure, as some of the well-respected nursing staffbecame active leaders for unionization, although they were not part of the initial group of nurseswho had first contacted the union. The election was held, and the union was voted in by two-thirds ofthe nursing staff. In the weeks that followed, the original group of nurses remarked that they weresurprised by the union’s victory; they had only wanted to “scare” management into making changesto their work environment.1. Using Maslow’s Hierarchy of Needs, diagram the nurses’ issues within each level.2. Explain why the nurses were motivated to contact the labor union using Herzberg’s Two-FactorTheory.Exercise 5–1 Job SurveyIntroductionObjective: To learn how job design affects performance.Time: About 25 minutes.Instructions: Take the survey below. Once you have completed it, total your scores. Compareyour final score with others in the class and discuss the following questions:• Normally, persons who are in a position of leadership will have scores that are higher thantheir workers’. Why is this?• If your employees were to take this survey today, what do you think their average scoreswould be?• Discuss Hackman and Oldham’s five dimensions and how they help to motivate a job holder.Ask for a few examples of how a job could be redesigned under each of the five dimensions.Job Design QuestionnaireDirections: Listed below are some statements about your job. For each statement, write in yourresponse based on how much you agree or disagree with it.My job:1. Provides much variety.______2. Allows me the opportunity to complete the work I start.______3. Is one that may affect a lot of other people by how well the work is performed.______4. Lets me be left on my own to do my own work.______5. Provides feedback on how well I am performing as I am working.______6. Provides me with a variety of work.______7. Is arranged so that I have a chance to do the job from beginning to end.______

8. Is relatively significant in the organization.______9. Provides the opportunity for independent thought and action.______10. Provides me with the opportunity to find out how well I am doing.______11. Gives me the opportunity to do a number of different things.______12. Is arranged so that I may see projects through to their completion.______13. Is very significant in the broader scheme of things.______14. Gives me considerable opportunity for independence and freedom in how I do mywork.______15. Provides me with the feeling that I know whether I am performing well or poorly.______SUMMARYScoring for Job Design QuestionnaireThe survey is designed to analyze five dimensions of the job:• Skill Variety: Total the scores for questions 1, 6, 11• Task Identity: Total the scores for questions 2, 7, 12• Task Significance: Total the scores for questions 3, 8, 13• Autonomy: Total the scores for questions 4, 9, 14• Feedback About Results: Total the scores for questions 5, 10, 15The lower scoring dimensions (normally, anything below 15) should be investigated to seewhether the job environment can be improved.About the SurveyHackman and Oldham’s Five Dimensions of Motivating Potential• Skill Variety: The degree to which a job requires a variety of challenging skills and abilities.• Task Identity: The degree to which a job requires completion of a whole and identifiable pieceof work.• Task Significance: The degree to which the job has a perceivable impact on the lives of others,either within the organization or in the world at large.• Autonomy: The degree to which the job gives the worker freedom and independence inscheduling work and determining how the work will be carried out.• Feedback: The degree to which the worker gets information about the effectiveness of his orher efforts, either directly from the work itself or from others.© Donald Clark, created March 18, 2000, last update August 28, 2010. Available at:www.nwlink.com/~donclark/leader/jobsurvey.html.REFERENCESAlderfer, C. (1972). Existence, relatedness, and growth. New York, NY: FreePress.Dent, E. B. (2002). The messy history of OB&D: How three strands came tobe seen as one rope. Management Decision, 40(3), 266–280.Dolea, C., & Adams, O. (2005). Motivation of health care workers: Review of

theories and empirical evidence. Cahiers de Sociologie et de DémographieMédicales, 45(1), 135–161.Grant, A. M., Fried, Y., & Juillerat, T. (2010). Work matters: Job design inclassic and contemporary perspectives. In S. Zedeck (Ed.), APA handbookof industrial and organizational psychology (Vol. 1, pp. 417–453).Washington, DC: American Psychological Association.Griffin, E. (1991). A first look at communication theory. New York, NY:McGraw-Hill Book Company.Hackman, J. R., & Oldham, G. R. (1975). Development of the job diagnosticsurvey. Journal of Applied Psychology, 60(2), 159–170.Hackman, J. R., & Oldham, G. R. (1976). Motivation through the design ofwork: Test of a theory. Organizational Behavior and HumanPerformance, 16, 250–279.Hackman, J. R., & Oldham, G. R. (1980). Work redesign. Reading, MA:Addison-Wesley.Herzberg, F. (1966). Work and the nature of man. New York, NY: TheWorld Publishing Company.Herzberg, F., Mausner, B., & Snyderman, B. (1959). The motivation towork. New York, NY: John Wiley & Sons.Latham, G. P., & Pinder, C. C. (2005). Work motivation theory and researchat the dawn of the twenty-first century. Annual Review of Psychology,56(4), 85–516.Lunenburg, F. C. (2011). Motivating by enriching jobs to make them moreinteresting and challenging. International Journal of Management,Business, and Administration, 15(1), 1–11.Maslow, A. H. (1954). Motivation and personality. New York, NY: Harper &Row.Maslow, A. H. (1970). Motivation and personality (2nd ed.). New York, NY:Harper & Row.McClelland, D. C. (1961). The achieving society. New York, NY: The FreePress.McClelland, D. C. (1985). Human motivation. Glenwood, IL: Scott-Foresman. O’Connor, D., & Yballe, L. (2007). Maslow revisited:Constructing a road map of human nature. Journal of ManagementEducation, 31(6), 738–756.Pink, D. H. (2011). Drive: The surprising truth about what motivates us.New York, NY: Riverhead Books/Penguin Group.Sashkin, M. (1996). The MbM questionnaire: Managing by motivation (3rd

ed.). Amherst, MA: Human Resource Development Press.Timmreck, T. C. (2001). Managing motivation and developing jobsatisfaction in the health care work environment. Health Care Manager,20(1), 42–58.Yukl, G. A. (2001). Leadership in organizations (5th ed.). Upper SaddleRiver, NJ: Pearson Education.OTHER SUGGESTED READINGCampbell, J. P., Dunnette, M. D., Lawler, E. E., & Weick, K. E. (1970).Managerial behavior, performance and effectiveness. New York, NY:McGraw-Hill Book Company.Maslow, A. H. (1943). A theory of human motivation. Psychological Review,50, 370–396.

CHAPTER 6Process Theories of MotivationLEARNING OUTCOMESAfter completing this chapter, the student should be able to understand: The various components of Expectancy Theory and how they impact anindividual’s level of motivation. Equity Theory and the methods to resolve inequity tension. The significance of the Satisfaction–Performance Theory. Goal-Setting Theory and the steps necessary for successfulimplementation. Reinforcement Theory and the four types of reinforcement.OVERVIEWUnderstanding individuals and what motivates them is a conundrum forhealth care managers, especially since we need to manage such diversegroups of employees. These employees are diverse not only in culture, race,and gender, but also in varying levels of education. On a daily basis, weneed to manage not only secretarial staff with minimal educationalrequirements, but also highly skilled individuals such as nurses, physicians,and other licensed health care professionals. As such, process theories assistus in predicting employees’ behavior so we may influence their behavior, ifnecessary.In this chapter, we examine five theories of motivation: (1) ExpectancyTheory, (2) Equity Theory, (3) Satisfaction–Performance Theory, (4) Goal-Setting Theory, and (5) Reinforcement Theory.EXPECTANCY THEORYOne widely cited theory of motivation is Victor Vroom’s (1964) ExpectancyTheory (also referred to as the VIE Theory). Expectancy Theory suggeststhat for any given situation, the level of a person’s motivation (force in

Vroom’s conceptualization) with respect to performance is dependent upon(1) the desire for a certain outcome; (2) the perception that individual jobperformance is related to obtaining the desired outcome; and (3) theperceived probability that individual effort will lead to the requiredperformance. The theory may be expressed as M = V × I × E (see Figure 6–1).Vroom (1964) explains that the force that drives a person to perform isdependent upon three factors: valence, instrumentality, and expectancy (pp.15–19).Valence is the strength of an individual’s want or need for, or dislike of, aparticular outcome. An outcome has a positive valence when the personprefers attaining it to not attaining it, a valence of zero when the person isindifferent to attaining or not attaining it, and a negative valence when theperson prefers not attaining it to attaining it. As such, valence can have awide range of both positive and negative values. The strength of a person’sdesire for, or aversion to, an outcome is based on the intrinsic properties ofan outcome that are valued or not (a second-level outcome in Vroom’sconceptualization), and/or on the anticipated satisfaction or dissatisfactionassociated with other outcomes that are related to any given outcome (afirst-level outcome in Vroom’s conceptualization). For example, someworkers may value an opportunity for promotion or advancement because oftheir need for achievement. As such, one outcome, advancement, ispositively related to or instrumental with respect to achieving anotheroutcome—achievement. Others may not want the promotion because itwould require additional time commitment and, therefore, less time forfamily or friends. Therefore, one outcome, advancement, is negativelyrelated to or instrumental with respect to another outcome—need foraffiliation.

Figure 6–1 Vroom’s Expectancy Theory (VIE)Instrumentality is an individual’s perception that his or her performanceis related to other outcomes, either positively or negatively. It is anoutcome–outcome association. In other words, an individual will perform ina certain manner because he or she believes that behavior will be rewardedwith something that has value to the individual. For example, a personbelieves that by producing both high-quality and high-quantity work, it willresult in recognition (e.g., praise) or a promotion from his or her supervisor.Expectancy is an individual’s perception that his or her effort willpositively influence his or her performance. It is an action–outcomeassociation. It can be defined as a momentary belief concerning thelikelihood that a particular act (effort) will be followed by a particularoutcome (performance). Expectancies can be described in terms of theirstrength. Maximal strength is indicated by subjective certainty that the actwill be followed by the outcome, while minimal (or zero) strength isindicated by subjective certainty that the act will not be followed by theoutcome. For example, an individual perceives that if he or she worksovertime, the management report will be completed by the deadline(maximal strength). However, if the employee perceives the deadline to beunrealistic and not obtainable because of the time required to complete thereport, the expectancy strength is minimal.Newsom (1990) summarized Expectancy Theory with what he termed the“Nine Cs”:

1. Challenge: Does the individual have to work hard to perform the jobwell? Managers need to review an employee’s job design. Is it routineand unchallenging? Does the job incorporate Herzberg’s Two-FactorTheory motivators?2. Criteria: Does he or she know the difference between good and poorperformance? Managers need to effectively communicate to anemployee the responsibilities and/or requirements of the task and howthe employee will be measured as to its successful completion. Amanager should not assume that an employee knows the criteria forperforming satisfactorily. In addition, managers need to providefeedback so an employee is aware of what he or she is doing right andwhat needs to be improved.3. Compensation: Do the outcomes associated with good performancereward the individual? Nadler and Lawler (1983) discussed the mixedmessage an organization sends to employees when employees arerewarded for seniority rather than performance. What theorganization gets is behavior oriented toward safe, secureemployment rather than efforts directed at performing well.4. Capability: Does the individual have the ability to perform the jobwell? Employees who lack the necessary skills, knowledge, andexperience to perform a task well will become frustrated and avoidfuture growth opportunities.5. Confidence: Does the individual believe he or she can perform the jobwell? Employees need to believe that they can perform a task well.Although an employee may have the knowledge and skill, he or shemay not see himself or herself with the ability to perform the taskwell. This may be based on past experiences of failure.6. Credibility: Does the individual believe that management will deliveron promises? Managers must deliver what they promised.7. Consistency: Does the individual believe that all workers receivesimilar preferred outcomes for good performance and similar lesspreferred outcomes for poor performance? Managers need to treat allemployees equally, on the basis of objective criteria.8. Cost: What does it cost an individual in time and effort to performwell?9. Communication: Does management communicate well andconsistently with the individual in order to affect the other eight Cs?Managers need to set clear goals and provide the right rewards fordifferent people. (See Figure 6–2.)

For managers, Expectancy Theory is very useful because it helps tounderstand a worker’s behavior. If employees lack motivation, it may becaused by their indifference toward, or desire to avoid, the existingoutcomes. Expectancy Theory is based on the assumption that individualscalculate the “costs and benefits” in choosing among alternative behavioralactions. For example, if an employee wants to move up the corporate ladder,then a promotion has a high valence for that employee. If the employeebelieves that high performance will result in excellent evaluation ratings,then the employee has a high expectancy. However, if the employee believesthe organization will not promote from within, then the employee has lowinstrumentality, and the employee will not be motivated to perform his orher job at a high level. So the important question for managers to ask is,“What rewards (outcomes) do my employees value?” (See Case Study 6–1:Jane Wants to Be an RN.)

Figure 6–2 Application of Expectancy Theory Using Newsom’s Nine CsCase Study 6–1 Jane Wants to Be an RNJane Smith is a 21-year-old single mother of two children, ages 3 and 4 years old. She lives in asmall apartment and depends on her mother to help care for her family. Jane is saving money to

send her children to preschool in the fall, which is located across the street from her mother’s houseand two blocks from the nursing home that she works at as a LPN. Jane works a straight day shiftwith an obligation to work every third weekend. A grant has been obtained from a national healthagency that will provide for full tuition for Jane and others like her to go to school to become an RN.The only drawback to this opportunity is that classes will begin in the fall (it is now June), whichmeans that Jane must attend classes on a full-time basis during the day and still continue to work inher current job but on the evening shift to take advantage of this opportunity. The program isscheduled to last one full year. The nursing home administrators have stated in a blanket policy thatthey will allow shift changes to employees who pursue this opportunity. Jane wants to accept theopportunity to pursue her education.Using Vroom’s Expectancy Model, explain Jane’s motivation to pursue her education.Gyurko, C.G. (2011). A synthesis of Vroom’s model with other social theories: An application tonursing education. Nursing Education Today, 31 (5), p. 507. Reprinted with permission.EQUITY THEORYJ. Stacy Adams (1963, 1965) proposed his Equity Theory, stating that aperson evaluates his or her outcomes and inputs by comparing them withthose of others. Adams’s theory is based in the social-exchange theories thatcenter on two assumptions. First, that there is a similarity between theprocess through which individuals evaluate their social relationships andeconomic transactions in the market. Social relationships can be viewed asexchange processes in which individuals make contributions (investments)for which they expect certain outcomes (Mowday, 1983). The secondassumption concerns the process through which individuals decide whethera particular exchange is satisfactory. If there is relative equality betweenthe outcomes and contributions of both parties to an exchange, satisfactionis likely to result from the interaction (Mowday, 1983). If an inequality isperceived, then dissatisfaction occurs, which triggers an internal tensionwithin one or more of the individuals. For example, a hardworking,dedicated employee believes that she is paid a fair salary given herexperience and education until she becomes aware that other departmentalstaff with the same level of seniority and education are paid higher salaries.This new information may cause the employee to become unmotivated, thuslowering her level of productivity.The two major components in Equity Theory are inputs and outcomes.Inputs are defined as those things a person contributes to an exchange. Inthe workplace, an employee’s inputs would be experience, education, efforts,skills, and abilities. Outcomes are those things that result from theexchange, such as salary, bonuses, promotions, and recognition. Adamsstates that equity exists when the ratio of a person’s outcomes to inputs is

equal to the ratio of others’ outcomes and inputs (see Figure 6–3).Figure 6–3 Adams’s Equity TheorySeveral important aspects of Adams’s theory are noted. First, thedetermination of whether inequity exists is based on the individual’sperceptions of input and outcomes, which may or may not be reality.Second, inequity will not exist if the person has high inputs and lowoutputs, as long as the other person has the similar ratio. Third, inequityexists when a person is either underpaid or overpaid. For example, ifemployees perceive they are overcompensated, they may increase their levelof productivity. If employees perceive they are undercompensated, they mayeither decrease their level of productivity or attempt to obtain additionalcompensation.Adams (1965) proposed that when an inequity is perceived by anindividual, (1) it creates tension within the person, (2) the tension isproportional to the degree of inequity, (3) the tension created within theindividual motivates him or her to relieve it, and (4) the strength of themotivation to reduce the tension is proportional to the perceived inequity.Adams states that there are several cognitive and behavioral mechanismsavailable to individuals to reduce the psychological discomfort (i.e., inequitytension) associated with the perceived inequity. He refers to these cognitiveand behavioral mechanisms as methods of inequity resolution. The sixmethods described by Adams are:

1. Altering Inputs: Reduce productivity, take longer break times, anduse sick days for personal activities.2. Altering Outcomes: Try to obtain an increase in pay, a bonus, or anew job title or resort to taking supplies from the company forpersonal use (i.e., stealing).3. Cognitively Distorting Inputs or Outcomes (self): Describe how muchharder he or she is working.4. Leaving the Field: Transfer to another department or quit theorganization.5. Distorting the Inputs or Outcomes of the Comparison Other: Describethe other person’s job as routine and unchallenging.6. Changing the Comparison Other: Find someone in the organizationmore like himself or herself—another high-performing worker.Equity Theory does not predict which method will be selected by theindividual. The behavior chosen by the individual depends on the situationwith the goal of maximum utility (see Case Study 6–2: I Don’t Know Whatto Do). According to Mowday (1983), the easiest method is trying to distortthe other’s inputs and outcomes. Leaving the organization will be consideredonly in extreme cases. Managers need to be aware of how employeesperceive inequities in the work environment because individuals willrespond to feelings of inequity in various ways. For instance, in general thelevel of demotivation displayed by the person will be proportional to theperceived inequity with others. However, for some employees the slightestindication of negative inequity between themselves and others may cause ahigh level of disappointment and a feeling of injustice, resulting indemotivation or hostile behavior toward others. Another group may lowertheir level of productivity and become disruptive in the workplace,expressing negative attitudes toward management and/or their peers. Otherindividuals may request additional compensation or more benefits to adjusttheir output upward or seek a new position that provides for higher levels ofoutputs. In conclusion, if subordinates perceive that they are not being dealtwith fairly, it is difficult, if not impossible, to motivate them.Case Study 6–2 I Don’t Know What to DoKatie was disgusted with the situation she was in. She was seriously thinking about applying forthe open RN position in the hospital’s ambulatory surgery center just to get away from Beth. Katiehas been employed at Good Point Hospital for the past 10 years. She originally started in thehousekeeping department, but she knew she wanted more. So Katie took advantage of the hospital’s

tuition reimbursement program and returned to school to earn her nursing degree. Katie didn’t carethat she was 39 years old at the time she returned to school and that it took her three long years toearn her associate of science degree. It was worth the time and effort, although sometimes she hadto admit it was stressful working full time during the day in the housekeeping department, withthree small children at home. But her husband Mike supported her, taking care of the children andhousehold chores at night and on weekends so she could attend class or study in the library. She feltvery blessed that she could set an example for her children by being the first person in her family toearn a college degree. It has been four years since she became an RN, and Katie has enjoyed workingin the hospital’s intensive care unit (ICU)—that was, until Beth joined the ICU nursing staff lastyear.When Katie returned home one evening, Mike could see that Katie was very upset. When Mikeasked her what was bothering her, she related,“Beth has been working at Good Point Hospital for two years and in the ICU for the past year. Iam now convinced that Beth has absolutely no work ethics. Maybe it’s part of her being in theMillennial generation a Millennial; her 21st birthday is next month. She spends half of her shifteither on the phone or emailing her friends. She calls in sick almost every other Monday or Fridaywhen she is not scheduled for the weekend shift. She’s always complaining how busy she is and howcan the hospital’s administration think she can get all her work done in a 12-hour shift! Beth’sworkload is similar to mine; in fact, I have more responsibility than she does, but I always seem toget my work done. Because Beth never finishes her jobs, it causes more work for me. For example,Beth is always the first one off the floor at the end of our shift and never completes her patients’medical charts, so the nurses from the incoming shift have to ask me to bring them up to date onBeth’s patients before they start their shift. I don’t mind helping them out, but it usually takes atleast 30 minutes, and since the hospital froze overtime, I don’t get paid to cover for Beth’s laziness!Today Beth started whining that because I have seniority, I get first pick for vacation time andholidays. I tried to lighten the mood by saying that when I’m gone, she will have the seniority. I hadto remind her that I’ve had my share of non-holiday time off, and everyone has to work his or herway up the ladder. I’ve spoken to Terry, our manager, about Beth on numerous occasions, but I feelI’m wasting my time. Terry says he’ll talk to Beth, but he never does. I think he’s overwhelmedtrying to manage the ICU along with the other two departments that were recently assigned to him.I just don’t know what to do since I’m not Beth’s supervisor. Beth has this attitude of ‘I don’t want towork, but pay me anyway.’ I’m so frustrated with the situation, I’m ready to leave the ICU!Discuss Katie’s motivation to quit the ICU using Adams’s Equity Theory.SATISFACTION–PERFORMANCE THEORYOne of the major criticisms of Expectancy Theory is that it does not takeinto account the relationship between employee performance and jobsatisfaction. As such, Lyman Porter and Edward Lawler (1968a) extendedExpectancy Theory and incorporated Equity Theory into a model to reflectthe relationship of an employee’s performance to job satisfaction. Jobsatisfaction is related to both absenteeism and turnover. This is a greatconcern to organizations because turnover and absenteeism have a directinfluence on an entity’s effectiveness (Lawler, 1983). Lawler points out:Absenteeism is very costly because it interrupts scheduling, createsa need for overstaffing, increases costs; turnover is expensive becauseof the many costs incurred in recruiting and training replacement

employees. Because satisfaction is manageable and influencesabsenteeism and turnover, organizations can control them. Bykeeping satisfaction high and specifically by seeing that the bestemployees are the most satisfied, organizations can retain thoseemployees they need the most. (p. 87)Interestingly, prior to Porter and Lawler (1968a), no motivational modelhad directly dealt with the relationship between satisfaction andperformance (Luthans, 2002). The Porter and Lawler model does not predictwho is satisfied; it simply gives the conditions that lead to employeesexperiencing feelings of satisfaction or dissatisfaction (Lawler, 1983). Theresearchers believe that performance leads to satisfaction rather thansatisfaction to improved performance.The Porter and Lawler model reflects that satisfaction results fromperformance itself, the rewards for performance, and the perceivedequitability of those rewards (see Figure 6–4).Porter and Lawler (1968a) stated that job satisfaction is generated whenan employee receives rewards for his or her performance. These rewardscan be intrinsic (e.g., sense of accomplishment) or extrinsic (e.g., bonus). Anemployee’s degree of satisfaction will be proportionate to the amount ofrewards he or she believes he or she is receiving.

Figure 6–4 Porter–Lawler Satisfaction–Performance ModelAn important aspect of Porter and Lawler’s theory is the fact that theamount of the reward an employee receives may be unrelated to how wellhe or she has performed (e.g., pay increases based on seniority or laborunion agreements). As such, for employees whose rewards are tied to factorsthat are beyond their control versus receiving rewards based on how wellthey perform, there will be little or no correlation between satisfaction andjob performance. However, if an employee holds a position (e.g., manager)where rewards are received on the basis of the quality and quantity of his orher performance, there would be a correlation between satisfaction andperformance. Porter and Lawler’s (1968a, 1968b) research confirmed thishypothesis. The researchers found that managers who are ranked high bytheir supervisors report significantly greater satisfaction than do the low-ranked managers. More important is that, although the best-performingmanagers did not report receiving any greater extrinsic rewards (e.g., payand security) as compared to their counterparts, they did report receivinggreater intrinsic rewards (e.g., expressed autonomy and the ability to obtainself-realization in the job). Therefore, the question is, “Does theorganization actively and visibly give rewards directly in proportion to thequality of job performance for all of its employees?” If the answer is yes,

then high satisfaction should be more closely related to higher performance,if the employees value the rewards distributed.The Satisfaction–Performance Model tells us two things. First, if anindividual is attracted by the value of the reward, if he or she perceives thata higher degree of effort on his or her part will lead to those rewards, and ifthe employee has the necessary abilities and accurate role perceptions, thenhigher performance will result. Second, if the intrinsic and extrinsicrewards an employee receives for higher performance are perceived asequitable, then satisfaction will result—satisfaction being the differencebetween perceived equity and actual rewards.Job satisfaction is a complex and multifaceted concept. It is circumstantialand subjective for each employee and situation being assessed.GOAL-SETTING THEORYIn the 1960s and 1970s, Gary Latham and Edwin Locke (1983) performeda number of laboratory and field research studies that determined thatparticipants who were given specific, challenging goals outperformed thosewho were given vague goals such as “do your best.” For example, in a 1974–75 study, Latham found that unionized truck drivers increased the numberof logs loaded onto their trucks from 60 percent to 90 percent of the legalallowable weight as a result of setting goals. They saved the company$250,000 in nine months. In 1982, another group of unionized drivers saved$2.7 million in 18 weeks by adhering to assigned goals of increasing theirdaily trips to the mill (Locke & Latham, 2002, p. 711). On the basis of theirstudies, Latham and Locke developed a goal-setting model. Although goalsetting is a simple concept, it requires careful planning and forethought onthe part of the manager (see Figure 6–5). A goal is the aim of an action ortask that a person consciously desires to achieve or obtain (Locke &Latham, 2002, 2006). Goal setting involves the conscious process ofestablishing levels of performance in order to obtain desirable outcomes.

Figure 6–5 Latham and Locke’s Goal-Setting ModelReproduced from Latham, G. P., & Locke, E. A. (1979). Goal setting—A motivational techniquethat works. Organizational Dynamics, 8(2), 68.Latham and Locke suggest that there are three steps to be followed: (1)setting the goal, (2) obtaining goal commitment, and (3) providing supportelements.1. Setting the Goal: The goal set should have two main characteristics.First, it should be specific, rather than vague, and measurable. Forexample, a goal statement such as “increase elective outpatientsurgeries by 5 percent within the next six months” is specific, with atime limit for goal accomplishment. Second, the goal should bechallenging yet reachable. Difficult goals lead to better performance.However, two points need to be made. For employees with low self-confidence or ability, goals should be set at a level that is easy and

attainable. For employees with high self-confidence and ability, goalsshould be made difficult but attainable. In either case, if employeesperceive the goals as unattainable, they will not accept them andperformance will not improve. In fact, the employee will experiencedissatisfaction and frustration. Managers need to be conscious thatseeking unattainable goals may cause employees to view managementwith suspicion and distrust.Latham and Locke stated that there are five possible methods, inaddition to an employee’s confidence and ability levels, for managersto use to determine goals for an employee. First, the manager coulduse time-and-motion studies to set an appropriate goal level. A secondoption, which would be more readily accepted, would be setting futuregoal levels on the basis of the average past performance of theemployee. However, if the employee’s past performance wasunacceptably low, upward adjustments would need to be made. Athird option would allow for the supervisor and subordinate to jointlyset the goal. This participative approach has the advantages of beingreadily acceptable by both parties, and promotes role clarity. Thefourth method may be determined by external sources. This is verycommon in the health care industry; because third parties determinereimbursements, the goal is to deliver service at the lowest possiblecost without reducing quality. The fifth method is determiningindividual goals that correspond to the long-term goals of the healthservices organization as determined by the organization’s board oftrustees.2. Obtaining Goal Commitment: If goal setting is to be successful, themanager needs to ensure that subordinates will accept and remaincommitted to the goals. Appropriate pay (i.e., rewards) with themanager’s supportiveness is usually sufficient for goal acceptance andcommitment by the employee. Employees receive a feeling ofsatisfaction for reaching challenging, fair goals, which tends toreinforce acceptance of future goals.Generally, employees resist goals for two reasons. First, they mayperceive themselves as being incapable of reaching the goals. Toovercome this resistance, managers need to provide training toincrease employees’ skills and knowledge, therefore increasing theirself-confidence that the goal can be achieved. Second, employees maynot see any relationship between their personal benefits (i.e., feelingof accomplishment or external rewards) and obtaining the goals.

Managers may use a participative approach so that employees have afeeling of control over the situation. Reward systems must be in placeto directly compensate employees for obtaining the agreed-upon goals.3. Providing Support Elements: Managers must ensure that employeeshave adequate resources (e.g., financial, equipment, time, assistance,etc.) to reach their goals. Furthermore, company policies andprocedures must not create barriers to employees’ goal attainment.Employees need to trust that managers are supporting, notundermining, their efforts. For example, perhaps the company’s goalis to have employees trained in new safety protocols. However, themanager’s bonus depends upon the organization’s financialperformance, not the employee’s implementation of the safetyprocedures. Therefore, the manager may not be motivated to allowemployees to stop their daily tasks to complete the training (Fusion,n.d.).Managers need to provide employees with an action plan of agreed-upongoals and rewards so there is no ambiguity in the process. In addition,feedback is essential. Employees must have access to information as to thestatus in their goal attainment. Finally, Latham and Locke point out thatgoal setting is not a solution for poor management or the low orundercompensation of employees.REINFORCEMENT THEORYReinforcement Theory is based primarily on the work of B. F. Skinner(1953), who experimented with the theories of operant conditioning.Skinner’s research found that an individual’s behavior could be redirectedthrough the use of reinforcement. Reinforcement Theory suggests that anemployee’s behavior will be repeated if it is associated with positive rewardsand will not be repeated if it is associated with negative consequences.Although Reinforcement Theory is not a motivation theory (at least not inthe context we have been discussing), it does help managers understand andinfluence, when necessary, behavioral change by the reinforcements used.Reinforcement is a behavioristic approach, which argues that reinforcementconditions behavior (Robbins, 2003). Since reinforcement is an importantmeans of understanding what controls an individual’s behavior, it isincluded in motivation discussions (see Figure 6–6) (Robbins, 2003; Tosi &Mero, 2003).There are four types of reinforcement: positive, negative, punishment,

and extinction.Positive reinforcement occurs when a desirable outcome is associated witha behavior. Desirable outcomes can be simple and symbolic, such as wordsof praise, a certificate of accomplishment, or a month’s use of the parkingspace directly outside the hospital’s main entrance. To fully appreciate itseffect, managers should use positive reinforcement only when an employeedisplays the desired behavior. For example, the director of nursing hasattempted to reduce the turnover time (i.e., time required to set up anoperating room [OR] after each surgical procedure) of the hospital’s ORs toimprove the efficiency of the department. The OR nurses formed a taskgroup, and after many months and careful planning with full cooperation ofthe physicians and support staff, the daily turnover time decreased by 15percent within a six-month period. The decrease in OR turnover timeallowed for one additional case to be scheduled per day. The director ofnursing recognized the team’s accomplishment by publishing it in the healthsystem’s newsletter and hosting a thank-you lunch for the department.

Figure 6–6 Reinforcement Theory and Types of ReinforcementsNegative reinforcement occurs when an unpleasant effect is eliminated oravoided, which, like positive reinforcement, encourages repeated positivebehavior. We return to our OR example. The nurse responsible for orderingsurgical supplies, by working with the hospital’s technology department,designed an inventory system using bar codes that alert her when suppliesare at a reordering level. With the use of technology, the systemautomatically transmits a message that an order must be placed to thepurchasing department. By designing and implementing the new inventoryordering system, the nurse has eliminated her need to work overtimecounting inventory and has eliminated the negative consequences (e.g.,unhappy patients and physicians, lost revenues) when a surgery case has tobe canceled and rescheduled because the hospital did not have the necessarysupplies on hand.Punishment can come in two forms: negative consequences and positiveconsequences, both undesirable. A negative consequence is an undesirable

response to an employee’s behavior in the attempt to stop the behavior frombeing repeated. For example, an OR nurse who is responsible for orderingsupplies was reprimanded by the department’s manager when she failed toplace an order for a required surgical instrument, causing an OR case to becanceled. (Because of this reprimand, the OR nurse was “motivated” todesign an inventory system so the situation would not occur again.) Apositive consequence occurs when something desirable is removed from theemployee. For example, when the OR nurse failed to order the necessarysurgical instrument, the department’s manager required her to update theinventory supply list within 24 hours, which required her to work on herscheduled day off and cancel her trip to Disney World.Extinction is defined as the removal of an established reinforcement(positive or negative) that was previously used to reinforce an employee’sbehavior. This removal may weaken an employee’s future behavior. Forexample, one hospital’s OR department had a policy that if the room chargenurse’s surgical cases started and ended on time (measured on a weeklybasis), he or she would receive a $50 certificate to a local restaurant. Whenthere was a change in the hospital’s senior management, this positivereinforcement was abruptly eliminated with the following message: “It isyour job to make sure the OR is run efficiently, which includes having thecases start and end on time. Therefore, we are eliminating the previouslyawarded gift certificate. If you have any questions regarding this newpolicy, please contact your manager.”Managers need to be careful regarding the administrating of punishmentreinforcements. Unless done carefully and appropriately, the effects cancause long-term consequences for the organization. It can cause employeeresentment, hostility, and turnover. Managers should punish onlyundesirable behavior and be very clear as to what constituted theundesirable behavior when discussing the situation with the employee; givereprimands or discipline actions as soon as possible after the behavior hasoccurred; administer punishment in private; and, when possible, combinenegative and positive reinforcements.Reinforcement schedules refer to the timing and frequency with which theconsequences are associated with behavior. The scheduling of thereinforcement is important because the frequency will determine the time ittakes to learn a new behavior (Tosi & Mero, 2003). Reinforcement schedulescan be continuous, fixed interval, variable interval, fixed ratio, or variableratio.

• A continuous reinforcement schedule requires the specific employee’sbehavior to be reinforced each time it occurs (e.g., the chief executiveofficer rewards all employees every time the hospital passes its JointCommission accreditation). Research suggests that continuousreinforcement is the fastest way to establish new behaviors or toeliminate undesired behaviors.• In a fixed-interval reinforcement schedule, the reinforcement isadministered at predetermined periods (e.g., annual performanceappraisals, weekly paycheck). A fixed-interval reinforcement scheduledoes not appear to be a particularly strong way to elicit desiredbehavior, and behavior learned in this way may be subject to rapidextinction.• A variable-interval reinforcement schedule allows reinforcements to beadministered at irregular intervals (e.g., special recognition forsuccessful performance, promotions to higher-level positions). Thisreinforcement schedule appears to elicit desired behavioral change thatis resistant to extinction.• A fixed-ratio reinforcement schedule requires the reinforcement to beadministered after a predetermined number of behaviors have occurred(e.g., sales commission based on a number of units sold). Fixed-ratioreinforcement schedules can produce high rates of responses thatcontinue as long as the reinforcement has value to the employee.• A variable-ratio reinforcement schedule is evident when the number ofbehaviors necessary for reinforcement varies (e.g., bonuses or specialawards that are applied after varying numbers of desired behaviorsoccur). Variableratio reinforcement schedules appear to produce desiredbehavioral change that is consistent and very resistant to extinction.(Tosi & Mero, 2003).Consider the following scenario:A hospital CEO is discussing his facility’s experiences at trying to effectively manage theordering and tracking of supplies in the hospital’s OR department.“We started looking at some product line assessments. As an example, a couple of years ago wemet with two different groups of ophthalmologists to look at their costs on a case-by-case basis.We then compared what they used and might use, and determined the areas in which we mightbe able to standardize products and equipment…. We had the ophthalmologists work withvendors and use a case supply cap, and we saved some money that way. Recently though, we’venoticed that some of the ophthalmologists are drifting back to their old routines again, so I thinkthis is something that you can’t just do once and expect it to manage itself.”What reinforcement schedule would you advise the CEO to use in the future? Why?

Reprinted with permission from Healthcare Financial Management Association’s ExecutiveRoundtable Series, July 2004, Improving OR throughput: Real world successes and challenges.SUMMARYIn this chapter, we discussed various process theories of motivation. Thesemotivation theories help health care managers predict employee behavior.Managers can then effectively influence that behavior, achievingorganizational success through increased job satisfaction.DISCUSSION QUESTIONS1. Discuss the various components of Expectancy Theory.2. Explain Newsom’s “Nine Cs.”3. Discuss the two components of Equity Theory.4. Explain the methods of inequity resolution.5. Discuss the significance of the Satisfaction–Performance Theory.6. Explain how the Satisfaction–Performance Theory relates toExpectancy Theory and Equity Theory.7. Discuss the three components of the Goal-Setting Theory.8. Explain how goals can be determined under the Goal-Setting Theory.9. Explain management’s responsibilities under the Goal-SettingTheory.10. Explain why we include Reinforcement Theory in motivationdiscussions.11. Discuss the types of reinforcements available to managers forchanging an employee’s behavior.12. Discuss the various reinforcement schedules and why their timingand frequency are important.CASE STUDIESCase Study 6–3 What Can Joe Do About Betty?Just before quitting time, Joe, the hospital’s health information department manager, watched histhree new trainees struggling with the complicated electronic medical records software they had tolearn to use to do their jobs. Across the room, Betty, who was an expert with the software, waspreparing to leave for the day, her tasks done ahead of time as usual. Also as usual, she gathered up

her belongings and left without saying good-bye to any of her coworkers. “There goes the answer tomy problem,” thought Joe, “if only I knew how to reach her.” With her expertise and experience inusing the system, Betty would seem to be an ideal coach for the new employees. However, she hadbegged off from taking on training duties when Joe had asked her. Her reasons were that she wasn’tcomfortable telling anyone else what to do, didn’t want the responsibility for someone else’s work,and preferred to work by herself at her own job.Joe was stunned by her refusal; he enjoyed helping his coworkers and felt it was why he hadadvanced to department manager last year instead of Betty, who had more seniority and experiencewith the company than he did. Since her work was excellent, Joe hesitated to make it an “either youdo what I want or you’re in trouble” situation; he believed employees worked best at what theywanted to work at. But his problem still remained: There was no money in the training budget andno other employees as skilled with the system as Betty was. Was there an approach to convincingher to help that he hadn’t thought of?As Betty walked to the hospital’s parking lot, she thought, “How could Joe think I would lift afinger to help him? I should have been the one promoted to department manager last year, not him.I’m the one with seniority and the necessary experience. In fact, I was the one who trained Joe whenhe first joined the hospital! Just because he has a master’s in health information management and Idon’t should not have been the determining factor, but obviously senior management thought sowhen they selected him over me! I could care less what happens from this point forward. I only havefive more years until I can retire with my full pension. As long as my work continues to be excellentthere is no way Joe can upset my plans. Not that he could since he hardly understands thecomplexity of the software we use, since it requires a person with a lot of technology knowledge andexperience.”Using Vroom’s Expectancy Theory (VIE), explain Betty’s lack of motivation.Case Study 6–4 How Much Longer Can Alice Continue Working for MGM Healthcare?Alice has been a business/finance trainer for MGM Healthcare Consulting Group’s clients for threeyears. Until recently, she had enjoyed her job responsibilities and coworkers, and although shewould like to earn more money, she believes her salary is fair compensation for her duties,experience, and education. Alice’s first career choice was to be a teacher, so she especially likes theability to teach others about her second passion—the business side of health care. She has an MHSAdegree, certification as a health care finance professional through HFMA as well as a lean Six SigmaGreen Belt. Alice has been recognized by her director for her excellent work each year.As a trainer, Alice needs to travel extensively eight months of the year to clients’ facilitiesthroughout the United States. During this period, Alice works 12-hour days, six days a week. Duringher “nontraveling” months, Alice is in the office preparing new training manuals and conductingeducational webinars for existing and potential clients. During this period, she works three and halfdays a week but collects a full paycheck. Alice has been fine with working this schedule because sheenjoys what she does and she feels in the end it all balances out. Plus, although she has neverrequested time off during the traveling months, her director had said she would cover for Alice if theneed arose.Alice’s traveling period just began, and she found out that her mother will need surgery thefollowing month, which will require a two-day hospitalization stay and complete bed rest for a week.Alice’s dad is available to help with the situation, but Alice and her mother are very close and shewants to be there to take care of her mother while she is recuperating. Alice tells her directorimmediately about her family situation, but her director refuses to accommodate her request, tellingAlice that due to being short staffed there is no one to cover her clients’ training requirementsduring that week period. Alice becomes frustrated and angry because she has never asked for timeoff during her traveling period, and now she will not be able to help her mother.Another issue that has frustrated Alice from the beginning is how her director micromanages her

and other coworkers when they are in the office during the nontraveling period. All changes to thetraining manuals, the content of the educational webinars—essentially everything—has to beapproved by the director before it can be finalized. This has caused deadlines to be missed, resultingin client complaints. Alice feels this affects her reputation with the existing clients in addition toaffecting the bonus money she would have received for signing up new clients to participate in theeducational webinars. She has also felt frustrated with the lack of growth opportunities within theconsulting company. The organization is small, so after working for the company for three years, shehas already reached the top position and pay scale below the director level.Although Alice enjoys working with her clients and coworkers, she has become dissatisfied withher job and no longer feels committed to doing whatever it takes to get the job done. She is startingto resent giving up her weekends for eight months of the year, her director’s delays that cause her toloss bonus money, and the lack of growth opportunities. She doesn’t know how much longer she cancontinue working for MGM Healthcare Consulting Group.Discuss Alice’s job dissatisfaction and lack of motivation using Porter–Lawler’s Satisfaction-Performance Theory.Case Study 6–5 Problems in the Purchasing DepartmentEmployees in the purchasing department of a large hospital were suffering from lack ofmotivation. On the day shift there had always been a few employees who were less productive thanothers. The other employees would have to pick up the slack to ensure that all supplies for thehospitals were ordered on a timely basis. This would cause the departmental staff who wereperforming their job properly to become frustrated and angry because the other employees were notbeing held accountable for their low levels of productivity. There was clearly a disconnect betweenwhat was expected of all employees and what was actually being done.Jack and Chris consistently worked hard and consistently exceeded the requirements of their jobs.They made sure that all daily requests for supplies were ordered so that there was not backlog todeal with at the beginning of each shift. However, they started to notice that Page and Betty spentmore time doing “other things” than their assigned jobs in the purchasing department.Jack and Chris started becoming less motivated to work as hard because they felt they werepicking up the slack of their coworkers. The overperformance levels for the department began tofall. Backlogs started to rise as well as complaints from the other functional units of the hospitalwhen requested supplies were not received in a timely fashion. In fact, surgical cases had to becanceled and rescheduled because the proper supplies were not available for the surgeons.Something had to be done!Using Goal-Setting Theory, create a plan that will motivate all the departmental staff to work totheir full potential and perform more efficiently.Case Study 6–6 How to Motivate Physicians to Improve ComplianceA hospital, located within a highly competitive market, is concerned over a decline in itsperformance on national quality indicators. Although many members of the medical staff arecooperative and compliant with the required documentation, a group of physicians don’t seem tounderstand the importance of these measures. When either the hospital administration or membersof the medical staff leadership confront these physicians, they often state they will try harder to becompliant, but ultimately don’t change their behavior. Others simply choose to ignore letters sent tothem or any attempts to discuss their noncompliance. Frustrated by the lack of cooperation by thesephysicians, the hospital and medical staff leadership decide to get tough on enforcement. Theydesign a tiered response system. Physicians who do not meet the documentation requirements will

be sent a warning letter. Failure to improve or respond will result in temporary loss of privileges.Continued lack of compliance will lead to loss of privileges.Will this punitive system work to motivate physicians to improve compliance? If no, why? Developrecommendations as to how to motivate physicians to improve compliance.Reproduced from Tarantino, D. P. (2008). If you want to motivate physicians, you have tounderstand and fulfill what drives human behavior. Physician Executive, 34(5), 84–85.Case Study 6–7 All in a Day’s WorkSarah Goodman, senior manager of network development for the Holy Managed Care Company,has just returned from a lunch meeting with the adviser for the MHSA (Master’s of Health ServicesAdministration) program at State University, and now she is back on the job attending moremeetings. At 1:30 p.m. she has a meeting to discuss pay issues. The Human Resources Departmenthas evaluated the salary picture for the entire organization and is concerned that women are notbeing paid as well as men. They want input on a strategy to bring the pay issue into line so as toavoid a gender discrimination charge. Personally, Sarah wondered if she got paid as well as Dave,her counterpart in Tampa. Certainly she has been there as long and worked about twice as hard ashe seems to! He does seem to benefit from the “good old boy network,” however.At 3:00 there is a performance appraisal Sarah had scheduled with her assistant Maria. Sarahwasn’t sure what to do about Maria. Her work was terrific from the standpoint of accuracy andamount. As long as she got a pat on the back pretty frequently, Maria was an ideal employee in a lotof ways. Sarah knew that Maria would be prepared for the interview, including her goals for the nextsix months. The problem was that Sarah really wanted to get Maria more involved with others in thedepartment. If she wasn’t able to get Maria ready to assume her position, how could Sarah ever hopeto be promoted? Productive as she was, Maria just wasn’t a “people person.”Then at 4:00, there is another performance appraisal scheduled. This one was going to be difficult.Janine was a fairly new employee and Sarah loved the work she produced, but she didn’t think she’dever seen a more uptight person! She seemed to need to be told at each step what to do next andworried constantly about breaking the rules. Sarah had begun to think Janine had even inventedsome new rules! Last week, for example, Sarah had asked Janine to stay a little late to finish aproject. She didn’t discover until the next day that Janine had been late picking up her baby from thebabysitter. Certainly overtime wasn’t required, and Sarah felt bad about causing the problem. Shecould have asked someone else to do the work, but thought it might be a way of encouraging Janineto “get out of the box” a little.By the time the meetings were over, Sarah figured she’d just have time to return her phone callsand scan the mail before it was time to go home. She’d promised Richard something special fordinner, mostly because she was planning to tell him about graduate school. The traffic would beawful, and she needed to stop by the store on the way. “Oh well! It’s all in a day’s work,” she thought.Discuss the various motivation theories reflected in this case study.Reprinted with permission from Pidge Diehl, EdD.Case Study 6–8 Why Aren’t My Employees Motivated?Roger Harris is the founder and managing partner of a large health management consulting firmthat specializes in strategic planning for hospitals. The firm has six partners, including Roger, and20 professional staff (all with graduate degrees in health administration). The staff is evenly divided

between males and females, single and married individuals between 25 and 35 years old. Of the 10married, two spouses work outside the home. All the married individuals have families of at leasttwo children, and all children are under 10 years old.The philosophy of the firm is to serve the needs of its clients and have fun serving those needs, allwhile making a profit. Because of the tight labor market, the firm’s salaries for its professional staffare well above the market in order to attract and retain the best talent. In addition, each employeehas a private office, breakfast served daily, free weekly car washes, and his or her dry cleaningdelivered to the office. The firm also offers the staff home computers if they prefer to work at homeon weekends during the firm’s busy time, which usually runs from October to May.During the busy period, staff are required to work approximately 55 to 60 hours per week. Staffreceive two weeks’ vacation annually, in addition to one week for continuing professional educationand one week personal time, which is utilized by 100 percent of the staff.Roger Harris is concerned because, although partners’ billable hours (i.e., hourly rates charged toclients for services rendered) have increased 12 percent over the past two years, the staff’s billablehours have decreased by 14 percent. In addition, Roger Harris noted that the turnover rate (i.e.,percentage of the newly hired graduates that stay with the firm for approximately three to fouryears before taking a position in one of their client’s hospitals) has increased to 50 percent (from 10percent five years earlier).In order to increase the firm’s productivity and retention rate, Roger Harris initiated a bonusprogram as follows: If a staff member bills out 2,000 hours annually, he or she receives a bonus equalto 5 percent of his or her annual salary. For every hour billed over the minimum 2,000 hours, theemployee is paid twice the hourly rate.All employees earned their 5 percent bonus, but no one’s productivity increased over the minimum2,000-hour base.Roger Harris was concerned by this lowering productivity and increasing turnover rate. Thinkingthat the staff needed outside professional recognition, he encouraged everyone to publish articles forthe various health management journals discussing aspects of their most interesting cases. All thestaff displayed their willingness to do so, as long as the time required to develop the articles wouldbe applied toward their minimum 2,000 hours’ bonus calculation.Roger Harris related to staff that anyone who demonstrated technical competence and the abilityto attract and retain clients to the firm would have the opportunity to become a partner. Eventhough individuals from the outside had filled the last two senior management-level positions, fourof the six partners had been promoted from within (after eight to ten years of continuousemployment with the firm). However, the most recent promotion to partner was made to anindividual hired from the outside after only three years of employment with the firm.Roger Harris thinks that the consulting firm is a great place to work, with interesting andchallenging cases, an excellent compensation package, and growth opportunity. Therefore, he cannotunderstand why staff’s productivity continues to decline and the turnover rate continues to increase.Using Expectancy Theory, explain to Roger Harris why nonpartner productivity level is low andwhy the firm is experiencing a high turnover rate with its professional staff.REFERENCESAdams, J. S. (1963). Toward an understanding of inequity. Journal ofAbnormal and Social Psychology, 67, 422–436.Adams, J. S. (1965). Inequity in social exchange. In L. Berkowitz (Ed.),Advances in experimental social psychology (Vol. 2, pp. 267–300). NewYork, NY: Academic Press.

Fusion, J. (n.d.). Motivation & goal setting theory. Available at:smallbusiness.chron.com/motivation-goal-setting-theory-1187.htmlLatham, G. P., & Locke, E. A. (1983). Goal setting—A motivationaltechnique that works. In J. R. Hackman, E. E. Lawler, & L. W. Porter(Eds.), Perspectives on behavior in organizations (pp. 296–304). New York,NY: McGraw-Hill Book Company.Lawler, E. E. (1983). Satisfaction and behavior. In J. R. Hackman, E. E.Lawler, & L. W. Porter (Eds.), Perspectives on behavior in organizations(pp. 78–87). New York, NY: McGraw-Hill Book Company.Locke, E. A. & Latham, G. P. (2002). Building a practically useful theory ofgoal setting and task motivation. A 35-year odyssey. AmericanPsychologist, 57(9), 705–717.Locke, E. A., & Latham, G. P. (2006). New directions in goal-setting theory.Current Directions in Psychological Science, 15(5), 265–268.Luthans, F. (2002). Organizational behavior (9th ed.). New York, NY:McGraw-Hill Book Company.Mowday, R. T. (1983). Equity theory predictions of behavior inorganizations. In J. S. Ott (Ed.), Classic readings in organizationalbehavior (pp. 94–102). Albany, NY: Wadsworth Publishing Company.Nadler, D. A., & Lawler, E. E. (1983). Motivation: A diagnostic approach. InJ. R. Hackman, E. E. Lawler, & L. W. Porter (Eds.), Perspectives onbehavior in organizations (pp. 67–78). New York, NY: McGraw-Hill BookCompany.Newsom, W. B. (1990, February). Motivate, now! Personnel Journal, 51–55.Porter, L. W., & Lawler, E. E. (1968a). Managerial attitudes andperformance. Homewood, IL: Irwin.Porter, L. W., & Lawler, E. E. (1968b). What job attitudes tell aboutmotivation. Harvard Business Review, 46(1), 118–126.Robbins, S. P. (2003). Organizational behavior (10th ed.). Upper SaddleRiver, NJ: Prentice Hall.Skinner, B. F. (1953). Science and human behavior. New York, NY:Macmillan.Tosi, H. R., & Mero, N. P. (2003). The fundamentals of organizationalbehavior: What managers need to know. London, UK: BlackwellPublishing.Vroom, V. H. (1964). Work and motivation. New York, NY: John Wiley &Sons.

CHAPTER 7Attribution Theory and MotivationPaul Harvey, PhD, and Mark J. Martinko, PhDLEARNING OUTCOMESAfter completing this chapter, the student should be able to understand: The basic premises of attribution theory. The differences between optimistic, pessimistic, and hostile attributionstyles. The role of attributions, emotions, and expectations in motivatingemployees. Techniques managers can use to promote accurate and motivationalattributions.OVERVIEWIn this chapter we discuss how attribution theory is used to providemanagers with a better understanding of the highly cognitive andpsychological mechanisms that influence employees’ motivation levels. Thechapter begins with an overview of attribution theory. We then discuss thedifferent attribution styles that can bias the accuracy of causal perceptions,potentially undermining the effectiveness of motivational strategies. Wethen describe the impact of attribution-driven emotions and expectations onmotivation. This is followed by an overview of techniques health caremanagers can use to promote motivational attributions among employees.ATTRIBUTION THEORYBefore describing the basic tenets of attribution theory, it is useful tounderstand exactly what is meant by the term attribution. An attribution isa causal explanation for an event or behavior. To illustrate, a nurse whoobserves a colleague performing a procedure incorrectly is likely to try to

form an attributional explanation for this behavior. The nurse mightconclude that the colleague is poorly trained, meaning that the observer isattributing the behavior to insufficient skills. People also form attributionsfor their own behaviors and outcomes. For example, a physician mightattribute her success in diagnosing a patient’s rare disease to herintelligence and training, or to good luck.As these examples might suggest, the attribution process is somethingthat people typically engage in many times each day. For many of us, theprocess is so automatic and familiar that we do not notice it. However, awide body of research indicates that the formation of causal attributions isvital for adapting to changing environments and overcoming the challengeswe are confronted with in our daily lives. When we experience desirableoutcomes, attributions help us understand what caused those events so wecan experience them again. When we experience unpleasant outcomes,attributions help us identify and avoid the behaviors and other factors thatcaused them to occur.Figure 7–1 Attribution–Emotion–Behavior ProcessFritz Heider (1958) argued that all people are “naïve psychologists” whohave an innate desire to understand the causes of behaviors and outcomes.Attribution theory holds that attributions for these behaviors and outcomesultimately help to shape emotional and behavioral responses (Weiner, 1985).A simplified depiction of this attribution–emotion–behavior process is shownin Figure 7–1. In order to understand these relationships, however, it isimportant to be familiar with the various dimensions along whichattributions can be classified.First, attributions can be classified along the dimension of locus ofcausality, which describes the internality or externality of an attribution. Aphysician who misdiagnoses a patient and attributes this medical error tohis own carelessness (i.e., overlooked the patient’s symptoms) is making aninternal attribution. If the same outcome is attributed to faulty laboratoryresults, the physician is making an external attribution. The locus ofcausality dimension is particularly relevant to emotional reactions. Internal

attributions for undesirable events or behaviors are frequently associatedwith self-focused negative emotions, such as guilt and shame. Externalattributions for the same behaviors and outcomes are generally associatedwith externally focused negative emotions, such as anger and resentment(Gundlach, Douglas, & Martinko, 2003; Weiner, 1985).Attributions can also be categorized along the stability dimension. Stablecauses are those that tend to influence outcomes and behaviors consistentlyover time and across situations. Causes such as intelligence and physical orgovernmental laws are generally considered relatively stable in naturebecause they are difficult, if not impossible, to change. Unstable causalfactors, such as the amount of effort exerted toward a task, arecomparatively easy to change. Unlike the locus of causality dimension,which primarily influences emotional reactions to events and behaviors, thestability dimension affects individuals’ future expectations (Kovenklioglu &Greenhaus, 1978). When an outcome such as poor performance is attributedto a stable cause, such as low intelligence, it is logical to expect that theemployee’s performance is not going to change in the future. If the samepoor performance is attributed to a less stable factor, such as temporaryillness or insufficient effort, we can expect that the employee could improvehis or her performance in the future.Researchers have also classified attributions in terms of the intentionalityand controllability of the cause (Weiner, 1995). However, for the purposes ofunderstanding the basic impact of attributions on motivation, we will limitour discussion to the aforementioned dimensions of locus of causality andstability. Thus, we can consider attributions that are internal and stable(e.g., intelligence), external and stable (e.g., laws), internal and unstable(e.g., effort), or external and unstable (e.g., temporary organizationalpolicies). Before examining the influence of these attributions onmotivational states, however, it is useful to understand how attributionstyles can bias and distort the attributions individuals form.ATTRIBUTION STYLEIt is important to recognize that, as with all perceptions, attributions arenot always an accurate reflection of reality. We can probably all think of aninstance where someone failed at a task because of his or her own actions,but erroneously blamed the failure on other people or circumstances. In fact,if we are totally honest with ourselves, we can each probably recall one ortwo instances where we made such false attributions ourselves.Astute observers may also notice that some people make these

attributional errors more frequently than others. These individuals are saidto have a biased attribution style. An attribution style is defined as atendency to consistently contribute positive and negative outcomes to aspecific type of cause (e.g., internal or external, stable or unstable). Theaforementioned tendency to attribute negative outcomes to external factorsis often coupled with a tendency to attribute positive outcomes to internalfactors. This self-serving attribution style is referred to as an optimisticattribution style (Abramson, Seligman, & Teasdale, 1978; Douglas &Martinko, 2001). This term reflects the fact that people with an optimisticattribution style often feel good about themselves and their capacity forsuccess. An obvious downside, however, is that this personal optimism maybe unfounded and can set the individual up for disappointments in thefuture. Not surprisingly, employees with an unjustified sense of entitlementtypically demonstrate high levels of this type of bias (Harvey & Martinko,2009).A second attribution style, known as a pessimistic attribution style,denotes the opposite tendency. Individuals who demonstrate thisattributional tendency frequently attribute undesirable events to internaland frequently stable factors such as lack of intelligence, while attributingdesirable outcomes to external and frequently unstable factors, such as goodluck. As the name suggests, people who exhibit this tendency often lackconfidence in themselves and are pessimistic concerning their chances forsuccess (Abramson, Seligman, & Teasdale, 1978). This tendency can alsopromote depression and a tendency toward learned helplessness.A third attributional tendency, known as a hostile attribution style, alsowarrants discussion. This style is similar to the optimistic style justdescribed in that it denotes a tendency toward external attributions fornegative outcomes. The two styles differ in that the external attributions forundesirable events associated with a hostile style are also stable in nature.A study by Douglas and Martinko (2001) suggested that the stability ofthese attributions could promote anger toward the external “entity” (e.g.,one’s manager) and increase the likelihood of an aggressive response. Itappears, for example, that a number of highly publicized incidents ofworkplace violence that have occurred in the United States were committedby individuals with a history of consistently external and stable causalexplanations for the negative events in their lives. As such, we can concludethat hostile attribution styles in the workplace are not only unproductivebut can also be dangerous as well.

Table 7–1 Summary of Attribution StylesAttributionalStyleImpact on AttributionsExamplesOptimisticBiased toward internal (often stable) attributions forpositive outcomes, external (often unstable) fornegative outcomes.Attribute successful diagnoses to personalability, and misdiagnoses to inadequateinformation from others.PessimisticBiased toward internal (often stable) attributions fornegative outcomes, external (often unstable) forpositive outcomes.Attribute successful outcomes to good luck; pooroutcomesare attributed to lack of personalability.HostileBiased toward external, stable attributions fornegative outcomes.Attribute most workplace problems to a biasedand vengeful manager.Before discussing the implications of these attribution styles (see Table7–1), and attributions in general, on employee motivation, one point shouldbe clarified. In many situations the causes of an event are perfectly clear.For example, a driver who is rear-ended at a traffic light well after comingto a complete stop is going to blame the other driver regardless of herattribution style. Thus, because attribution styles are only tendencies tomake certain types of attributions, they are unlikely to have an effect insituations where the causes of an outcome are obvious. However, when thecauses are ambiguous, attribution styles are more likely to have an effect. Amanager’s goal, therefore, should be to make (as well as to encourage)accurate and unbiased attributions so that employees’ successes can berepeated and the causes of problems can be rectified. (See Exhibit 7–1 atend of chapter.)ATTRIBUTIONS AND MOTIVATIONAL STATESOur discussion of attributions and motivational states is divided into foursections, each of which describes a desirable or undesirable motivationalstate and the capacity of specific attributions and attribution styles to bringabout these states. Two undesirable states, learned helplessness andaggression, are discussed first. Two desirable motivational states,empowerment and resilience, are then discussed.Learned HelplessnessAfter repeated punishments and failures, people often become passive andunmotivated and stay that way even after the environment changes so thatpersonal or professional success is possible (Abramson, Seligman, &Teasdale, 1978; Martinko & Gardner, 1987). This phenomenon has beenlabeled “learned helplessness” because it describes a situation in which

individuals come to believe that effort is futile because failure is inevitable.They have, in effect, learned to be helpless.Learned helplessness is a consequence of the reinforcement process. Whenpeople see that behaviors lead to desired rewards and outcomes, they aremotivated to repeat those behaviors. When specific behaviors do not achievedesired outcomes, the motivation to perform those behaviors is lost. Learnedhelplessness was first observed by Overmier and Seligman (1967) in dogsplaced in a shuttle box with two sides. One side had an electric grid, and theother side was safe. Initially, the dogs were tethered to the electrified half ofthe chamber. Before administering an unpleasant, but nonlethal, shock, alight flashed. The dogs quickly learned to associate the flash of light withthe impending electrical shock, because of classic conditioning. After theconditioning was complete, the experimenters removed the tethers that hadpreviously made escaping to the nonelectrified side of the chamberimpossible. Instead of leaping to safety when the light flashed, however,most of the dogs froze, whimpered, and braced themselves for the shock. Itwas concluded that the dogs had “learned” helplessness, believing that theshock was inevitable regardless of their efforts.More recent research suggests that this tendency toward learnedhelplessness is also common in people and that organizational rules andnorms can cause learned helplessness among employees in the same waythe experiments induced it in dogs (Martinko & Gardner, 1987).Specifically, organizational policies/norms and leaders’ behaviors that causeemployees to feel that success or recognition is unobtainable are likely toinhibit motivation. For instance, a manager who routinely takes credit forher subordinates’ successes while blaming them for their failures may findherself with employees who see little reason to work any harder than isnecessary to keep their jobs. Similarly, an organization that forcesemployees to follow outdated and ineffective procedures may find itself withemployees who show little urgency or interest in their work, given that theyexpect the effort to fail. If you expect to fail, why bother trying?The significance of organizationally induced learned helplessness is that,like the aforementioned dogs, it often remains even when the barriers tosuccess are removed. To continue the previous examples, if the unfairmanager is replaced or restrictive policies are removed, we might expectthat employee motivation and performance would immediately improve. Thereality, however, is that employees who work under such conditions for anextended period of time often retain their learned helplessness and remainunmotivated even after the situation and conditions change.

This tendency can be explained by the attribution process. Externalbarriers to success in the workplace can, ironically, promote internal andfrequently stable attributions for failures while promoting externalattributions for successes. Over time, these attributions can manifestthemselves in the form of a pessimistic attribution style, causing employeesto accept blame for failures they did not contribute to, while attributingsuccesses to their manager or to other external factors. To illustrate, amanager who consistently takes credit for departmental successes whileblaming employees for failures can, over time, cause employees to believeand feel that they are incompetent at their jobs. This perception can remaineven after the manager is removed if proper steps to restore employees’confidence are not taken. This example also illustrates one of the downsidesof the aforementioned optimistic attribution style. Organizational leaderswho demonstrate this tendency may feel good about themselves (at least inthe short term), but their tendency to take credit for successes and attributeblame for failures to others may cause their employees to lose confidenceand experience learned helplessness.AggressionAnother undesirable motivational state discussed here differs fromlearned helplessness in several ways. Perhaps the most significant is that,unlike the diminished motivation associated with learned helplessness,aggression refers to a state of heightened motivation. The problem is thatthis motivation is focused on an undesirable behavior or goal.Instrumental aggression describes behaviors targeted at obtaining a goalthat the employing organization is not providing. For instance, an employeewho feels he is underpaid and steals from his employer is performinginstrumental aggression. Hostile aggression refers to behaviors aimedprimarily at harming another person or entity. An employee who physicallyattacks a manager, for example, probably does so not to get anything fromthe manager, except the satisfaction of inflicting physical pain. Beyond theobvious surface-level differences in these forms of aggression, there aredifferent underlying motivations (Martinko, Douglas, et al., 2005). Whereasinstrumental aggression is primarily motivated by a desire to obtainsomething, hostile aggression is motivated by a desire to retaliate and harmothers.Both types of motivation may be sparked by the causal perceptionsassociated with hostile attribution styles. Case Study 7–1, at the end of thechapter, describes a study that indicated that individuals can more easily

justify instrumental acts of deviance, such as forging paperwork or lyingabout their performance, in response to negative workplace events thatwere attributable to stable organizational factors (e.g., inadequateresources). Research has also shown that the attribution of undesirableworkplace outcomes to external and stable causes can increase thelikelihood of a hostile aggressive response. Similarly, research suggests thatindividuals with a hostile attribution style are more likely to engage in actsof hostile aggression than others (Douglas & Martinko, 2001). In addition toempirical research evidence, anecdotal reports suggest that a number ofworkplace shootings in the United States, such as those at several U.S. PostOffice facilities, were perpetrated by individuals with external attributionaltendencies.Several studies have suggested that a hostile attribution style can trulybe a double-edged sword for managers. In addition to having a heightenedtendency toward aggressive behaviors, employees with hostile attributionstyles also appear to be prone to perceive that they, themselves, are victimsof such behavior. One study found that employees with hostile attributionstyles were significantly more likely than other employees to view theirsupervisors as abusive in their behaviors toward them (Martinko, Harvey,et al., 2011). Building on this finding, a later study compared pairs ofemployees who shared the same supervisor and found that employees with astronger hostile bias consistently rated the shared supervisor as being moreabusive than more objective employees did (Harvey, Harris, Gillis, &Martinko, 2014). Worse, this study also showed that although theperceptions of mistreatment in these employees may have been inaccurate,they were nonetheless correlated with retaliatory behavior targeting theemployees’ supervisors.From this evidence we can conclude that employees who attributenegative events at work to external and stable causes are more likely thanothers to become motivated to engage in aggressive behaviors. A keyelement in determining which form of aggression will occur, or if anyaggression will occur at all, appears to be the perceived intent of theresponsible party. In cases where an undesirable workplace event is deemedto be caused by factors beyond the control of any specific party (e.g., aneconomic downturn), aggression becomes less likely (Harvey, Martinko, &Borkowski, 2007). There is some evidence, however, that some individualswill remain motivated to engage in acts of instrumental aggression in thesesituations (see Martinko, Douglas, et al., 2005). When it is perceived that anexternal and stable factor caused a negative outcome and could have been

prevented, hostile aggression toward the “guilty” party becomes more likely.This is probably due to the feelings of anger associated with suchperceptions (Weiner, 1995). That is, when causality and intent can beattributed to a specific person or entity, people often feel anger, which, inturn, frequently motivates acts of hostility.EmpowermentTurning our attention to desirable motivational states, we first discussthe notion of empowerment. Empowerment refers to a heightened state ofmotivation caused by optimistic effort-reward expectations (Conger &Kanungo, 1994). Put differently, empowered individuals expect their effortstoward their goals to succeed and are therefore motivated to exert highlevels of effort. Empowerment is also associated with high levels ofinnovation and managerial effectiveness (Spreitzer, 1995).Because empowerment among employees is generally good for overallorganizational effectiveness, it is helpful to understand the cognitiveprocesses that help foster this state of heightened motivation. Research hasshown that the causal attribution process can tell us a lot about howemployees become empowered. Unlike learned helplessness, empowermentappears to result from the attribution of negative workplace events tofactors that are either internally controllable or that are external, unstable,and uncontrollable. Thus, a physician who misdiagnoses a patient’s disease,but believes the error was under her control (e.g., “I didn’t think to checkfor this disease, but I will know to do so in the future”), is less likely toexperience strongly negative emotions and learned helplessness than aphysician who attributes the error to his incompetence. Similarly, aphysician who attributes a similar error to an external, unstable, anduncontrollable factor (e.g., the patient gave incomplete information andthere was not enough time to run a full battery of diagnostic tests) is likelyto feel optimistic about her future chances for successful diagnoses.Naturally, we can also expect individuals who attribute positive events tointernal factors, such as their intelligence, skill, and effort, to experienceempowerment (Martinko & Gardner, 1987). It follows that individuals withan optimistic attribution style are more likely to demonstrate empowermentthan those with pessimistic or hostile attribution styles. Recall, however,that attribution styles can cause individuals to form inaccurate perceptionsof causality. A caveat, therefore, is that those with an optimistic attributionstyle may become disillusioned with themselves and feel empowered evenwhen their skills and abilities are lacking. Thus, as we discuss later in the

chapter, it may be more important to promote attributions that are accuratethan to encourage attributions that are optimistic.ResilienceResilience is defined as a “staunch acceptance of reality … strongly heldvalues, and an uncanny ability to improvise and adapt to significant change”(Coutu, 2002, p. 47). Research suggests that resilient people are relativelygood at developing accurate attributions (Huey & Weisz, 1997). Morespecifically, it appears that people with low levels of resilience have atendency to be overly external or internal in their attributions for negativeoutcomes. Thus, people who are non-resilient are likely to err in theirattributions and are prone to blame others or themselves for their failures.As we have discussed, either of these attributional errors can promotenegative motivational outcomes. High levels of resilience have the oppositeeffect, helping people keep their attributions in line with reality (recall thatresilience denotes a “staunch acceptance of reality”).Resilience, then, can be thought of as a factor that helps individuals avoidthe attributional errors that can hurt motivation levels. By promotingaccurate causal perceptions, resilience helps to keep people grounded inreality and helps to prevent pessimistic and hostile attributional tendencies.It is also likely that resilience can help prevent overly optimisticattributions, and the disillusionment and unfounded optimism noted in theprevious section.If we assume that resilience is good for promoting motivation throughaccurate attributions, the next logical question is, where does resiliencecome from? We begin the next section by addressing this question, afterwhich we discuss some additional techniques for promoting empowermentwhile discouraging learned helplessness and aggression.Table 7–2 Summary of Attributions Associated with Motivational StatesMotivational StateAssociated Attributional TendencyLearnedHelplessnessTend to favor internal and stable attributions for failures; external attributions for successesAggressionTend to favor external and stable attributions for failuresEmpowermentTend to favor internal and stable attributions for successes; external and unstable attributions forfailuresResilienceTend to favor accurate attributions, not biased toward overly internal or external attributions forsuccesses or failuresPROMOTING MOTIVATIONAL ATTRIBUTION

PROCESSESIn this section, we summarize five techniques that can be used bymanagers to promote and maintain employee motivation. These techniquesare grounded in the formation of accurate and empowering attributions.Screening for ResilienceIn the previous section, we discussed the benefits of resilience for formingattributions that are accurate and motivational. Unlike most of thesuggestions in this section, however, our advice concerning resilience doesnot focus on increasing it among existing employees. This is becauseindividuals’ levels of resilience appear to form very early in life (Masten,2001). With proper emotional support, children have shown remarkablyhigh levels of resilience in dealing with undesirable circumstances, such aspoverty and violence. Conversely, we are probably all familiar with bothchildren and grown adults who break down in response to relatively minorproblems. This suggests that resilience levels are formed early in life andare unlikely to change dramatically in the course of normal life events (notethat drastic events such as war and serious disease often result in increasedresilience levels in adults, but these do not fall under the umbrella of“normal life events”).Employers may determine that their organizations require a high level ofresilience in their employees. Hospitals, for example, can provide a verystressful and emotionally draining working environment. If employees formoverly hostile or pessimistic attributions in response to the negative eventsthat are bound to happen in such settings, motivational problems are likelyto arise. This type of organization, then, will probably benefit from aresilient workforce. A less stressful organization, on the other hand, mightnot require such resilience among employees.Organizations such as hospitals that require high levels of resilienceshould, then, try to attract and hire individuals that demonstrate highlevels of resilience. Although it is unlikely that managers can increase theresilience levels of employees, they can try to form a workforce that hashigh preexisting levels. This can be accomplished through the use ofstandardized measures of resilience (see Huey & Weisz, 1997, for anexample) during the employee screening process, or through simpleinterview questions. Asking potential candidates to describe past hardships,and their responses to these hardships, is likely to shed light both oncandidates’ resilience levels and their attributional tendencies (Campbell &

Martinko, 1998).Attributional TrainingAlthough resilience is a fairly stable and unchanging personalcharacteristic, accurate and optimistic attributional tendencies can befostered in other ways. One technique for accomplishing this is attributionaltraining (Martinko & Gardner, 1987). This can take several forms, one ofwhich is measuring employees’ attribution styles with an existingassessment device (see Kent & Martinko, 1995; Lefcourt, 1991; Lefcourt etal., 1979; Peterson, Bettes, & Seligman, 1985; Peterson, Semmel, et al.,1982; and Russell, 1982, for examples of these instruments) and discussingtheir attributional biases with them. Often, by simply realizing that theyfavor overly optimistic, pessimistic, or hostile attributions, individuals canbegin to deliberately adjust their “perceptual lenses” to correct for theirbiases. Over time, this correction can become subconscious, allowingemployees to form accurate attributions without additional cognitive effort.A second form of attributional training is less formal and involvesdiscussing the causes of employees’ successes and failures on a case-by-casebasis. This can help employees understand both the internal and externalfactors involved with workplace outcomes, by helping them to understandthe “big picture” in terms of the multiple personal and situational factorslikely to contribute to positive and negative events. This promotes a morethorough causal search process and can help employees avoid the cognitiveshortcuts that enable overly optimistic, pessimistic, or hostile attributions.ImmunizationAnother technique recommended by Martinko and Gardner (1987) is toimmunize against demotivational attributions by enabling successes early inan employee’s career or tenure with an organization. An employee who failsmiserably at the first few tasks she is assigned in a new position mayquickly decide that she lacks the ability to succeed at the job (an internaland somewhat stable attribution). If she is allowed to tackle a number ofmore surmountable assignments before engaging in more difficult tasks,however, she is likely to see that she has the basic ability to succeed at thejob. This will probably promote more optimistic attributions throughout theemployee’s tenure by providing a basic level of confidence at the beginning.Increasing Psychological Closeness

In addition to individual attributional biases, employees can also becomethe unwitting victims of their managers’ inaccurate attributional tendencies(Martinko, 1995). Managers provide an important, and often highly valued,source of feedback for employees. If this feedback consistently attributesblame for negative outcomes to employees’ internal characteristics,employees might accept the feedback as accurate even if it is not, andexperience organizationally induced learned helplessness (Martinko &Gardner, 1987).Research suggests that people in observational capacities (which is oftenthe case for managers) frequently tend to be overly dispositional in theirattributions for others’ performance (Jones & Nisbett, 1971). That is, theytend to focus on the influence of actors’ effort and ability levels whileoverlooking situational factors that contribute to performance. In otherwords, managers can be overly hard on employees when their performanceis low. Managers might also demonstrate an optimistic attribution style andtake credit for the successes of their departments without giving credit totheir subordinates, while also blaming employees when their department’sperformance suffers. Again, these tendencies can be demotivational,particularly if employees believe their managers’ attributional explanationsfor their performance.One technique for avoiding this tendency is to promote psychologicalcloseness. Psychological closeness describes the extent to which two or morepeople form the same perceptions regarding their situation. Research hasshown that managers who have direct experience with the work theiremployees perform are relatively less likely to form inaccurate attributionsregarding employee performance. Managers who have little or no experiencewith their employees’ tasks (or who have not performed them in a longtime) appear to be less familiar with the situational challenges associatedwith the work and are more likely to blame employees’ effort and abilitylevels when their performance is low (Fedor & Rowland, 1989).To increase psychological closeness between managers and employees,organizations should work to ensure that managers have experience withthe work their subordinates perform. This can be accomplished throughinternal promotions (i.e., selecting future managers from the pool ofemployees currently performing the job to be supervised) and by requiringexisting managers to perform the jobs they are managing from time to time.These techniques will ensure that managers are familiar with both theinternal and external factors associated with performance, allowing moreaccurate and motivational attributional feedback to be formed and

communicated to employees.Multiple Raters of PerformanceA final recommendation for improving the accuracy and motivationalcapacity of employees’ attributions is the use of multiple raters ofperformance, when possible (Martinko, 2002). As mentioned previously,managers can demonstrate attribution styles that bias them towarddemotivational explanations for employee performance. This tendency canbe offset by the use of multiple performance raters.An illustrative example of this style of judging performance is the use ofmultiple judges to evaluate figure skaters in the Olympics. This system isused to help ensure that potential biases among one or more raters can beoffset by the accuracy, or counteracting biases, of other judges. Similarly,organizations can use more than one individual to rate the performance ofemployees. An increasingly common example of this is the use of 360-degreeevaluations, in which peers, managers, subordinates, customers, and theemployees themselves rate performance. Although each of these parties maydemonstrate some attributional inaccuracy, the hope is that through the useof multiple sources, an accurate picture of the causes of each employee’ssuccesses and failures will emerge. With this information, the proper stepscan be taken to correct poor performance and encourage future successes,ultimately promoting empowerment among employees. (See Case Study 7–1at end of chapter.)SUMMARYOur overarching goal in this chapter was to illustrate the importance ofattributional perceptions in predicting employee motivation. One of the keyfindings from research on this topic is that internal and stable attributionsfor successes in the workplace, as well as external and unstable attributionsfor negative workplace events, are associated with higher levels ofempowerment. We have seen repeatedly, however, that such attributionsare desirable only when they are accurate. If an employee fails at a taskbecause the employee is simply not “cut out” for the type of work beingperformed, it is generally better for the employee to realize that the task istoo demanding. Similarly, if failures are caused by unstable internal factorssuch as insufficient effort, it is important for employees to make thatattribution, even if it is not the most desirable short-term conclusion. These

accurate attributions help steer employees down the path towardempowerment, and managers can assist in the process by providing honestand accurate assessments of the causes of employees’ performance.DISCUSSION QUESTIONS1. What is an attribution?2. Differentiate between optimistic, pessimistic, and hostile attributionstyles.3. Why might an optimistic attribution style be undesirable?4. How can different types of attributions and attribution stylesencourage high or low levels of learned helplessness, aggression, andempowerment?5. How does resilience promote motivational attributions?6. How can organizational leaders promote accurate and motivatingattributions among their employees?CASE STUDIES AND EXERCISECase Study 7–1 Managing Employees’ AttributionsDavid was just promoted to manage a small medical transcription department and has inherited aproblem. His predecessor recently completed annual performance evaluations of the staff, and it isnow time to distribute annual raises based, in large part, on these evaluations. Of the sevenemployees David now manages, all received fairly strong evaluations, mostly in the “above average”range, although no one received the highest rating of “excellent.” The budget for David’s departmentwill not be growing much for the next few years, and there is very little room for salary increases.Had any of the employees achieved higher performance levels, he might have been able to apply forextra merit pay funding, but this does not appear to be an option.Because all seven employees received relatively strong evaluations, and there was not muchdifference between the highest and lowest performers, he has decided to allocate the raises equallyamong them. These raises will probably be disappointingly small, however. David is trying to decidehow to break the disappointing news to his staff in the least demotivational way possible. He isweighing the following options:1. Explain to the staff that they deserve larger raises but, based on the long-term departmentalbudget, this was the best he could do for them.2. Explain to the staff that he could have gotten them larger raises if their performance levels hadbeen higher.3. Explain to the staff that they deserve larger raises and that he, as their manager, failed them bynot doing more for them.4. Explain to the staff that these raises are fair, given their performance levels.Discussion Questions

1. What attributions are being communicated in each of these explanations? Are they internal orexternal? Are they stable or unstable?2. From a motivational standpoint, what potential pros and cons do you see for each of theseexplanations?3. Which of these four options (or which combination of two or more) do you think would be leastdemotivational for the staff? Why?Case Study 7–2 “Unhealthy” Motivation: How Physicians Justify Deviant BehaviorWe probably all know the feeling; something bad happens at work and there are a few choices fordealing with it. You can go “by the book,” and potentially suffer some unpleasant consequences, orbend the rules just a bit to make the whole thing go away. For example, imagine a situation whereyou miss a deadline by a few hours. You can choose to tell your manager or, because your managerhappens to be in a long meeting, finish the job late and slip it under some paperwork on her desk,claiming that it has been there all day. You know what you should do, but you also know that thesneakier alternative is probably the path of least resistance. What would you do?Your answer to this question would probably depend, at least in part, on why you missed thedeadline in the first place. If you missed the deadline because you procrastinated all week and thentook an extended lunch break on the day the work was due, you might feel a degree of guilt overlying to your manager. Attribution theory suggests that this is because you are attributing themissed deadline to an internal and unstable/controllable factor—namely, insufficient effort. Thisguilt might, depending on other factors, such as your values and the consequences of your managerlearning of the missed deadline, reduce your willingness to lie about finishing the work on time.Your response might change, however, if you feel that you missed the deadline because theamount of time your manager gave you to complete the work was unreasonably short. If you workedlate and skipped lunch all week, but still needed a couple extra hours to get the work done, you aremuch less likely to blame yourself. Instead, you will probably attribute the missed deadline to anexternal and relatively stable factor—your manager. Such attributions are associated with anger,and anger is a strong motivator of deviant behavior. This attribution-driven anger might help youfeel justified in sneaking the work onto your manager’s desk. After all, why should you get in troubleif the request was unreasonable?To test the strength of attributions such as these to motivate deviant behaviors, Harvey et al.(2005) examined the relationship between attributions, emotions, and the justification of workplacedeviance using a sample of physicians. The researchers gave the physicians a hypothetical scenariosimilar to the one just described and asked them whether they would feel comfortable altering dateson paperwork to disguise the fact that a nonlethal, but procedural, mistake had been made indiagnosing a patient. Each physician was given the same hypothetical scenario with one difference—the cause for the mistake (i.e., the attribution) was varied so that in some cases the mistake was dueto internal and stable or unstable factors (i.e., the physician has poor attention to detail or wasdistracted), or to external and stable or unstable factors (i.e., the physician’s department ischronically understaffed, or an emergency meeting was called and the required test could not beordered on time).As you might expect, on the basis of the preceding discussion, physicians were more likely to saythey would alter the paperwork when the cause of the mistake was beyond their control and wasstable (i.e., likely to occur again) in nature. Before taking an overly dim view of these physicians,however, remember that the hypothetical mistake described in the scenarios was deliberatelydesigned to be minor and inconsequential. Still, this study provides some insight into the power ofattributions to motivate behaviors we might not normally consider.This justification process is an almost unavoidable part of life. There are always going to be timeswhere it is tempting to break the rules because we feel that it is a justifiable response to awrongdoing we have suffered. Indeed, many timeless stories are based on the notion of justifiable

wrongdoing—Robin Hood returning the king’s wealth to the peasants, for example.There is a decidedly darker side to the justification process, however. Perpetrators of manyserious crimes throughout history have, at least at the time of the crime, convinced themselves thatthey were justified in their behavior. In many cases, the justification can be traced to a desire forrevenge resulting from the attribution of negative events to externally controllable, stable factors.Thus, we can see that there is more at stake than productivity when it comes to forming accurateattributions.Exhibit 7–1 Attribution Style Self-Assessment: Measure Your Attribution Style for Negative EventsTo complete this assessment, begin by reading each of the hypothetical scenarios below andimagine them happening to you. Then, try to imagine what the most likely cause of each eventwould be if it did happen to you.1. You recently received a below-average performance evaluation from your supervisor.What is the most likely cause of this outcome? __________a. To what extent was this outcome caused by something about you?Nothing to do with me 1 2 3 4 5 6 7 Totally due to meb. Will this cause be present in similar future situations?Never present 1 2 3 4 5 6 7 Always present2. Today, you were informed that suggestions you made to your supervisor in a meeting wouldnot be implemented.What is the most likely cause of this outcome? __________a. To what extent was this outcome caused by something about you?Nothing to do with me 1 2 3 4 5 6 7 Totally due to meb. Will this cause be present in similar future situations?Never present 1 2 3 4 5 6 7 Always present3. You recently learned that you will not receive a promotion that you have wanted for a longtime.What is the most likely cause of this outcome? __________a. To what extent was this outcome caused by something about you?Nothing to do with me 1 2 3 4 5 6 7 Totally due to meb. Will this cause be present in similar future situations?Never present 1 2 3 4 5 6 7 Always present4. You recently discovered that you are being paid considerably less than another employeeholding a position similar to yours.What is the most likely cause of this outcome? __________a. To what extent was this outcome caused by something about you?Nothing to do with me 1 2 3 4 5 6 7 Totally due to meb. Will this cause be present in similar future situations?Never present 1 2 3 4 5 6 7 Always present

5. You recently received information that you failed to achieve all of your goals for the lastperformance reporting period.What is the most likely cause of this outcome? __________a. To what extent was this outcome caused by something about you?Nothing to do with me 1 2 3 4 5 6 7 Totally due to meb. Will this cause be present in similar future situations?Never present 1 2 3 4 5 6 7 Always present6. You have a great deal of difficulty getting along with your coworkers.What is the most likely cause of this outcome? __________a. To what extent was this outcome caused by something about you?Nothing to do with me 1 2 3 4 5 6 7 Totally due to meb. Will this cause be present in similar future situations?Never present 1 2 3 4 5 6 7 Always present7. You just discovered that a patient recently complained about the services you provided.What is the most likely cause of this outcome? __________a. To what extent was this outcome caused by something about you?Nothing to do with me 1 2 3 4 5 6 7 Totally due to meb. Will this cause be present in similar future situations?Never present 1 2 3 4 5 6 7 Always present8. A large layoff has been announced at your organization, and you are told that you will be oneof those laid off.What is the most likely cause of this outcome? __________a. To what extent was this outcome caused by something about you?Nothing to do with me 1 2 3 4 5 6 7 Totally due to meb. Will this cause be present in similar future situations?Never present 1 2 3 4 5 6 7 Always presentEnter the sum of your A scores here: __________Enter the sum of your B scores here: __________Scoring Key:Your A score represents the locus of causality dimension of your attribution style for negativeoutcomes. A score above 28 represents an internal attribution style, with scores closer to themaximum of 56 indicating a relatively more internal style (i.e., a tendency to attribute negativeoutcomes to internal causes). A score below 28 represents an external attribution style, withscores closer to zero indicating a relatively more external style (i.e., a tendency to attributenegative outcomes to external causes).Your B score represents the stability dimension of your attribution style for negativeoutcomes. A score above 28 represents a stable attribution style, with scores closer to themaximum of 56 indicating a relatively more stable style (i.e., a tendency to attribute negativeoutcomes to stable causes). A score below 28 represents an unstable attribution style, with scorescloser to zero indicating a relatively less stable style (i.e., a tendency to attribute negativeoutcomes to unstable causes).

Modified from Kent, R. L., & Martinko, M. J. (1995). The measurement of attributions inorganizational research. In Martinko, M. J. (Ed.) Attribution theory: An organizationalperspective (pp. 53–75). Delray Beach, FL: St. Lucie Press. Reprinted with permission.Discussion Questions1. According to this test, do you have an attribution style that favors internal or externalattributions for negative outcomes?2. According to this test, do you have an attribution style that favors stable or unstableattributions for negative outcomes?3. Would you characterize your attribution style as optimistic? Pessimistic? Hostile?4. If you were managing an employee with this attribution style, how would you help him orher stay motivated when negative events occur?REFERENCESAbramson, L. Y., Seligman, M. E. P., & Teasdale, J. D. (1978). Learnedhelplessness in humans: Critique and reformulation. Journal of AbnormalPsychology, 87, 49–74.Campbell, C. R., fe Martinko, M. J. (1998). An integrative attributionalperspective of empowerment and learned helplessness: A multi-methodfield study. Journal of Management, 24, 173–200.Conger, J. A., & Kanungo, R. N. (1994). Charismatic leadership inorganizations: Perceived behavioral attributes and their measurement.Journal of Organizational Behavior, 15, 439–452.Coutu, D. L. (2002). How resilience works. Harvard Business Review, 80,46–55.Douglas, S. C., & Martinko, M. J. (2001). Exploring the role of individualdifferences in the prediction of workplace aggression. Journal of AppliedPsychology, 86, 547–559.Fedor, D. B., & Rowland, K. M. (1989). Manager attributions forsubordinate performance. Journal of Management, 15, 37–48.Gundlach, M. J., Douglas, S. C., & Martinko, M. J. (2003). The decision toblow the whistle: A social information processing framework. Academy ofManagement Review, 28, 107–123.Harvey, P., & Martinko, M.J. (2009). An empirical examination of the roleof attributions in psychological entitlement and its outcomes. Journal ofOrganizational Behavior, 30(4), 459–416.Harvey, P., Harris, K. J., Gillis, W. E., & Martinko, M. J. (2014). Abusivesupervision and the entitled employee. Leadership Quarterly, 25(2), 204–

217.Harvey, P., Martinko, M. J., & Borkowski, N. (2007). Unethical behavioramong physicians and students: Testing an attributional and emotionalframework. Presented at the 2007 Academy of Management Conference,Philadelphia, PA.Heider, F. (1958). The psychology of interpersonal relations. New York, NY:John Wiley & Sons.Huey, S. J., & Weisz, J. R. (1997). Ego control, ego resiliency, and the five-factor model as predictors of behavioral and emotional problems in clinic-referred children and adolescents. Journal of Abnormal Psychology, 106,404–415.Jones, E. E., & Nisbett, R. E. (1971). The actor and the observer: Divergentperceptions of the causes of behavior. In E. E. Jones, D. E. Kanouse, H.H. Kelley, R. E. Nisbett, S. Valins, & B. Weiner. (Eds.), Attribution:Perceiving the causes of behavior (pp. 79–94). Morristown, NJ: GeneralLearning Press.Kent, R., & Martinko, M. J. (1995). The development and evaluation of ascale to measure organizational attribution style. In M. Martinko (Ed.),Attribution theory: An organizational perspective (pp. 53–75). DelrayBeach, FL: St. Lucie Press.Kovenklioglu, G., & Greenhaus, J. H. (1978). Causal attributions,expectations, and task performance. Journal of Applied Psychology, 63,698–705.Lefcourt, H. M. (1991). The multidimensional-multiattributional causalityscale. In J. P. Robinson, P. R. Shaver, & L. S. Wrightsman (Eds.),Measures of personality and social psychological attitudes (Vol. 1, pp.454–457). San Diego, CA: Academic Press.Lefcourt, H. M., Von Baeyer, C. L., Ware, E. E., & Cox, D. J. (1979). Themultidimensional-multiattributional causality scale: The development of agoal specific locus of control scale. Canadian Journal of BehaviouralScience, 11, 286–304.Martinko, M. J. (1995). The nature and function of attribution theorywithin the organizational sciences. In M. J. Martinko (Ed.), Attributiontheory: An organizational perspective (pp. 7–16). Delray Beach, FL: St.Lucie Press.Martinko, M. J. (2002). Thinking like a winner: A guide to highperformance leadership. Tallahassee, FL: Gulf Coast Publishing.Martinko, M. J., Douglas, S. C., Harvey, P., & Joseph, C. (2005). Managingorganizational aggression. In R. Kidwell & C. Martin (Eds.), Managing

organizational deviance: Readings and cases (pp. 237–260). ThousandOaks, CA: Sage.Martinko, M. J., & Gardner, W. L. (1987). The leader-member attributionprocess. Academy of Management Review, 12, 23–249.Martinko, M. J., Harvey, P., & Sikora, D., & Douglas, S. C. (2011).Perceptions of abusive supervision: The role of attribution style.Leadership Quarterly, 22, 751–164.Masten, A. S. (2001). Ordinary magic: Resilience processes in development.American Psychologist, 56, 227–238.Overmier, J. B., & Seligman, M. E. P. (1967). Effects of inescapable shockupon subsequent escape and avoidance learning. Journal of Comparativeand Physiological Psychology, 63, 23–33.Peterson, C., Bettes, B. A., & Seligman, M. E. P. (1985). Depressivesymptoms and unprompted casual attributions: Content analysis.Behavior Research and Therapy, 23, 379–382.Peterson, C., Semmel, A., Von Baeyer, C., Abramson, L., Metalsky, G., &Seligman, E. (1982). The attributional style questionnaire. CognitiveTherapy and Research, 6, 287–300.Russell, D. (1982). The causal dimension scale: A measure of howindividuals perceive causes. Journal of Personality and Social Psychology,42, 1137–1145.Spreitzer, G. M. (1995). Psychological empowerment in the workplace:Dimensions, measurement, and validation. Academy of ManagementReview, 38, 1442–1465.Weiner, B. (1985). An attributional theory of achievement motivation andemotion. Psychological Review, 97, 548–573.Weiner, B. (1995). Judgments of responsibility: A foundation for a theory ofsocial conduct. New York, NY: Guilford Press.OTHER SUGGESTED READINGSchermerhorn, J. R. (1987). Improving health care productivity throughhigh-performance. Health Care Management Review, 12(4), 49–55.

PART IIILeadership“Power is America’s last dirty word. It is easier to talk about money—andmuch easier to talk about sex—than it is to talk about power. People whohave it deny it; people who want it do not want to appear hungry for it; andpeople who engage in its machinations do so secretly” (Kantner, 1979, p.65).Power is the ability to influence others’ actions, thoughts, or emotions.When discussing power, the topic of leadership always enters into theconversation because the two terms are almost inseparable. In Part III, weattempt to answer the often-asked question, “What does it take to be aneffective leader?” We begin our discussion in Chapter 8, in which we providean overview of the definition of power and the types, sources, and uses ofpower. Chapter 9 discusses the early theories of leaderships, such as theGreat Man and trait theory. In Chapter 10, we turn our attention to thenext generation of leadership theories—contingency theories and situationalmodels. These theories state that leaders apply different styles in differentsituations, depending on the factors involved. Chapter 11 provides insightinto some of the contemporary theories in leadership, such astransformational, servant, and collaborative leadership. Thesecontemporary theories of leadership look to the person and theorganization’s culture in the attempt to answer the question, “What does ittake to be an effective leader?”

CHAPTER 8Power, Politics, and InfluenceLEARNING OUTCOMESAfter completing this chapter, the student should be able to understand the: Definition of power. Difference between potential and kinetic power. Different sources of power. Ways managers develop a power base. Definition of organizational politics and the various political behaviors. Definition of upward influence and the various influence tacticscategories.OVERVIEWSince 2002, Modern Healthcare has annually published a list of the 100most powerful people in health care. Modern Healthcare’s readers developthe list. The readers are first asked to nominate and then vote forindividuals they believe have the greatest power to influence the U.S.health care delivery system. Burda (2003) related that the one theme thatcaught his attention was control. He stated, “Controlling something of valuemakes you powerful, and that’s what the people on the list have in common”(p. 36). So, then, it would be no surprise to learn that for the 2014 list, 16percent of the top 100 powerful people are elected or appointed federalemployees (President Obama taking the number-one position) who hold thepurse strings on an annual budget in excess of $770 billion or hold the powerto impose, delay, or eliminate costly regulatory requirements on health careproviders.Power has been defined in a variety of ways. Thibaut and Kelley (1959)defined power as having behavioral or fate control over the behavior ofanother. Mechanic (1962) defined it as any force that results in behaviorthat would not have occurred if the force had not been present. Siu (1979)defined power as the influence over the beliefs, emotions, and behaviors of

people, which is the definition adopted for our discussions.Power exists only when there is an unequal relationship between twopeople and where one of the two is dependent upon the other (Emerson,1962). Using the example of the annual 100 most powerful people ranking inhealth care reflects these two components of power: unequal relationshipand dependency. Health care providers are dependent on the federalgovernment, specifically the Medicare and Medicaid programs, forreimbursements. Any change in the levels of reimbursement can have eitherpositive or negative effects on the industry. For example, the AffordableCare Act of 2010 transformed Medicare from a passive payer to an activepurchaser of higher quality, more efficient health care through the value-based purchasing (VBP) initiative. The Centers for Medicare and MedicaidServices rule that denies payment for hospital-acquired conditions referredto as “never events” strongly encouraged patient safety efforts. There is anunequal relationship because of the federal government’s ability to enactnew regulations that require major changes in how health care providersand suppliers conduct business (e.g., Affordable Care Act of 2010, Stark Iand Stark II regulations, Health Insurance Portability and AccountabilityAct of 1996, Sarbanes–Oxley Act of 2002).Potential power exists when an individual has the ability to influence butdoes not use it (e.g., a supervisor sitting at her desk completing paperwork,but without staff interaction). When the individual actually uses the powerto influence, it is referred to as kinetic power (e.g., a supervisor awards abonus to a subordinate for completing a challenging task on time andcorrectly) (Siu, 1979).The concept of power is an integral part of organizational behavior. Forexample, power is central to the topics of attitudes, perception, andmotivation, as well as leadership, group dynamics, and changemanagement.Sources of PowerJohn French and Bertram Raven (1959) identified five bases or sources ofsocial power: reward power, coercive power, legitimate power, referentpower, and expert power. An individual is not limited to one source ofpower; individuals may hold and exercise multiple sources of powersimultaneously.Reward power is defined as the ability to give rewards, something thatholds value to another individual. Reward power has two components. First,the individual (P) must perceive that the other person (O) has the ability to

reward. Second, the reward must have some value to P. If O offers a rewardto P and then fails to deliver, future attempts by O to change P’s behaviorby using reward power have been diminished.Coercive power is defined as the ability to punish either by administeringa punishment or by withholding something that an individual needs orwants. Coercive power stems from P’s expectation that O will administer apunishment if P fails to conform to the influence attempt. As with rewardpower, for coercive power to be effective, P must perceive that O has theability to punish or sanction, and this negative valence must have somevalue (e.g., avoidance of punishment) to P.Legitimate power is authority given to an individual on the basis of agiven role or position. There are three bases of legitimate power: culture,social structure, and delegation of power. In some cultures, certain groupsare granted the right to prescribe behavior for others. For example, in somecultures the aged or one sex is granted the power to demand conformity ofbehavior by others. Social structure is the second basis for legitimate power.In formal organizations, this power is granted by the title someone holdswithin the company’s hierarchy. The third base of legitimate power isdelegation of the power by the legitimizing agent. For example, adepartment manager may accept the authority of a vice president in certainareas because the organization’s president has specifically delegated theauthority to the vice president. It is important to remember that O onlyholds legitimate power if P accepts O as holding a legitimate power position.Referent power stems from P’s affective regard (i.e., attraction) for, oridentification with, O. Interestingly, O has the ability to influence P eventhough O may be unaware of this referent power. Also, because P desires tobe associated with or identified with O, P will assume attitudes, beliefs, orbehavior displayed by O. Therefore, the greater the attraction, the greaterthe identification and the greater the referent power.Expert power exists when P awards power to O on the basis of P’sperception of O’s knowledge within a given area. P evaluates O’s expertnessin relation to his or her own knowledge as well as against an absolutestandard. The expert is seen as having superior knowledge or ability in veryspecific areas. Therefore, the attempt to exert expert power outside of thespecific area will reduce that expert power, and an undermining ofconfidence may take place.In recent years, two other sources of power have been discussed:informational and connection (Hersey & Blanchard, 1982). A person whohas access to valuable or important information possesses informational

power. Connection power is related to who you know, vertically andhorizontally, both within and outside the organization. Both of these sourcesof power are discussed further in the following sections.OTHER SOURCES OF POWER WITHIN ANORGANIZATIONDavid Mechanic (1962) found that employees without formally definedpower positions exercise significant personal power within an organizationby creating a sense of dependency. Employees create this dependency bycontrolling access to:1. Instrumentalities, which includes any aspect of the physical plant ofthe organization or its resources (e.g., equipment, materials,budgets).2. People, including anyone within the organization or anyone outsidethe organization upon whom the organization is in some waydependent.3. Information, which includes knowledge of the norms, procedures, andtechniques of doing business within the organization.The most effective way for lower-level employees to achieve power is tohave higher-ranking employees dependent upon them. Thomas Scheff’sresearch (1961) provides us with an illustration of this dependencyrelationship and the power associated with it. Scheff’s study involved a statemental hospital that failed to implement reforms because of the oppositionof the hospital attendants. The failure was largely due to the wardphysicians’ dependency on the attendants. The dependency resulted fromthe physicians’ short tenure, lack of interest in administration, and thelarge amount of administrative responsibilities the physicians had toassume. An implicit trading agreement developed between physicians andattendants whereby attendants would take on some of the responsibilitiesand obligations of the ward physicians in return for increased power indecision-making processes concerning patients. Failure of the wardphysician to honor his or her part of the agreement resulted in informationbeing withheld, disobedience, lack of cooperation, and unwillingness of theattendants to serve as a barrier between the physician and a ward full ofpatients demanding attention and recognition. When the attendantswithheld cooperation, the physicians had difficulty in making gracefulentrances and departures from the ward, in handling necessary paperwork

(officially their responsibility), and in obtaining information needed to dealadequately with daily treatment and behavior problems. When theattendants opposed change, they could wield influence by refusing toassume responsibilities officially assigned to the physician.Another example is new physician residents’ dependency on the floornurses in a large teaching hospital. These new physicians are dependent onthe nurses for providing information regarding how to maneuver throughthe hospital maze to obtain the necessary care for their patients. How aretests ordered? What paperwork must be completed? Does the patient needan authorization from his or her insurance company? The new residents aredependent on the nurses’ goodwill toward them. If the nurses withhold theircooperation, the physicians would have little or no alternative but toattempt to decipher the hospital’s policies and procedures, which would be avery time-consuming process.Increasing complexity within organizations has made the expert or staffperson more powerful as a result of the organization’s dependency on his orher specialization, knowledge, and skills. Experts have tremendouspotentialities for power by withholding information or providing incorrectinformation. For example, Mechanic (1962) discusses the situation of a layhospital administrator (as opposed to a hospital administrator who is also aphysician) who makes an administrative decision that physicians oppose onthe basis of medical necessity. A lay administrator is not in a position tocontest these claims independently. To evaluate these claims, theadministrator would need to engage medical consultants to serve as a bufferbetween the medical staff and the lay administration.Employees also form coalitions that demonstrate power to get things donein a highly functionally structured organization, such as a hospital.Hospitals are complex entities organized into functional units such asmedical, nursing, administration, and physical plant, which are controlled athigh levels of authority. It is not unusual for coalitions to form at theintermediate and lower levels that overlap the functional units. Forexample, the hospital’s orthopedic unit secretary knows the person inpatient support services who schedules patient transport or the person inthe centralized supply unit who coordinates deliveries to the variousdepartments. The secretary can handle informally what would be very time-consuming if handled formally. As such, managers become dependent onemployees who know how to get around the system, which gives thoseemployees power.Employees also gain power because others have delegated responsibilities

to them that they themselves do not want to do, but which are accompaniedwith a certain amount of power. For example, a physician usually delegatesthe responsibility of scheduling his or her appointments to a secretary. Thesecretary schedules both patient and nonpatient appointments and, as such,wields enormous power as to who will or will not see the physician thisweek. Ask any pharmaceutical representative trying to schedule anappointment to discuss a new drug with a physician! An administrativeassistant in a primary care physician’s (PCP’s) office who issues patientreferrals has the power of selecting what specialists the physician’s patientswill be referred to within the managed care network. A specialist couldexperience a decrease in his or her patient referrals by not cooperating withthe PCP’s administrative staff’s requests (e.g., seeing referred patients in atimely fashion).DEVELOPING A POWER BASEManagers are dependent on others because of two organizational factors:division of labor and limited resources (Kotter, 1977). Managers aredependent on subordinates, peers, supervisors, other units within theorganization, outside suppliers, and many others. Managers are sensitive tothis issue, and they cope with their dependency by eliminating it, limiting it,or establishing power over others (Kotter, 1977). Kotter describes four waysmanagers have been successful in developing a power base.• Creating a Sense of Obligation: Managers will go out of their way to dofavors for people who they expect will feel an obligation to return thosefavors.• Building a Reputation as an Expert in a Certain Area: Managers willestablish themselves as experts so that others will defer to them onthose matters. This can be accomplished through visible achievement(i.e., professional reputation and track record).• Identification: Managers will try to foster others’ unconsciousidentification with them or ideas they stand for. Managers try to lookand behave in ways that others respect. They go out of their way to bevisible to their employees and give speeches about their organization’sgoals, values, and so on.• Perceived Dependence: Managers will attempt to have others believethat they are dependent on the manager, for either help or not beinghurt. The manager can accomplish this by securing resources thatanother person requires to perform his or her job. At the same time, the

manager makes it known that he or she can also have the sameresources removed. Managers may also resort to influencing others’perception of the manager’s available resources, which may be morethan, in reality, he or she possesses. In trying to influence people’sjudgments, managers pay attention to the trappings of power and totheir own reputations and images. They associate with people andorganizations that are known to be powerful.Kotter (1977) notes that managers who build their power based onperceived expertise or on identification can often use it to influence attitudesas well as someone’s immediate behavior, which would result in a lastingimpact.ORGANIZATIONAL POLITICSAllen et al. (1979, p. 77) describe organizational politics as the intentionalacts of influence to enhance or protect the self-interest of individuals orgroups. On the basis of their research, eight types of political behaviorswere identified. They are as follows:• Attacking or Blaming Others: Attacking or blaming others is oftenassociated with scapegoating—blaming others for a problem or failure.It may also include trying to make a rival look bad by minimizing his orher accomplishments.• Using Information as a Political Tool: Using information as a politicaltool may include withholding important information when doing somight further an employee’s political interests. This type of behaviorcan also include information overload—for example, to bury or obscureimportant (but potentially damaging) details that the employee hopes gounnoticed.• Creating and Maintaining a Favorable Image: Creating andmaintaining a favorable image includes drawing attention to one’ssuccesses and the successes of others, creating the appearance of being aplayer in the organization, and developing a reputation of possessingqualities considered to be important to the organization (i.e., impressionmanagement). The behavior also includes taking credit for the ideas andaccomplishments of others.• Developing a Base of Support: Examples of developing a base of supportinclude getting prior support for a decision before a meeting is calledand getting others to contribute to an idea to secure their commitment.

• Ingratiation/Praising Others: Ingratiation/praising includes praisingothers and establishing good rapport for self-serving purposes.Organizational jargon for this behavior includes buttering up the boss,apple polishing, and brown-nosing.• Developing Allies and Forming Power Coalitions: Developing allies andforming power coalitions includes developing networks of coworkers,colleagues, and/or friends within and outside the organization forpurposes of supporting or advocating a specific course of action.• Associating with Influential People: Associating with influential peopleincludes developing professional connections with organizations andpeople that are known to be powerful.• Creating Obligations and Reciprocity: Creating obligations andreciprocity includes performing favors to create obligations from others,commonly known as “you scratch my back and I’ll scratch yours.”From an organizational perspective, withholding and distortinginformation are the most dysfunctional and should be safeguarded againstby the company. Note the similarities between Kotter’s power bases andAllen et al.’s types of political behavior: creating a favorable image,developing allies and forming power coalitions, creating obligations, andassociating with influential people. Although Kotter and Allen et al.developed their arguments 25 years ago, they are still valid today.UPWARD INFLUENCEThere has been a growing recognition among organizational behaviorresearchers that a political influence perspective is a useful way to examinethe effectiveness of managers (Falbe & Yukl, 1992; Farmer & Maslyn, 1999;Pfeffer, 1992). This perspective has focused on employees’ influence tacticsdirected upward at those higher levels in the formal organizationalstructure. Kipnis, Schmidt, and Wilkinson (1980), on the basis of theirresearch, grouped influence tactics into various categories, of which sixrelate to upward influence. These categories are as follows:• Assertiveness includes such influence tactics as demanding compliance,ordering, and setting deadlines, as well as nagging and expressinganger.• Ingratiation includes behaviors such as praising, politely asking, actinghumble, making the other person feel important, and acting friendly.• The rationality tactic consists of using reason, logic, and compromise in

attempting to influence others. This also includes attempts to convinceothers that certain actions are in their own best interests.• The exchange category refers to such behavior as offering to help othersin exchange for reciprocal favors.• Upward appeal is indicated by behavioral attempts to gain support fromsuperiors in an organization.• Coalition formation refers to attempts to build alliances with others.Kipnis and Schmidt (1988) assessed the use of upward influence withhospital supervisors, clerical workers, and chief executive officers. Using thetactics of the six categories of upward influence, Kipnis and Schmidtidentified four clusters:• Shotguns: Individuals who use all tactics, but especially assertivenessand higher authority.• Tacticians: Individuals with a high use of reason or rationality, butaverage use of other tactics.• Bystanders: Individuals with lower than average scores on all tactics.• Ingratiators: Individuals with the highest use of friendliness oringratiation tactics, but average use of other tactics.In the early stages, this research stream has been productive. There is agrowing knowledge of how various employee tactics used to influencebehaviors of those in higher positions within the organization work or do notwork under certain circumstances and within different cultures (Farmer &Maslyn, 1999; Ralston, Vollmer, et al., 2001; Ralston, Hallinger, et al.,2005).A study by Carney, Cuddy, and Yap (2010) explored the use of bodylanguage to increase one’s power position. The researchers found (p. 1) thatposing in high-power nonverbal displays (as opposed to low-powernonverbal displays) would cause neuroendocrine and behavioralchanges for both male and female participants: High-power posersexperienced elevations in testosterone, decreases in cortisol, andincreased feelings of power and tolerance for risk; low-power posersexhibited the opposite pattern. In short, posing in displays of powercaused advantaged and adaptive psychological, physiological, andbehavioral changes, and these findings suggest that embodimentextends beyond mere thinking and feeling, to physiology andsubsequent behavioral choices.

In other words, Carney, Cuddy, and Yap (2010) showed that anindividual’s nonverbal displays can govern how he or she thinks and feelsabout themselves and that a person’s body movements can change his or hermind. The technique study is referred to as the “power pose.”SUMMARYIn this chapter, we discussed what is meant by power and how individualscan use it to influence others. As noted, the concept of power is an integralpart of organizational behavior. Power is central to the subject ofleadership.DISCUSSION QUESTIONS1. Discuss what is meant by the term “power.”2. Explain the difference between potential and kinetic power.3. Describe the different sources of power.4. Explain what is meant by a manager’s power base and the waysmanagers develop it.5. Describe organizational politics and the resulting political behaviors.6. Discuss what is meant by upward influence and the various influencetactics categories associated with it.CASE STUDIESCase Study 8–1 What Can Joe Do About Betty?Just before quitting time, Joe, the hospital’s health information department manager, watched histhree new trainees struggling with the complicated electronic medical records software they had tolearn to use to do their jobs. Across the room, Betty, who was an expert with the software, waspreparing to leave for the day, her tasks done ahead of time as usual. Also as usual, she gathered upher belongings and left without saying good-bye to any of her coworkers. “There goes the answer tomy problem,” thought Joe. “If only I knew how to reach her.” With her expertise and experience inusing the system, Betty would seem to be an ideal coach for the new employees. However, she hadbegged off from taking on training duties when Joe had asked her. Her reasons were that she wasn’tcomfortable telling anyone else what to do, didn’t want the responsibility for someone else’s work,and preferred to work by herself at her own job.Joe was stunned by her refusal; he enjoyed helping his coworkers and felt it was why he hadadvanced to department manager last year instead of Betty, who had more seniority and experiencewith the company than he did. Since her work was excellent, Joe hesitated to make it an “either youdo what I want or you’re in trouble” situation; he believed employees worked best at what they

wanted to work at. But his problem still remained: There was no money in the training budget andno other employees as skilled with the system as Betty was. Was there an approach to convincingher to help that he hadn’t thought of?As Betty walked to the hospital’s parking lot, she thought, “How could Joe think I would lift afinger to help him? I should have been the one promoted to department manager last year, not him.I’m the one with seniority and the necessary experience. In fact, I was the one who trained Joe whenhe first joined the hospital! Just because he has a master’s in health information management and Idon’t should not have been the determining factor, but obviously senior management thought sowhen they selected him over me! I could care less what happens from this point forward. I only havefive more years until I can retire with my full pension. As long as my work continues to be excellentthere is no way Joe can upset my plans. Not that he could, since he hardly understands thecomplexity of the software we use since it requires a person with a lot of technology knowledge andexperience.”Describe French and Raven’s five sources of power. In the above case, who has power(s) and why?Case Study 8–2 Scott’s DilemmaScott is a licensed physical therapist who works for a national rehabilitation company. Therehabilitation facility in which Scott works is located in an urban Southwest city. He has worked atthis facility for four years and, up until recently, was satisfied with his working environment and theinteractions he shared with his coworkers. In addition, Scott received personal fulfillment fromhelping his patients recover from their disabilities and seeing them return to productive lives.Last year the health system went through reorganization, with some new people being brought inand others reassigned. Scott’s new boss, George, was transferred from one of the system’s Midwestfacilities. Almost immediately upon taking his new position, George began finding fault with Scott’scare plans, patient interactions, and so on. Scott began feeling as if he couldn’t do anything right. Hewas experiencing feelings of anxiety, stress, and self-blame. Although his previous performanceevaluations had been above average, Scott was shocked by his first performance review underGeorge’s authority—it was an extremely low rating.Scott began trying to work harder, thinking that by working harder he could exceed George’sexpectations. Despite Scott’s long hours and addressing George’s critiques, George continued to findfault with Scott’s work. Staff meetings began to be a great source of discomfort and stress becauseGeorge would belittle Scott and single him out in front of his colleagues.Scott began to feel alienated from his family, friends, and colleagues at work. His eating andsleeping habits were adversely affected as well. Scott’s activities held no joy for him any more, andthe career that he had once loved and been respected in became a source of pain and stress. Hebegan to call in sick more often and started visualizing himself confronting and even hurting George,which created even more guilt and anxiety for Scott.As time went on, George encouraged Scott’s coworkers to leave Scott alone to do his work. Theperception of the coworkers became more sympathetic to George’s point of view. Scott’s coworkersmused that perhaps Scott really was a poor worker and that George knew better because of hisposition as the supervisor of the rehabilitation department. Eventually, Scott’s coworkers began todistance themselves from him, in order to protect their own interests. They began to see Scott as anoutsider, with whom it was unsafe to associate.In an effort to resolve the situation, Scott spoke to George directly, stating his feelings andexpressing an interest in how they might improve the situation. Rather than making the situationbetter, what George perceived as Scott’s insubordination served to enrage George, and the personalattacks against Scott intensified. Feeling frustrated and helpless, Scott then decided to take hisproblem to the Human Resources Department (HRD). A human resources manager listened toScott’s complaints and suggested that Scott return with documented evidence of what Scottperceived to be George’s mistreatment. In an effort to help ease the situation, the HRD manager

discussed the issue with George, which only stirred the flames of George’s anger and his negativebehavior toward Scott.As a last resort, Scott decided to go to George’s boss, Rebecca. Rebecca met with George to get hisside of the story. George portrayed Scott as an unproductive employee with no respect for authority.The result was a strong letter of reprimand in Scott’s file for insubordination.Describe French and Raven’s five sources of power. What power(s) do the individuals in Scott’sdilemma hold?Reproduced from “Case Discussion: Workplace Bully,” by J. Pinto, M. Vecchione, & L. Howard,October 2004. Presented at the 12th Annual International Conference of the Association onEmployment Practices and Principles, Ft. Lauderdale, FL.REFERENCESAllen, R. W., Madison, D. L., Porter, L. W., Renwick, P. A., & Mayes, B. T.(1979). Organizational politics: Tactics and characteristics of its actors.California Management Review, 22, 77–83.Burda, D. (2003, August 25). Command and control: To make powerful list,you need to hold the purse strings or hire the workers. ModernHealthcare, p. 36.Carney, D. R., Cuddy, A. J. C., & Yap, A. J. (2010). Power posing: Briefnonverbal displays affect neuroendocrine levels and risk tolerance.Psychological Science, 21(10), 1363–1368.Emerson, R. M. (1962). Power-dependence relations. American SociologicalReview, 27, 40–40.Falbe, C. M., & Yukl, G. (1992). Consequences for managers of using singleinfluence tactics and combinations of tactics. Academy of ManagementJournal, 35, 652–652.Farmer, S. M., & Maslyn, J. M. (1999). Why are styles of upward influenceneglected? Making the case for a configurational approach to influence.Journal of Management, 25(5), 653–682.French, J., & Raven, B. (1959). The bases of social power. In D. Cartwright(Ed.). Studies in social power (pp. 150–167). Ann Arbor, MI: University ofMichigan Press.Hersey, P., & Blanchard, K. (1982). Management of organizationalbehavior: Utilizing human resources (4th ed.). Englewood Cliffs, NJ:Prentice Hall.Kantner, R. M. (1979, July/August). Power failure in management circuits.Harvard Business Review, 57(4), 65–75.Kipnis, D., & Schmidt, S. M. (1988). Upward influence styles: Relationship

with performance evaluations, salary, and stress. Administrative ScienceQuarterly, 33, 542–542.Kipnis, D., Schmidt, S. M., & Wilkinson, I. (1980). Intraorganizationalinfluence tactics: Explorations in getting one’s way. Journal of AppliedPsychology, 65, 452–452.Kotter, J. P. (1977, July/August). Power, dependence, and effectivemanagement. Harvard Business Review, 55(4), 125–136.Mechanic, D. (1962, December). Sources of power of lower participants incomplex organizations. Administrative Science Quarterly, 7(3), 349–365.Pfeffer, J. (1992). Managing with power: Politics and influence inorganizations. Boston, MA: Harvard Business School Press.Ralston, D. A., Hallinger, P., Egri, C. P., & Naothinsuhk, S. (2005). Theeffects of culture and life stage on workplace strategies of upwardinfluence: A comparison of Thailand and the United States. Journal ofWorld Business, 40(3), 321–337.Ralston, D. A., Vollmer, G. R., Srinvasan, N., Nicholson, J. D., Tang, M., &Wan, P. (2001). Strategies of upward influence: A study of six culturesfrom Europe, Asia, and America. Journal of Cross-Cultural Psychology,32(2001), 748–755.Scheff, T. J. (1961). Control over policy by attendants in a mental hospital.Journal of Health and Human Behavior, 2, 105–105.Siu, R. G. H. (1979). The craft of power. New York, NY: John Wiley & Sons.Thibaut, J., & Kelley, H. H. (1959). The social psychology of groups. NewYork, NY: John Wiley & Sons.Reproduced from Carney, D.R., Cuddy, A.J.C. & Yap, A.J. (2010). Power posing: brief nonverbaldisplays affect neuroendocrine levels and risk tolerance. Psychological Science, 21(10), 1363–1368.

CHAPTER 9Trait and Behavioral Theories ofLeadershipLEARNING OUTCOMESAfter completing this chapter, the student should be able to understand the: Difference between leaders and managers. Importance of early behavioral and trait studies. Role of behavioral and trait theories in the evolution of leadershipresearch. Contributions of the early leadership studies at Ohio State and theUniversity of Michigan. Design and application of Blake and Mouton’s Managerial (Leadership)Grid.OVERVIEWWhat is leadership? Leadership can be described as a complex process bywhich a person sets direction and influences others to accomplish a mission,task, or objective and directs the organization in a way that makes it morecohesive and coherent (Winder, 2003). What makes an individual a leader,and what makes a leader effective? The answers to these questions havebeen the focus of organizational researchers for nearly a century. In thischapter, we discuss some of the earlier studies in leadership, referred to asthe trait and behavioral theories, that laid the foundation for otherleadership theories such as contingency theories and contemporary ortransformational theories.Often when exploring leadership in organizations, the first question askedis, “Are managers leaders?” or “Is there a difference between managers andleaders?” Kotter (1988) believes that managers and leaders perform twodistinctive but complementary activities. Winder (2003) and Hellriegel,Slocum, and Woodman (1995) point out that a manager is a person who

directs the work of employees and is responsible for results. By contrast, aleader inspires employees with a vision and helps them cope with change.Leaders make people want to achieve an organization’s goals and objectives,while managers direct people to accomplish a particular task or objective. Inthe words of Peter Druker and Warren Bennis, “Management is doingthings right; leadership is doing the right things.” Khan (2010) emphasizesthat organizations need both strong leadership and strong management foroptimum effectiveness. Robbins relates (as cited in Khan, 2010, p. 2) that intoday’s dynamic world, organizations require leaders who can challenge thestatus quo, create the needed vision, and motivate followers toward itsachievement. To achieve the vision, leaders need strong managers who cansuccessfully develop the plans, create the structure and processes, andefficiently handle the daily operations.Table 9–1 Leaders vs. ManagersLeadersManagersInspire employees with a visionDirect the work of employees and devise systems to monitoremployees’ progress toward achieving preset goalsHelp employees cope with changeDetermine how to achieve preset goals and be responsible forachieving themMake people want to achieve high goals andobjectivesTell employees to accomplish a particular task or objectiveArticulate a direction or vision of what thefuture might look likeHandle activities through planning and budgetingDevelop strategies for producing changesneeded to move in a new directionAchieve their goals by organizing and staffingRecruit and keep employees who understandand share their visionsCreate an organizational structure and sets of jobs for accomplishingthe organization’s strategiesAs noted, management and leadership are two separate behaviors thatoccur within an organization, but both are necessary for an organization toachieve its goals (see Table 9–1). Note that the distinctions in the table arebased on behaviors—that is, what an individual does—and are not based onparticular characteristics, personality, or traits. Therein, we begin todiscover the distinct contributions and applications of the theories presentedin this chapter—trait and behavioral.TRAIT THEORYThe belief that innate traits could be found and be the basis foridentifying leaders is illustrated by the following quote from Henry Ford:“The question ‘who ought to be boss’ is like asking ‘who ought to be the

tenor in the quartet?’ Obviously, the man who can sing tenor.” One mightconclude that not all of us are born to sing tenor, and not all of us are bornto lead. Similar thoughts were expressed by sociologist Jerome Dowd, andat the time, many accepted his belief that individuals possess differentdegrees of intelligence, energy, and moral force and that the masses ofsociety, in whatever direction they may be influenced, are always led by thesuperior few (Bass, 1990). Leaders, it was believed, were born with thepersonality, social, and physical characteristics that set them apart—traitsthat made them distinct from nonleaders.The earliest trait studies of leadership reflect the social and psychologicalcontext of their times. These studies generally assumed that leaders wereborn—the Great Man Theory—and these born leaders possessed specificcharacteristics or traits that set them apart. More than 100 studiessummarized by Stogdill (1948) and Mann (1959) sought to distinguishleaders from nonleaders on the basis of personality characteristics andindividual traits, including intelligence, initiative, understanding of thetask, and preference for a position of control and dominance. Early traittheorists suggest that characteristics such as intelligence, maturity, innermotivation, achievement drive, and employee centeredness are more likelyto be found in midlevel and top managers than in team leaders or first-linesupervisors. Leaders tend to be emotionally mature, have a broad range ofinterests, and are high achievers. They are able to work effectively withemployees in a variety of situations, and they respect others and realizethat to accomplish tasks they must be considerate of others’ needs andvalues (Stogdill, 1974).As study in leadership traits continued, a review by Geier (1967) of 20different studies demonstrated the wide variance in the leadership traitschosen for investigation. Nearly 80 different traits were identified across the20 studies, and only five were common to four or more of the investigations.Thus, no clear set of traits upon which we can distinguish great leadersemerged. Despite the difficulties in linking traits to successful leaders,evidence does reveal that many successful leaders share some basic traitsbased on observed characteristics of both successful and unsuccessfulleaders (see Exhibit 9–1). Other studies established differences in drive(achievement, ambition, energy, tenacity, and initiative), cognitive ability,honesty and integrity, self-confidence, knowledge of business, and desire tolead (Kirkpatrick & Locke, 1991). However, as noted by Robbins (2005), thepower of these traits to predict leadership was modest. No consistentpatterns between specific traits and effective leadership materialized.

Lussier and Achua (2012) note that no universal list has emerged of traitsthat all great leaders possess or that will guarantee leadership success in allsituations. Leadership emerges from the combined influence of multipletraits (Zaccaro, Kemp, & Bader, 2004).Exhibit 9–1 Trait TheoryOne researcher studied a large number of North American organizations and leaders andconcluded that there are some common traits that leaders possess. Leaders who possess thesetraits are able to lead in a variety of situations:• Physical vitality and stamina• Intelligence and action-oriented judgment• Eagerness to accept responsibility• Task competence• Understanding of followers and their needs• Skill in dealing with people• Need for achievement• Capacity to motivate people• Courage and resolution• Trustworthiness• Decisiveness• Self-confidence• Assertiveness• Adaptability/flexibilityData from On Leadership, by J. Gardner, 1989. New York: Free Press.Winder (2003) points out another criticism of early trait theory related toits reference to leaders’ physical characteristics such as appearance,physique, energy, and health. This is not surprising when one considers thatthe early leadership studies were conducted in the 1930s. How did thetypical leader appear during that period? Leaders in the 1930s would havebeen male, Caucasian, authoritarian, and educated. Absent these traits, itwould have been difficult to find minor differences from one organizationalleader to the next. However, as we recognize today, physical characteristicsare not requirements for leadership.The failure of early studies to determine a clear set of leadership traits leda number of researchers to question the value of trait leadership theory andto explore another area of distinction—leader behavior. Rather than askingwhat traits distinguish leaders, behavioral theories of leadership ask thequestion “How do leaders act or behave differently than nonleaders?” Theunderlying assumption or hypothesis shifts from being born with innate

leadership abilities to being able to acquire leadership behaviors. Can weidentify and teach particular behaviors that promote effective leadership?Many would support the position that leadership can be learned, cultivatedthrough work experience, training, education, opportunity, motivation, andeven a little luck (Kotter, 1988).LEWIN’S BEHAVIORAL STUDYOne of the earliest studies to examine the effect of leadership behaviorwas performed in the 1930s under the direction of Kurt Lewin, who isrecognized as the father of group dynamics. Lewin (1951) and his colleaguesobserved the behavior of children under different leadership styles used bythe adult participants. The study involved 10-year-old boys who wereparticipating in an arts and craft club. The boys were placed into groupsmatched on personal characteristics (for example, IQ and popularity), andall groups worked on the same project (produced the same item). Eachgroup was exposed to three types of leadership styles:• Authoritarian: The authoritarian leader remained aloof and used orders(without consultation) in directing the group’s activities.• Democratic: The democratic leader offered guidance and encouraged thechildren while actively participating in the group’s activities.• Laissez-Faire: The laissez-faire leader gave the children knowledge, butdid not direct the activities, nor did this leader become involved orparticipate in the group’s activities.The researchers measured and recorded both the amount of workproduced and the levels of aggression displayed by the children. The resultsestablished that leadership style had a clear impact on group productivity aswell as the behaviors and interpersonal relationships among groupmembers. With the democratic leadership style, group morale was high andrelationships between the group members and leader were friendly. Whenthe group leader was absent, the children continued with their work. Thegroup’s work reflected levels of originality and quality; however, members ofthe group did not produce as many items as did the group under theauthoritarian leader. Under authoritarian leadership, the group displayedtwo types of behavior: aggressive and apathetic. The aggressive childrenwere defiant and continually wanted the leader’s attention. They blamedone another when anything went wrong within the group. Although theapathetic children placed fewer demands on the leader, they displayed

outbursts of aggression when the leader was absent. When groupsexperienced the laissez-faire leadership style, the children displayed lowlevels of satisfaction and a low tendency or ability to work independently. Inaddition, group members displayed little cooperation. Under the laissez-fairestyle, the group produced the least number of items, and the items were oflow quality.Overall, the democratic leadership style appeared the most successful.However, some of the children reported that they preferred theauthoritarian style. Thus, this study provided us with not only our initialexamination of leadership behavior but also alerted us to the possibility thatfollowers may exhibit a preference for specific leadership styles. In concertwith the latter, Gladding (1995) suggested that different types of groupsprefer specific styles of leadership. He contended that members’ preferencewould be based on the leadership style they perceived as right or naturaljudging from their personal socialization process.Comprehensive research projects conducted at Ohio State University andthe University of Michigan during the 1940s focused further attention onthe identification of leader behaviors. As we discuss here, these foundationalstudies had a significant impact on future conceptualizations and theresearch leadership theorists.OHIO STATE LEADERSHIP STUDIESThe focus of the researchers at Ohio State University in the late 1940swas on the identification of independent dimensions of leadership behavior.The researchers developed an assessment tool, the Leader BehaviorDescription Questionnaire, which was used to discover how leaders carryout their activities. Leaders from the military, educational, manufacturing,and other sectors were included in the research project. The researchersfound that two dimensions of leadership were consistent among the studiedgroups: consideration for people and initiating structure.Consideration for people focused on the human side of the business andwas also called relationship behavior. This dimension recognized thatindividuals have needs and require relationships. The initiating structuredimension put an importance on tasks and goals. These findings wereimportant to the study of organizational behavior and leadership by not onlyidentifying these concepts but also recognizing that the two dimensionswere independent. In other words, consideration for workers and initiatingstructure existed simultaneously and to different degrees. A matrix wascreated that showed the various combinations and quantities of the

elements (see Figure 9–1).Leaders who ranked high on both dimensions were more likely toinfluence the workforce to higher levels of satisfaction and performance. Aweakness noted in the Ohio State studies was that situational factors wereabsent from the research. Although a combination of the dimensions wasdeveloped, the effectiveness of each combination in relation to workplacesituations was not identified. Not all workplace situations require anemphasis on initiating structure. For example, health care professionalswho are intrinsically motivated and highly skilled may not require initiatingstructure from their manager.Figure 9–1 Ohio State StudiesUNIVERSITY OF MICHIGAN STUDIESDuring the same period of time as the Ohio State studies, researchers atthe University of Michigan were also conducting research in an attempt to

determine the most effective style of leadership based on two dimensions ofleadership behavior: an employee-centered focus or a production-centeredfocus. Employee-centered leaders emphasized interpersonal relations, took apersonal interest in the needs of their subordinates, and accepted individualdifferences among members. Production-centered leaders emphasized thetechnical aspects of the job, focused on accomplishing the tasks, and saw themembers as a means to an end—that is, achievement of the tasks. Theresearchers found that general supervision (i.e., providing support anddirection without being authoritarian) created higher levels of productivitythan did production-centered supervision and that low-producingsupervisors placed an emphasis on production, displaying little concern fortheir employees. Years of research have confirmed the University ofMichigan studies (Luthans, 2002). A particular note of interest from thesestudies is that productivity is not directly related to employee satisfaction.Likert (1961) expanded on the Michigan studies with extensive researchinto what differentiates effective managers from ineffective managers.Likert related that job-centered managers were found to be the leastproductive, while employee-centered managers were found to be the mosteffective. In addition, effective managers set specific goals, but gaveemployees freedom in the way they achieved those goals (i.e.,empowerment).

Figure 9–2 Blake and Mouton’s Leadership GridBlake and Mouton’s Leadership (Formerly Managerial) GridDuring the 1960s, Blake and Mouton reexamined the two dimensions ofleaders that were identified in the Ohio State studies: consideration forpeople and initiating structure. Their work developed a two-factorframework (Razik & Swanson, 1995, p. 53). The Managerial Grid (renamedthe Leadership Grid) is based upon the assertion that one best leadershipstyle exists. The Leadership Grid provides the manager with a conceptualassessment as to what his or her current leadership style is and,

theoretically, provides an avenue of development in becoming an idealmanager.Although there is a possibility of being categorized in one of 81 possiblepositions on the grid, we will examine five positions to assist ourunderstanding of the Leadership Grid. The Leadership Grid (see Figure 9–2) identifies a vertical axis, on a scale from one to nine, describing a concernfor people. A horizontal axis, also on a scale from one to nine, identifies aconcern for production/results. The five notable positions are: impoverishedmanagement (1,1); authority-compliance (9,1); middle-of-the-roadmanagement (5,5); country club management (1,9); and team management(9,9).Let us examine leadership characteristics in each one of the fivequadrants to better understand how the grid functions. At the lower leftposition on the grid (1,1), the impoverished manager (also referred to aslaissez-faire type leadership) exercises minimal effort on getting the taskaccomplished, doing only that amount of work that is required to sustain hisor her position within the organization. Additionally, the impoverishedmanager is much more focused on his or her own well-being than on thesubordinates he or she supervises. This manager possesses a low concern forpeople and a low concern for production. Such managers do just enough toget by—avoiding conflicts, having little social contact with subordinates,and so on.The authority-compliance/task manager is positioned at the lower right onthe grid (9,1). This manager exhibits a true autocratic presence and is oftenreferred to as a dictator. The managerial focus in this quadrant is efficiency,with an ongoing effort to improve work processes to increase production.There is, at best, negligible concern for people. These managers considerstaff as a means of production. The task manager is unconcerned by thepotential negative impact his or her leadership style might have on staff,such as conflict or stress.Located directly in the middle of the grid, at the (5,5) position, is themiddle-of-the-road manager. This manager appears to balance the concernfor task and the concern for people in an effort to boost morale andsatisfaction. On the surface this may seem to be a very effective approach tomanagement, but this balancing act is often difficult to sustain over time.One might consider the middle-of-the-road manager the perfect politician.These managers play both sides of the field, depending upon situationalfactors. They will tell you exactly what they think you want to hear andthen, in contradictory fashion, tell someone else exactly what they want to

hear despite their earlier stance. This is not to suggest that the middle-of-the-road manager operates exclusively on political alliances, but it should beclear that under the best of circumstances it is difficult to balance an equalconcern for people and an equal concern for production.On the upper left on the grid (1,9), we find the country club manager.This individual is most concerned with ensuring that employees’ needs aremet and that the work environment is comfortable and friendly. The lack offocus on concern for production diminishes the overall capacity foremployees to meet or exceed organizational goals. This style of managementwill probably not lead to many successful ventures based upon productionexpectations.The final quadrant is found in the upper right corner of the grid (9,9).Blake and McCanse (1991) labeled this position team management(formerly the ideal manager). As this label suggests, the team managerdevelops a sense of purpose and accomplishment in both concern for peopleand concern for task. This is not a balancing act as was described for themiddle-of-the-road manager, but it is a theoretically perfect infusion ofconcern for people and concern for task. Khan (2010, p. 12) relates that theideal [team] manager “works to motivate employees to reach their highestlevel of accomplishment. They believe in creating a situation whereby peoplecan satisfy their own needs by commitment to the objectives of theorganization.” One might ask, “What is the likelihood of scoring a 9,9 onBlake and Mouton’s Leadership Grid?” Although possible, it is very unlikely.One should presume that there is always room for improvement, therebydiminishing the possibility of attaining the elusive 9,9 score.In 1991 when Blake and McCanse renamed the Managerial Grid as theLeadership Grid, they added two more styles: the opportunisticmanagement style and the paternalistic management style. Theopportunistic management style refers to a manager that uses anycombination of the five basic styles for personal reward and advancement(see Figure 9–3). The purpose of his or her performance and effort is torealize personal gain.

Figure 9–3 Opportunistic Management StyleSOURCE Robert R. Blake, R.R. & McCanse, A.A. (1991). Leadership Dilemmas—Grid Solutions, p.31. Used with permission from Grid International, Inc.The paternalistic management style refers to a manager who uses both1,9 and 9,1 styles but does not integrate the two (see Figure 9-4). In otherwords, the person acts “fatherly or motherly” toward his or her subordinatesbut is the key decision maker, and this manager rewards loyalty butpunishes noncompliance.The grid is a useful tool in identifying leadership style, both perceived andreal. Managers are often surprised at where they score on the grid. Scoresmay lead to self-reflection and increased understanding of theirmanagement style, which then provides opportunities for increasingmanagerial effectiveness.

Figure 9–4 Paternalistic Management StyleSOURCE Robert R. Blake, R.R. & McCanse, A.A. (1991). Leadership Dilemmas – Grid Solutions, p.30. Used with permission from Grid International, Inc.SUMMARYTrait and behavioral theories focused attention on the individual. Weredifferences found? Yes. Were the researchers able to produce a clear set of

traits or behaviors upon which to definitely distinguish leaders? No.Examining the findings across numerous studies, we uncover a lack ofconsistency and modest relationships. One, however, would not want todiminish the importance of the early leadership research or of thecontribution these efforts made as traits and behaviors have reemerged incontemporary leadership theories and behavioral competencies.The theoretical evolution of leadership has led us to the next generation ofresearch: contingency theories. Some suggest the questionable reliabilityand disputed validity of early leadership research efforts may be attributedto the absence of a single important dimension known as the contingencyfactor. Contingency refers to the leader’s contextual situation. “Effectiveleaders analyze the factors pertaining to the situation, task, followers, andthe organization, and then choose the appropriate style” (Osland, Kolb, &Rubin, 2001, p. 290). The leadership and management traits and behaviorsthat work in one organizational context may not be effective in another.Factors both internal and external to the organization change, and leadersand organizations must change in response, particularly in health care.Consider a few of the impetuses that are dramatically reforming the healthcare system—the call for quality and performance in concert with cuttingcosts, and the economic, social, technological, and political environments incontext with a newly emerging diverse workforce. All of these factors (andmore) provide compelling reasons to incorporate the application ofcontingency leadership theory in attaining organizational goals.DISCUSSION QUESTIONS1. Is leadership synonymous with management, or is leading just one ofthe many things that a manager does? In what ways are they thesame or different?2. Explain the findings of Lewin’s behavioral studies regardingleadership styles and behaviors.3. Discuss the contributions and the weaknesses of trait theory.4. Discuss the results of the Ohio State studies in regard to theirsignificant impact on leadership research.5. Explain the difference between the University of Michigan studiesand the Ohio State studies.6. Explain Blake and Mouton’s Managerial (Leadership) Grid inrelationship to previous leadership research.

CASE STUDY AND EXERCISESCase Study 9–1 Leadership StyleA small group of nurses, employed at a large community hospital, were unhappy about their workenvironment and would meet daily during lunch to discuss the situation. There had been a recentchange in the hospital’s senior management, which caused a high level of uncertainty and anxietyamong the nursing staff. The nurses felt overworked as a result of the industry’s current nursingshortage. Their wages and benefits had been stagnant, with no salary market adjustments for thepast two years. The nurses saw the situation as management requiring them to do more work withfewer resources, with no appreciation or recognition of their efforts. Whenever the nursesapproached management with their concerns, they perceived them as falling on deaf ears since nochanges were made.Feeling like they had no other choice, the nurses contacted a labor union. The labor union beganan organizing effort in the hospital shortly thereafter, holding an aggressive campaign over a six-week period. There was tremendous peer pressure, as some of the well-respected nursing staffbecame active leaders for unionization, although they were not part of the initial group of nurseswho had contacted the union. The election was held, and the union was voted in by two-thirds of thenursing staff. In the weeks that followed, the original group of nurses remarked that they weresurprised by the union’s victory; they had only wanted to scare management into making changes totheir work environment.Using Blake and Mouton’s Leadership Grid, explain the leadership style displayed bymanagement to the nursing staff.EXERCISE 9–1Write a description of an effective manager. Write words that you woulduse to describe an effective leader. When you review your list, consider thedifferences and similarities in your adjectives. How did the review of theseconcepts in the chapter influence your word choices? Are you comfortabledistinguishing the roles? To what degree, if at all, do you believe a managershould also be a leader, or a leader also be a manager?EXERCISE 9–2Think of some individuals whom you feel are really exceptional leaders.What, if anything, do they have in common?Think of some individuals whom you believe are truly poor leaders. What,if anything, do they have in common?Do your answers identify traits or behaviors? Which, traits or behaviors,do you personally view as dominant in effective leadership?

EXERCISE 9–3Have you ever known people who were successful leaders in one situationand failures in another? Why is this so?EXERCISE 9–4 LEADERSHIP QUESTIONNAIREObjective: To determine the degree that a person likes working with tasks and other people.Time: 45 MinutesInstructions1. Complete the 18 items in the questionnaire section.2. Transfer your answers to the two respective columns provided in the scoring section. Totalthe score in each column and multiply each total by 0.2. For example, in the first column(people), if you answer 5, 3, 4, 4, 3, 2, 5, 4, 3, then your final score is 5 33 3 0.2 5 6.6.3. The total score for the first column (people) is plotted on the vertical axis in the matrixsection, while the total score for the second column (task) is plotted on the horizontal axis.Intersect the lines to see which leadership dimension you normally operate out of:• Task Manager (Authoritarian)• Impoverished Manager• Ideal Manager (Team Leader)• Country Club ManagerQuestionnaireBelow is a list of statements about leadership behavior. Read each one carefully. Then, usingthe following scale, decide the extent to which it actually applies to you. For best results, answeras truthfully as possible.1. _____I encourage my team to participate when it comes to decision-making time and I try toimplement their ideas and suggestions.2. _____Nothing is more important than accomplishing a goal or task.3. _____I closely monitor the schedule to ensure a task or project will be completed in time.4. _____I enjoy coaching people on new tasks and procedures.5. _____The more challenging a task is, the more I enjoy it.6. _____I encourage my employees to be creative about their jobs.7. _____When seeing a complex task through to completion, I ensure that every detail is accountedfor.8. _____I find it easy to carry out several complicated tasks at the same time.9. _____I enjoy reading articles, books, and journals about training, leadership, and psychology, andthen putting what I have read into action.10. _____When correcting mistakes, I do not worry about jeopardizing relationships.11. _____I manage my time very efficiently.

12. _____I enjoy explaining the intricacies and details of a complex task or project to my employees.13. _____Breaking large projects into small manageable tasks is second nature to me.14. _____Nothing is more important than building a great team.15. _____I enjoy analyzing problems.16. _____I honor other people’s boundaries.17. _____Counseling my employees to improve their performance or behavior is second nature to me.18. _____I enjoy reading articles, books, and trade journals about my profession, and thenimplementing the new procedures I have learned.Scoring SectionAfter completing the questionnaire, transfer your answers to the spaces below:People QuestionTask Question1. _______2. _______4. _______3. _______6. _______5. _______9. _______7. _______10. _______8. _______12. _______11. _______14. _______13. _______16. _______15. _______17. _______18. _______TOTAL _______TOTAL _______× 0.2 = _______× 0.2 = _______(Multiply the Total by 0.2 to get your final score)(Multiply the Total by 0.2 to getyour final score)Matrix SectionPlot your final scores on the following graph (Figure 9–5) by drawing a horizontal line fromthe approximate people score (vertical axis) to the right of the matrix, and drawing a vertical linefrom the approximate task score on the horizontal axis to the top of the matrix. Then, draw twolines from each dot until they intersect. The area of intersection is the leadership dimension thatyou operate out of.

Figure 9–5The ResultsThis chart will give you an idea of your leadership style. But, like any other instrument thatattempts to profile a person, you have to take in other factors, such as how your manager andemployees rate you as a leader, whether you get your job done, if you take care of youremployees, if you are growing your organization, and so on.Review the statements in the survey and reflect on the low scores by asking yourself, “If Iscored higher in that area, would I be a more effective leader?” If the answer is yes, then itshould become a personal action item.

SOURCE Available at www.nwlink.com/~donclark/leader/leader.html. Created January 27,1998; last update October 20, 2013. Copyright 1998 by Donald Clark. Reprinted with permission.REFERENCESBass, B. M. (1990). Bass & Stodgill’s handbook of leadership (3rd ed.). NewYork, NY: The Free Press.Blake, R. R., & Mouton, J. S. (1964). The managerial grid. Houston, TX:Gulf Publishing Co.Blake, R. R., & McCanse, A. A. (1991). The leadership grid. Houston, TX:Gulf Publishing Co.Gladding, S. T. (1995). Groupwork: A counseling specialty. Englewood Cliffs,NJ: Prentice-Hall Inc.Geier, J. G. (1967). A trait approach to the study of leadership in smallgroups. Journal of Communications, 17(4), 316–323.Hellriegel, D., Slocum, J. W., & Woodman, R. W. (1995). Organizationalbehavior. New York, NY: West Publishing Company.Khan, A. (2010). The dilemma of leadership styles and performanceappraisal: Counter strategies. Journal of Managerial Sciences, 4(1), 1–30.Kotter, J. (1988). The leadership factor. New York, NY: Free Press.Kirkpatrick, A., & Locke, E. (1991). Leadership: Do traits matter. Academyof Management Executive, 5(2), 48–60.Lewin, K. (1951). Field theory in the social sciences. New York, NY: Harper& Row.Likert, R. (1961). New patterns of management. New York, NY: GarlandScience Publishing.Lussier, R., & Achua, C. (2012). Leadership: Theory, application, and skilldevelopment. Mason, OH: Cengage Learning.Luthans, F. (2002). Organizational behavior (9th ed.). Boston, MA:McGraw-Hill Book Company.Mann, R. D. (1959). A review of the relationship between personality andperformance in small groups. Psychological Bulletin, 66(4), 241–270.Osland, J., Kolb, D., & Rubin, I. (2001). Organizational behavior: Anexperiential approach (7th ed.) (p. 290). Upper Saddle River, NJ: PrenticeHall.Razik, T. A., & Swanson, A. D. (1995). Fundamental concepts of educationalleadership and management (pp. 51–52). Upper Saddle River, NJ:

Prentice Hall.Robbins, S. P. (2005). Organizational behavior (8th ed.). Upper SaddleRiver, NJ: Prentice Hall.Stogdill, R. M. (1948). Personal factors associated with leadership: A surveyof the literature. Journal of Psychology, 25, 35–71.Stogdill, R. M. (1974). Handbook on leadership. New York, NY: Free Press.Winder, R. (2003). Organizational dynamics and development. Futurics,27(1/2), 5.Zaccaro, S. J., Kemp, C., & Bader, P. (2004). Leader traits and attributes.In J. Antonakis, A.T. Cianciolo, & R.J. Sternberg (eds.). The nature ofleadership (pp. 101-123). Thousand Oaks, CA: Sage Publications, Inc.*We wish to acknowledge and thank Dr. Gloria Deckard, who was the contributing author of anearlier version of this chapter, which appeared in Organizational Behavior in Health Care (2011),Jones and Bartlett Publishers.

CHAPTER 10Contingency Theories andSituational Models of LeadershipLEARNING OUTCOMESAfter completing this chapter, the student should be able to: Appreciate the contributions of contingency theories in understandingleadership. Distinguish between the various contingency theories. Apply the various contingency theories of leadership to today’s workenvironments.OVERVIEWLeadership is truly a complex concept related to a multitude of factorsthat extend beyond the individual to include situational factors. Thesimplicity of examining leadership on the basis of individual traits andbehaviors becomes more complex as we add the interrelationships ofleadership style, personal and professional values, one’s ability to control bymeans of influence, subordinate relationships, subordinate development, andthe variability of other situational factors. In contingency theories, thecritical component becomes the characteristics of the situation rather thanthe individual. Analyzing contingent factors and properly matchingleadership style can allow an individual, in the right context, to effectivelymove an organization toward its strategic goals by influencing otherorganizational members to participate in the collaborative effort to achievecorporate success and economic sustainability.Understanding the development and application of leadership theoryprepares the health care manager to fulfill three explicit administrativeresponsibilities: predict, explain, and control. Successful leaders must havethe capability to predict how, when, where, and why things happen.Prediction permits the leader to enhance opportunities and diminish threats

that are constantly arising in the workplace. The ability to explain theseoccurrences instills a sense of confidence on the part of peers andsubordinates, further augmenting the legitimacy of one’s ability to lead in avariety of situations. Finally, a leader recognizes and accepts the role ofcontrol, whereby individuals are influenced to participate in theachievement of strategic goals and organizational sustainability.Contingency, by definition, means an event that may occur but that is notlikely or intended; a possibility that must be prepared for; the condition ofbeing dependent on chance or uncertainty. As such, contingency is aboutpossessing the knowledge, skills, and abilities to respond to a changingsituation. Analyzing and responding to the contingencies that influenceleader effectiveness may provide one with the ability to succeed in an ever-changing health care environment. Health care leadership is about steppingup in times of uncertainty and moving forward to minimize potentialthreats and exploit opportunities for the organization.In this chapter, we discuss the various contingency leadership theoriesand their implications for the leader, the employee, and the health careorganization. To maximize your understanding of these theories, considerhow they apply to you and your work environment. Developing knowledgeand a working application of contingency theories will enhance your abilityto successfully accomplish your managerial responsibilities to predict,explain, and control.FIEDLER’S CONTINGENCY THEORYIn studies of the relationship between leadership style and situationvariables, Fiedler and his associates (1965, 1967, 1974) posit thatindividuals possess dominant leadership characteristics that are wellestablished and generally inflexible. Leaders are characterized into one oftwo styles, either task-oriented (active, controlling, and structuring) orhuman relations–oriented (passive, permissive, and considerate). Fiedlerbelieved that an individual’s leadership style was grounded and somewhatinflexible; thus, leaders would improve their overall effectiveness by beingplaced in situations that best suited their orientation. Situations thatdisplay more variability and provide “contingencies” are analyzed acrossthree dimensions:• Leader–Member Relations: The degree of certainty, trust, and deferencebetween the subordinate and the leader. This factor addresses themanager’s perception of his or her cooperative relations with

subordinates. In other words, is the cooperation between the managerand subordinates good or poor? (Rating: good or poor.)• Task Structure: The extent to which job assignments are clear throughthe implementation of formalization and policy. This factor relates towhether the structure of the work task is highly structured, subject tostandard procedures, and subject to adequate measures of assessment.Certain tasks are easy to structure, standardize, and assess, such as theoperation of an assembly line. (Rating: high or low.)• Leader Position Power: The degree of control and influence the leaderlegitimately possesses in dealing with organizational activities; highlydependent upon the support the leader receives from seniormanagement. This factor asks if the manager’s level of authority isbased on punishing or rewarding behavior. For example, does themanger derive authority from providing bonuses profitability goals orterminating employees for failure to meet the goals? (Rating: strong orweak.)A leader’s contribution to the successful performance by his or her groupis determined by the leader’s style (i.e., task or relations) in conjunctionwith situational variables (i.e., relationships, task structure, and powerposition). Effective leaders seek or are placed in situations that best matchtheir leadership style.Fiedler’s research and the identification of leadership style were basedupon a questionnaire known as the Least Preferred Coworker (LPC) Scale.Fiedler (1970) developed the LPC by asking the participants to describetheir most and least preferred coworkers. Each participant was asked tothink of all others with whom he or she had ever worked and then todescribe the person with whom he or she worked best (i.e., most preferredcoworker) and then the person with whom he or she worked least well (i.e.,least preferred coworker or LPC). From the items identified, Fiedler createda scale that contains contrasting adjectives (such as pleasant/unpleasant,supportive/hostile, considerate/inconsiderate, and agreeable/disagreeable) tomeasure whether a person was task- or relations-oriented. Fiedler believedthat the ratings individuals ascribed to their least preferred coworker, aperson they least enjoyed working with, reflected more about themselvesthan the person they chose to describe. Thus, individuals who scored theLPC in relatively positive terms were labeled “relations-oriented,” whileindividuals who scored the LPC in relatively unfavorable terms were labeled“task-oriented.”

In assessing the three situational dimensions (leader–member relations,task structure, and position power), four levels of situational favorablenesscan be determined. Figure 10–1 identifies these four levels in a continuumof situational favorableness, from Very Unfavorable to Unfavorable andFavorable to Very Favorable. Fiedler’s research suggests that aligning theleadership style with the favorableness of the situation determines theeffectiveness of the leader regarding a group’s performance. If the leader isgenerally accepted and trusted by subordinates (good leader-memberrelations), if the tasks for which individuals are responsible are clear andfully understood through formalization and direction (high task structure),and the leader’s power is recognized (strong position of power), then thesituation is very favorable. On the opposite side of the coin, if the leaderlacks acceptance or trust by subordinates (poor leader–member relations), ifthe tasks for which individuals are responsible are unclear and not fullyunderstood because of a lack of formalization and an absence of direction(low task structure), and the leader’s power is not recognized (weak positionpower), then the situation is very unfavorable. In either scenario, the leaderwith a task-oriented leadership style would be the most effective. When thesituation variables are determined to be mixed (i.e., moderately unfavorableor moderately favorable), the human relations–oriented leadership approachwould be most effective.Figure 10–1 Fiedler’s Contingency TheoryIn a very unfavorable situation (i.e., leader–member relations are poor,there is low task structure, and the leader has little position power), one canunderstand the importance of a task-oriented leadership approach. But why

would a task-oriented leadership approach be best suited for a veryfavorable situation? In a very favorable situation the leader–memberrelationship is good, the task structure is high, and the position power isstrong. This combination provides an environment in which individuals areprepared to be guided and expect to be told what to do. For example, Fiedlersuggests one consider the captain of an airliner in its final landing; wewould hardly want him or her to turn to the crew for a discussion on how toland the plane!Fiedler’s Contingency Theory made a tremendous contribution towardcontingency theories for three reasons. It was the first theory tosystematically account for situational factors (i.e., relationships, taskstructure, and position power). Second, the theory considers the leader’sdominant orientation (i.e., a function of a leader’s needs and personality),not the leader’s behavior (Tosi & Mero, 2003). As Tosi and Mero (2003) pointout, although this orientation may affect the leader’s behavior, it is theleader’s orientation toward his or her group that determines how effectivethe group will be. Third, because the leader’s orientation is relatively stable,it is not likely that a leader will change orientations when confronted withdifferent situations, though the leader can change his or her behavior whennecessary and when the leader wants to (Tosi & Mero, 2003). Fiedlerbelieved that it would be easier to change the situation (i.e., workenvironment) to fit the leader’s style. As such, an organization should notchoose a leader who fits a situation, but should change the situation toagree with the style of its leader, since the leader’s personality is not likelyto change (Fiedler, 1970). (See Case Study 10–1: The New Chief Safety andCompliance Officer Position.)Over the past 25 years, Fiedler (1995; Fiedler, Potter, et al., 1979; Fielder& Garcia, 1987) introduced other variables into the original ContingencyTheory. Fiedler (1996) suggests that when leaders are under stress, theirintelligence and experience tend to interfere with each other, diminishingthe leader’s ability to think rationally, logically, and analytically. Fiedlerand Garcia (1987) refer to this reconceptualization as cognitive resourcetheory.This theory describes how group performance is a construct of a complexinteraction between (1) two leader traits—intelligence and experience, (2)one type of leader behavior—directive leadership, and (3) two aspects of theleadership situation—interpersonal stress and the nature of the task (Yukl,1998, p. 286). In other words, cognitive resource theory states that: (1) aleader’s intellectual abilities correlate positively with performance under low

stress but negatively under high stress and (2) a leader’s experiencecorrelates negatively with performance under low stress but positivelyunder high stress (Fiedler, 2008, p. 99). For example, leaders under stresswill fall back on their previously learned knowledge and behavior (e.g.,relying on intuition and hunches); therefore, the greater the range of theirexperience, the better their performance. Under low-stress conditions, moreexperienced leaders are not challenged and tend to be bored and cut corners(Fiedler, 1996).Case Study 10–1 The New Chief Safety and Compliance Officer PositionBen Allrod, chief executive officer of a 300-bed community hospital located in Midwest suburbia,received a call from the hospital’s director of nursing, Paul Muir, to ask whether they could meetimmediately to discuss a problem. It was unlike Paul to make such a request, so Ben agreed to meetimmediately.When Paul arrived, Ben could see that he was distressed. His face was pale and he appearednervous. Ben asked, “What’s up?” Paul related, “A few hours ago a patient received the wrong bloodtype during a transfusion. The nurse realized something was wrong when the woman began reactingadversely to the transfusion. Although this type of a mistake is not automatically fatal, the patientdied a few minutes ago. However, we cannot be certain that the wrong blood type was the cause ofher death because 60 percent of people who receive the wrong blood type would not exhibit anysymptoms of the problem. The patient may have expired because of other reasons; she was very sickwith multiple diagnoses.” Paul reminded Ben that, in addition to the family, the state’s MedicalError Oversight Board would need to be notified of this medical error.Ben was very shocked to hear this news, considering that two months ago the hospital had toreport to the state’s Medical Error Oversight Board that a metal clamp was left inside a patientafter surgery because the surgeon forgot to order a postsurgical X-ray. Thank goodness the patientwas not injured. At that time, the hospital’s chief operating officer, Harry Benson, stated that newprocedures would be implemented so the problem should not happen again.Ben thanked Paul for the information and instructed him to notify the state’s Medical ErrorOversight Board and that he would personally meet with the family to express his sympathy for theloss of their loved one and inform the family that “we” will be looking into the matter.After Paul left, Ben knew he had to do something immediately. Although Harry Benson had beenresponsible for developing and implementing all the necessary policies and procedures to preventmedical errors, Harry was not doing enough and things were going to have to change—now! Hewould deal with Harry later, but his first priority was creating a new position—Chief Safety andCompliance Officer. This new position would report directly to him and would have full authority todo whatever was needed to ensure that these problems did not occur again. He immediately draftedthe job description.The selected candidate will play a key role in the development of the organization’scompliance culture with a focus on prevention. This position will be responsible fordeveloping, implementing, and communicating the organization’s compliance and safetystandards, policies, and procedures. The position will oversee the design, organization, andimplementation of systemwide compliance education and training programs. The position isresponsible for monitoring and evaluating compliance activities to ensure program goals arebeing met across all functional areas. The position is responsible for establishing andparticipating in internal disciplinary actions for compliance violations.The candidate must have an MHA or related degree, 10 years of experience in the safety and

compliance area, including seven years in the health care industry and five years in amanagerial role. The position offers a competitive compensation package with excellentbenefits.Using Fiedler’s Contingency Theory, analyze the situational factors and determine what type ofindividual would be the most effective for Ben Allrod to hire. Could Ben change situational factorsinstead of hiring a new leader? If so, what changes would you recommend?HOUSE’S PATH–GOAL LEADERSHIP THEORYPath–Goal Leadership Theory was first introduced by Evans (1970) andfurther developed by House (1971). House (1971) suggests that effectiveleaders provide the path, the support, and resources to assist subordinatesin attaining organizational goals. This theory combines elements of the OhioState studies (i.e., consideration and initiating structure) with expectancytheories of motivation.Four separate, but fully integrated, components make up House’s Path–Goal Leadership Theory: Leadership Behaviors, Environmental ContingencyFactors, Subordinate Contingency Factors, and Outcomes (see Figure 10–2). The first component, Leadership Behavior, identifies four specificleadership styles:1. The directive leader provides employees a detailed understanding ofexpectations, a plan to accomplish those expectations, and theresources to achieve the tasks. The directive leadership style canincrease employee motivation and satisfaction where role ambiguityexists.2. The supportive leader shows concern for people, ensuring the workenvironment does not impede specific tasks that lead towardorganizational goals, and creates a supportive atmosphere. Thesupportive leadership style may increase employee motivation andsatisfaction where tasks are routine or stressful.3. The participative leader seeks input from a multiplicity of internalsources, including the technical core of employees, to assist in thedecision-making process. The participative leader maintainsresponsibility for the final decision, but includes the workforce in theprocess, ultimately enhancing buy-in from affected parties. Theparticipative leadership style can improve motivation and satisfactionin environments that are uncertain or in the process of change.4. The achievement-oriented leader establishes stimulating goals andexpects high levels of performance in achievement of the stated goals.

The achievement-oriented style of leadership creates an environmentof trust, where the leader acknowledges the workforce’s abilities toaccomplish organizational goals.Figure 10–2 House’s Path–Goal Leadership TheoryReproduced from Robbins, S. P. (2003). Organizational behavior (10th ed.). Upper Saddle River, NJ: Prentice Hall, p. 326.Whereas Fiedler proposed that leadership styles were grounded andinflexible, House proposed that leadership styles are adaptable and thatmanagers may be called upon to utilize any one of the four identified stylesof leadership, depending on the situation (Razik & Swanson, 1995; Robbins,2005).Leadership style is dependent on two contingency factors: environmentaland subordinate. House considered external dynamics, which are referred toas environmental contingency factors. These factors include: (1) clarity ofthe task to be performed, (2) hierarchical authority systems, and (3) groupdynamics (i.e., work-group members’ relationships). These factors are

generally considered to be outside the control and influence of the workerand the manager. The second set of contingency factors, considered internaldynamics, is referred to as subordinate contingency factors. These factorsinclude the employee’s locus of control; knowledge, skills, and abilities (realor perceived); and experience. Subordinate contingency factors arecharacteristics exhibited by the employees (Robbins, 2005).The integration of leadership style, environmental contingency factors,and subordinate contingency factors leads to outcomes (performance andsatisfaction). According to House and Mitchell (1974), a leader’s role is toinfluence subordinates’ perceptions and motivate them toward achieving thedesired outcomes (i.e., performance and satisfaction). To be effective,managers should:1. Increase personal payoffs to subordinates for work goal attainment;2. Provide coaching and direction, when needed;3. Clarify expectations of workers;4. Reduce frustrating barriers;5. Increase opportunities for personal satisfaction contingent on effectiveperformance.The appropriate leadership style that a manager should use is the onethat compensates for any item absent from the employee (i.e., experience,ability) or the work setting (i.e., task structure). The leadership style shouldnot duplicate what the employee already has available to him or her. Forexample, the nurse manager should not provide direction (i.e., directiveleadership style) as to how to complete a patient’s history and physical to anurse with 20 years of experience. However, the nurse manager shouldprovide direction and/or training to a nurse with 20 years of clinicalexperience but limited or no experience with technology or use of electronicmedical records for documenting a patient’s history and physical for the firsttime.TANNENBAUM AND SCHMIDT’S CONTINUUM OFLEADERSHIP BEHAVIORTannenbaum and Schmidt (1958, 1973) conducted one of the first studiesthat indicated a need for leaders to evaluate the situational factors prior tothe implementation of a particular leadership style (Ott, 1996). TheContinuum of Leadership Behavior model is based on the variety ofbehaviors noted in earlier leadership studies, particularly the distinction of

task versus human relations orientation. This model identifies two styles ofleadership that occur across a continuum, from boss-centered (task) throughsubordinate-centered (relationship).As illustrated in Figure 10–3, the Tannenbaum and Schmidt (1958)model covers a range of leadership behaviors. The model identifies theamount of authority (boss-centered) used by the manager and the amount offreedom afforded to employees (subordinate-centered). At one end of thecontinuum (boss-centered), the manager takes complete control of thesituation, makes a decision, and announces it to the employees. There is noeffort to solicit feedback, ideas, or input. At the other end of the continuum(subordinate-centered), the manager and employees collaboratively makedecisions within clearly defined organizational constraints. Within the twoextremes of the continuum lie a multitude of managerial options to eitherinclude or exclude employee involvement in decision-making processes. Theappropriateness of the behavior is dependent upon situational (contingent)factors.

Figure 10–3 Tannenbaum and Schmidt Continuum of Leadership BehaviorReproduced from Robert Tannenbaum and Warren H. Schmidt, Harvard Business Review, How to Choose a LeadershipPattern, March–April 1958, p. 96. Used with Permission.How do managers determine where on the continuum they shouldposition themselves? Determinants may include (1) the manager’s style ofleadership, (2) the culture of the organization, (3) the complexity of the taskat hand, or (4) the relationship between the manager and the employee,specifically the level of confidence the manager has in the employee and thelevel of comfort in delegating a task or seeking participation in the decisionprocess. Another situational factor important to the process is the level ofacceptance by the employee to participate and acknowledge responsibilityfor delegated tasks. When an employee conveys a desire to participate, thesubordinate-centered leadership is appropriate. Conversely, when amanager is faced with an employee who avoids involvement beyond what isminimally expected, the boss-centered leadership style would be the suitableapproach.

One approach is not preferred over the other. The situational factors willdetermine appropriateness. Today’s health care managers are faced with anonslaught of ongoing critical decisions for which they are accountable andresponsible. With this in mind, it is imperative that managers functioneffectively at each placement on the leadership continuum. Attempts tomaintain a subordinate-centered position on the continuum will not meetthe needs of the organization when a manager is faced with making adecision that requires information that employees may not possess or whenthe situation is so critical that it prevents time to collaborate withemployees.Given appropriate time to seek involvement in a decision, thesubordinate-centered approach is preferred for obvious reasons. Employeeswho are permitted to participate in the decision-making process most oftenare less threatened by the impending change by feeling more a part of thesolution rather than as an observer who has no control over what may ormay not happen. Unnecessary exclusion from a participatory effort cancreate an environment of distrust, fear, hopelessness, and anger. Amanager’s decision as to where on Tannenbaum and Schmidt’s continuumhe or she should be positioned is critical to both the task and how he or sheis perceived by those affected by the positioning.HERSEY AND BLANCHARD’S SITUATIONALLEADERSHIP MODELThe work of Hersey and Blanchard (1988) suggests leaders should adapttheir leadership style based on three dimensions: (1) task behavior, (2)relationship behavior, and (3) level of maturity of the subordinate. Taskbehavior refers to a leader’s clear definition of work roles andresponsibilities while ensuring task clarity. Relationship behavior refers tothe development of personal relationships, as well as emotional andpsychological contracts between the leader and the subordinates. These twodimensions, task behavior and relationship behavior, are shaped by the finaldimension, the level of maturity of the subordinate. The level of maturity ordevelopment of the subordinate is characterized by three specific criteria:1. The level of motivation exhibited by the subordinate.2. The willingness of the subordinate to assume responsibility.3. The experience and educational level of the subordinate.According to Hersey and Blanchard’s Situational Leadership Model (see

Figure 10–4), as the employee cultivates knowledge, skills, and abilities toperform at increasing levels of expectations, the manager modifies his orher leadership style. As the subordinate passes through different stages ofcommitment and competence, the leader varies the amount of direction andsupport given. The leader plays various roles of directing, coaching,supporting, and delegating as the subordinate “matures” and becomes ableto perform more activities. The varying amounts of direction and supportgiven are conceptualized into four leadership styles: Telling, Selling,Participating, and Delegating.

 

Figure 10–4 Hersey and Blanchard’s Situational Leadership ModelReproduced from Luthans, F. (2002). Organizational behavior (9th ed.). Boston, MA: McGraw-Hill, p. 616.The Situational Leadership Model identified that when the level ofmaturity of the follower (i.e., subordinate) is very low, a high-task, low-relationship style of leadership is most effective. As an example, thissituation occurs when an employee is new to an organization, attempting tolearn task expectations while assimilating into a new culture. Theemployee, new to the environment, seeks direction by being told what to do;hence, the effective leader uses a telling style of leadership.As the new employee better develops knowledge, skills, and abilities,thereby increasing his or her level of performance, the leader canincorporate a selling style of leadership. This method of leadership (high-task, high-relationship) is effective when the employee becomes increasinglyconfident and is willing to accept additional responsibilities. The leader nolonger merely directs the employee as to what must be done, but makes theeffort to tell the employee what to do and how his or her role is important toachieving departmental objectives and organizational goals. It is importantthat the leader recognize the importance of both the task behavior and therelationship behavior at this stage of maturity development.As the maturity of the employee continues to increase to higher levels, theleader is required to place less of an emphasis on the task, but continues toadvance the relationship (low-task, high-relationship). At this level ofmaturity the employee has demonstrated the ability to perform toorganizational expectations with minimal managerial influence, allowingthe leader to function most effectively using a participative style ofleadership. In this stage of the model, the leader seeks input from thesubordinate in areas concerning processes, tasks, and productivity concerns.The leader still makes the decision and ensures compliance, but theemployee participates in the decision-making process through an exchangeof information between the leader and employee.Upon full maturity, the employee has fully developed by exhibiting anunquestionable ability to perform expected tasks. This subordinate’smaturity level is very high (low-task, low-relationship), creating anenvironment conducive to a delegating style of leadership. At this point inthe model, the leader modifies his or her own behavior to a level where theleader is comfortable to not only delegate, but to allow the employee to

identify innovative ways to accomplish the task.Empirical research, as in other leadership studies, is critical of theSituational Leadership Model. Critics question the coherence of the resultsof the model, where a questionnaire identifies 12 situations that aresupposed to represent levels of subordinate maturity and that managershave only one of four styles of leadership. Hersey and Blanchard admit themodel may be oversimplified, yet one can clearly apply the model in apractical workplace environment (Luthans, 2002).LEADER-MEMBER EXCHANGE THEORYWhereas the contingency theories discussed thus far relate leadershipstyle with general situational and subordinate factors across a group ofemployees, Leader–Member Exchange (LMX) directs us to the differentiatedrelationships that arise between individual subordinates and theirsupervisors.The foundation for LMX comes from the work of George Graen and JamesCashman (1975), who coined the phrase Vertical Dyad Linkage (VDL) todescribe how leaders develop dyadic (two-person) relationships withsubordinates that affect the behavior of the leader and the subordinate.Over time and through a process of role-taking, role-making, androutinization (see Exhibit 10–1), the leader cognitively assigns subordinatesas belonging to an in-group or an out-group. Individuals assigned to the in-group are perceived by the leader as being more committed toorganizational goals and more likely to fulfill responsibilities with higherlevels of performance. The in-group is “rewarded with more of the leaders’positional resources (i.e., information, confidence, and concern) thanindividuals assigned to the out-group” (Luthans, 2002, p. 583). For example,a group of early careerists are enrolled in the hospital’s managementdevelopment program, where they must interact with the vice president ofhuman resources, the facilitator of the program. Those young careerists whoare considered to be in the in-group may have a higher number ofinteractions with the vice president than those considered to be in the out-group. For instance, if Valerie’s personality is similar to the vice president’spersonality, then the vice president may spend extra time meeting with andcoaching Valerie regarding her career development. This high level ofinteraction will increase the likelihood that Valerie will be in the vicepresident’s in-group and that they will develop a high-quality relationship.Additionally, Valerie may be given special projects during the developmentprogram that further enhances her career opportunities within the hospital

because she is within the vice president’s in-group. Bob, another of theyoung professionals, may have relatively little interaction with the vicepresident outside of the program’s scheduled training time because the vicepresident dislikes Bob’s communication style. Therefore, Bob would be in thevice president’s out-group, and they would have a low-quality relationship.Not surprisingly, in-group members report fewer problematic issues withleader–member interactions and higher levels of responsiveness with theleader than do members of the out-group. Additionally, in-groups are moreoften led with less emphasis on formal authority to control and influence,while out-groups are more often supervised with a much stronger emphasison formal authority to control and influence. The mere nature of the highquality of the leader–member relationship that occurs with the in-groupgenerates individuals who accept greater responsibility and exhibit higherlevels of contribution to organizational goals (Graen & Ginsburgh, 1977;Liden & Graen, 1980).The Leader–Member Exchange (LMX) theory takes VDL one step further.LMX examines the characteristics of individuals belonging to the in-group,noting similarities that exist between in-group members and the leader inthe dyadic relationship. Individuals with high self-efficacy will tend to formin-group relationships with the leader. In this dyadic relationship, the leaderperceives the followers to be more friendly, approachable, and similar inpersonality to the leader him- or herself. The perception of similaritybecomes a very important factor for inclusion in the in-group and theresultant development of relationships and contributions to taskaccomplishment.Exhibit 10–1 The Three Phases of LMXThe Leader-Member Exchange Theory states that all relationships between leaders andsubordinates go through three stages. These are:1. Role-Taking.2. Role-Making.3. “Routinization.”1. Role-TakingRole-taking occurs when team members first join the group. Leaders use this time to assessnew members’ skills and abilities.2. Role-MakingNew team members then begin to work on projects and tasks as part of the team. In this stage,leaders generally expect that new team members will work hard, be loyal and prove trustworthy

as they get used to their new role.The theory says that, during this stage, leaders sort new team members (often subconsciously)into one of two groups.• In-Group – if team members prove themselves loyal, trustworthy and skilled, they’re put intothe In-Group. This group is made up of the team members that the leader trusts the most.Leaders give this group most of their attention, providing challenging and interesting work,and offering opportunities for additional training and advancement. This group also gets moreone-to-one time with the leader. Often, people in this group have a similar personality andwork-ethic to their leader.• Out-Group – if team members betray the trust of the leader, or prove that they’re unmotivatedor incompetent, they’re put into the Out-Group. This group’s work is often restricted andunchallenging. Out-Group members tend to have less access to the leader, and often don’treceive opportunities for growth or advancement.3. RoutinizationDuring this last phase, routines between team members and their leaders are established.In-Group team members work hard to maintain the good opinion of their leaders, by showingtrust, respect, empathy, patience, and persistence.Out-Group members may start to dislike or distrust their leaders. Because it’s so hard to moveout of the Out-Group once the perception has been established, Out-Group members may have tochange departments or organizations in order to “start over.”Once team members have been classified, even subconsciously, as In-Group or Out-Group, thatclassification affects how their leaders relate to them from then on, and it can become self-fulfilling.For instance, In-Group team members are often seen as rising stars and the leader trusts themto work and perform at a high level. This is also the group that the leader talks to most, offeringsupport and advice, and they’re given the best opportunities to test their skills and grow. So, ofcourse, they’re more likely to develop in their roles.This also holds true for the Out-Group. The leader spends little, if any, time trying to supportand develop this group. They receive few challenging assignments or opportunities for trainingand advancement. And, because they’re never tested, they have little chance to change theleader’s opinion.Mind Tools.com, Available at: http://www.mindtools.com/pages/article/leader-member-exchange.htm Reprinted with permission.According to Robbins (2005, p. 163), “Studies confirm many of the LMXpredictions that leaders do differentiate among followers and those with in-group status have higher performance ratings, lower turnover intentions,and higher satisfaction with superiors than those in the out-group.”SUMMARYContingency theories provide us with the understanding that oneleadership style is not effective across all the variable situations that existin organizations. The leader who is able to respond to ever-increasing levels

of environmental uncertainty through the utilization of more than one styleof leadership will be most likely to increase employees’ levels of motivation,satisfaction, and productivity. One should not underestimate the importanceof the interrelationship of applying the appropriate leadership style basedupon the accurate analysis of situational factors.DISCUSSION QUESTIONS1. Describe Fielder’s Contingency Model. What is the impact of hisassumption that leadership style is “fixed”?2. Summarize the Path–Goal Leadership Theory. What theories ofmotivation can you tie to the assumptions of the model?3. Identify health care situations in which Tannenbaum and Schmidt’sContinuum of Leadership Behavior would suggest the autocraticleadership style as the most appropriate.4. Discuss the role of leadership style in response to follower maturity(development) as presented in the work of Hersey and Blanchard.5. What impact does the assignment of followers to the in- or out-group(LMX) have on worker performance and satisfaction?6. Apply the contingency theories discussed in this chapter as theyrelate to your work environment to assess the appropriate style ofleadership and the implications for motivation, satisfaction, andproductivity.EXERCISE 10–1Write a brief description of a personal experience as either the leader orfollower when:• A “telling” style of leadership was used.• A “selling” style of leadership was used.• A “participating” style of leadership was used.• A “delegating” style of leadership was used.Examine the effectiveness of the style by answering some questions aboutit, such as: Did it work? Could a different style have worked better? Whichstyle do you prefer your supervisor to use with you? Which style are youmost comfortable using yourself? Why?Form a group of three to four individuals, and share and discuss your

questions with your group.Case Study 10–2 What Can Joe Do About Betty?Just before quitting time, Joe, the hospital’s health information department manager, watched histhree new trainees struggling with the complicated electronic medical records software they had tolearn to use to do their jobs. Across the room, Betty, who was an expert with the software, waspreparing to leave for the day, her tasks done ahead of time as usual. Also as usual, she gathered upher belongings and left without saying good-bye to any of her coworkers. “There goes the answer tomy problem,” thought Joe. “If only I knew how to reach her.” With her expertise and experience inusing the system, Betty would seem to be an ideal coach for the new employees. However, she hadbegged off from taking on training duties when Joe had asked her. Her reasons were that she wasn’tcomfortable telling anyone else what to do, didn’t want the responsibility for someone else’s work,and preferred to work by herself at her own job.Joe was stunned by her refusal; he enjoyed helping his coworkers and felt it was why he hadadvanced to department manager last year instead of Betty, who had more seniority and experiencewith the company than he did. Since her work was excellent, Joe hesitated to make it an “either youdo what I want or you’re in trouble” situation; he believed employees worked best at what theywanted to work at. But his problem still remained: There was no money in the training budget andno other employees as skilled with the system as Betty was. Was there an approach to convincingher to help that he hadn’t thought of?As Betty walked to the hospital’s parking lot, she thought, “How could Joe think I would lift afinger to help him? I should have been the one promoted to department manager last year, not him.I’m the one with seniority and the necessary experience. In fact, I was the one who trained Joe whenhe first joined the hospital! Just because he has a master’s in health information management and Idon’t should not have been the determining factor, but obviously senior management thought sowhen they selected him over me! I could care less what happens from this point forward. I only havefive more years until I can retire with my full pension. As long as my work continues to be excellentthere is no way Joe can upset my plans. Not that he could since he hardly understands thecomplexity of the software we use since it requires a person with a lot of technology knowledge andexperience.”Using Fiedler’s Contingency Theory, explain what style of leadership Joe should use with Bettygiven the current situation in his department.Case Study 10–3 A New Employee Scheduling SystemYou are the director of human resources of Baptist Health System, an integrated network ofnonprofit hospitals, physician clinics, and home medical services with over 4,000 employees. Youwish to implement a new software application to upgrade and automate employee-relatedscheduling. You estimate that replacing the organization’s antiquated system and automating thislabor-intensive, time-consuming task can save the health system thousands of dollars each year.Frank is a person in the organization’s Office of Technology (OT) who has the skill set you need.However, Frank does not report to you, and you know that OT is understaffed and overworked. Youhave permission from Frank’s boss, Jane, to use some of his time only if it doesn’t interfere with hisregular duties.Scenario One:Upon obtaining Jane’s permission, you send Frank an email stating, “I need you to assist staff inmy department with the implementation of a new software application to upgrade and automate the

organization’s employee-related scheduling. This needs to be completed within two weeks. Myassistant will contact you tomorrow to discuss the specific details of this project so you can startimmediately.”Scenario Two:You schedule a meeting with Frank for the next day to discuss your situation. “Frank, I want totalk to you about this project I am working on because I understand that you have experience withdatabase conversions, and Jane told me that you were the best person to talk to about this subject.This project is very important to the organization because, like most health care organizations, weare facing ongoing challenges of labor cost control and maintaining the appropriate staff levelsnecessary to maintain high levels of patient care. Baptist has been using an antiquated application tomanage staffing and scheduling for several years; the software is outdated and no longer fulfills theneeds of the organization. We need a new employee scheduling system that is flexible and scalableenough to accommodate continued organizational growth.“Frank, let me tell you what I’m trying to accomplish in the next 30 days. The system has tointegrate with our existing time and attendance system so information can be shared between ourfacilities. We also want to get a handle on our data in real time, not 14 days after the pay period.Additionally, The Joint Commission has high levels of tracking and reporting, so the organizationhas to find a way to deal with these reporting expectations. Frank, how can you help us reach ourgoal?”Using Hersey and Blanchard’s Situational Leadership Model, discuss how Frank will react undereach of the preceding scenarios. Why?Exhibit 10–2 Leadership Style SurveyDirectionsThis questionnaire contains statements about leadership style beliefs. Next to each statement,circle the number that represents how strongly you feel about the statement by using thefollowing scoring system:• Almost Always True: 5• Frequently True: 4• Occasionally True: 3• Seldom True: 2• Almost Never True: 1Be honest about your choices, as there are no right or wrong answers—this is only for self-assessment.Leadership Style Survey

On the fill-in lines, mark the score of each item on the questionnaire. For example, if youscored item one with a 3 (Occasionally), then enter a 3 next to Item One. When you have enteredall the scores for each question, total each of the three columns.

This questionnaire is to help you assess what leadership style you normally use. The lowestscore possible for a leadership style is 10 (Almost never), while the highest score possible for astage is 50 (Almost always).The highest of the three scores indicates what style of leadership you normally use. If yourhighest score is 40 or more, it is a strong indicator of your normal style. The lowest of the threescores is an indicator of the style you use least. If your lowest score is 20 or less, it is a strongindicator that you normally do not use this leadership style.If two of the scores are close to the same, you might be going through a transition phase, eitherpersonally or at work, except:If you score high in both the participative and the delegative, then you are probably adelegative leader.If there is only a small difference between the three scores, then this indicates that you haveno clear perception of the leadership style you use, or you are a new leader and are trying to feelout the correct style for you.Available at: www.nwlink.com/~donclark/leader/survstyl.html. Created July 15, 1998; lastupdate August 21, 2010. Copyright by Donald Clark. Reprinted with permission.REFERENCESEvans, M. G. (1970). The effects of supervisory behavior on the path–goalrelationship. Organizational Behavior and Human Performance, 5, 277–298.Fiedler, F. E. (1965). Engineer the job to fit the manager. Harvard BusinessReview, 43, 115–122.

Fiedler, F. E. (1967). A theory of leadership effectiveness. New York, NY:McGraw-Hill Book Company.Fiedler, F. E. (1970). The contingency model: A theory of leadershipeffectiveness. In C. W. Backman & P. F. Secord (Eds.). Problems in socialpsychology (pp. 279–289). New York, NY: McGraw-Hill Book Company.Fiedler, F. E. (1995). Cognitive resources and leadership performance.Applied Psychology—An International Review, 44, 5–28.Fiedler, F. E. (1996). Research on leadership selection and training: Oneview of the future. Administrative Science Quarterly, 41(2), 241–250.Fiedler, F. E. (2008). The curious role of cognitive resources in leadership. InR. E. Riggo, S. E. Murphy, & F. J. Pirozzolo (Eds.). Multiple intelligencesand leadership. Mahwah, NJ: Lawrence Erlbaum Associates.Fiedler, F. E., & Chemers, M. M. (1974). Leadership and effectivemanagement. Flenview, IL: Scott, Foresman.Fiedler, F. E., & Garcia, J. E. (1987). New approaches to effective leadership:Cognitive resources and organizational performance. New York, NY: JohnWiley & Sons.Fiedler, F. E., Potter, E. H., Zais, M. M., & Knowlton, W. (1979).Organizational stress and the use and misuse of managerial intelligenceand experience. Journal of Applied Psychology, 64, 635–674.Graen, G., & Ginsburgh, S. (1977). Job resignation as a function of roleorientation and leader acceptance: A longitudinal investigation oforganizational assimilation. Organizational Behavior and HumanPerformance, 19, 1–17.Graen, S. G., & Cashman, J. F. (1975). A role-making model of leadership infromal organizations: A development approach. Organization andAdministrative Sciences, 6, 143–165.Hersey, P., & Blanchard, K. H. (1988). Management of organizationalbehavior. Upper Saddle River, NJ: Prentice Hall.House, R. J. (1971). A path-goal theory of leader effectiveness.Administrative Sciences Quarterly, 16(3), 321–338.House, R. J., & Mitchell, T. R. (1974). Path–goal theory of leadership.Journal of Contemporary Business, 3(4), 81–97.Liden, R. C., & Graen, G. (1980). Generalizability of the vertical dyadlinkage model of leadership. Academy of Management Journal, 23, 451–466.Luthans, F. (2002). Organizational behavior (9th ed.). Boston, MA:McGraw-Hill Book Company.

Ott, J. S. (1996). Classic readings in organizational behavior (2nd ed., p.168). Albany, NY: Wadsworth Publishing Company.Razik, T. A., & Swanson, A. D. (1995). Fundamental concepts of educationalleadership and management. Upper Saddle River, NJ: Prentice Hall.Robbins, S. P. (2005). Organizational behavior (8th ed.). Upper SaddleRiver, NJ: Prentice Hall.Tannenbaum, R., & Schmidt, W. (1958). How to choose a leadershippattern. Harvard Business Review, 36(2), 95–501.Tannenbaum, R., & Schmidt, W. (1973). How to choose a leadershippattern. Harvard Business Review, 51(3), 1–10.Tosi, H. L., & Mero, N. P. (2003). The fundamentals of organizationalbehavior: What managers need to know (p. 254). Malden, MA: BlackwellPublishing.Yukl, G. (1998). Leadership in organizations (4th ed.). Englewood Cliffs, NJ:Prentice-Hall.*We acknowledge and thank Dr. Gloria Deckard, who was the contributing author of an earlierversion of this chapter, which appeared in Organizational Behavior in Health Care (2011), Jones andBartlett Publishers.

CHAPTER 11Contemporary Leadership TheoriesLEARNING OUTCOMESAfter completing this chapter, the student should be able to: Define transformational leadership. Identify the similarities and differences between transformational andtransactional leadership approaches. Discuss the appropriate application of transformational leadership stylein the contemporary work environment. Examine transformational leadership in the health managementsetting. Define charismatic, servant, and collaborative leadership. Identify characteristics common to charismatic, servant, andcollaborative leaders. Describe the effect of charismatic, servant, and collaborative leadershipon organizational outcomes and the attainment of strategicorganizational goals. Discuss the development of behavioral competencies for health careleaders.OVERVIEWIn this chapter, we examine various contemporary leadership theories,including transformational, charismatic, servant, and collaborative. Thesetheories build upon both individual trait and behavior theories, as well ascontingencies theories of leadership. When one first attempts to examineleadership, the focus is typically on an individual who possesses sufficientsources of power to exert influence and control over members of theorganization in the effort to achieve organizational goals. The flaw in usingthis approach is the narrow focus on the individual. More appropriateassessment of leadership includes the characteristics of the leader, as wellas subordinates, peers, supervisors, and the organization itself. This broader

perspective provides a more detailed examination of the leader, the externalenvironment, and the situation—all factors that determine appropriatenessof leadership style. Contemporary theories also emphasize emotion, vision,and values.While contemporary theories recognize the complexities and expand themultiplicity of variables impacting leadership, they also return us to theexamination of individual characteristics and behaviors. Novick, Morrow,and Mays (2008) suggest that transformational leadership seeminglyappears as the reemergence of trait-based theories. Indeed, numerousstudies in recent years have focused on personality traits of effectivetransformational, transactional, and charismatic leaders (DeHoogh, DenHartog, & Koopman, 2005). Many credit this resurgence to the work ofJudge, Bono, Ilies, and Gerhardt (2002), who group the numerous traitsidentified in leadership studies into a “Big Five” personality framework. Byorganizing similar traits into five categories (Extroversion, Agreeableness,Conscientiousness, Emotional Stability, and Openness to Experience),stronger and more consistent relationships emerged. This five-factor view ofpersonality provided a new framework for linking personality and leaderbehavior and effectiveness in studies on charismatic, transformational, andtransactional leadership (Bryman, 1992; Den Hartog & Koopman, 2001;Digman, 1990). A second individual trait that has received considerableattention is emotional intelligence (EI). Emotional intelligence involves theability to monitor one’s own and others’ feelings and emotions, todiscriminate among them, and to use this information to guide one’sthinking and actions (Salovey & Mayer, 1990).While innate personality traits play a role in leadership, the varianceexplained by personality remains limited. A leader may have intrinsic traitsthat enhance or allow leadership to emerge, but he or she must also haveknowledge, skills, vision, and values to effectively influence followers andfacilitate individual and organizational performance. Therefore, we concludethis chapter with a brief review of the development of behavioralcompetencies for health care leadership.TRANSFORMATIONAL VERSUS TRANSACTIONALLEADERSHIPIt is helpful to define the terms “transactional” and “transformational” toestablish a foundation in regard to how each approach is appropriate andvital to organizational success.

In general terms, transactional leadership is directed toward taskaccomplishment and the maintenance of good relations between the leaderand subordinates through consideration of performance and reward. Thetransactional leadership model has been considered the most prevalentleadership model used in health care (Schwartz & Tumblin, 2002). Incontrast, transformational leadership is directed toward the influence andmanagement of institutional change and innovation through revitalizationand vision (Dessler, 1998, p. 350).Leader behaviors include characteristics identified as consideration andinitiating structure. Consideration is the recognition that individuals haveneeds and require relationships; initiating structure denotes an emphasis ontasks and goals. Burns (1978) reported that transactional leadership style isbased on both consideration and initiating structure. Transactionalbehaviors are “largely oriented toward accomplishing the task at hand andmaintaining good relations with those working with the leader byexchanging promises of rewards for performance” (Dessler, 1998, p. 350).Transactional leaders seek to maintain the status quo and rewardsubordinates for doing what is expected from them. Expectations ofperformance and the resultant rewards are clearly identified and deliveredupon completion of the agreement. As DeHoogh, Den Hartog, and Koopman(2005, p. 840) put it, “transactional leaders influence followers through task-focused behaviors; they clarify expectancies, rules and procedures,emphasizing a fair deal.” Trastek, Hamilton, and Niles (2014) relate thatthe transactional leadership model is unable to account for the complexmotivations of health care providers, and it fails to build trust between theleader and the follower.In contrast to the transactional leadership model, the transformationalstyle of leadership incorporates emotion, values, and vision to motivateindividuals and seeks to change the status quo. Transformational leadershipis all about change, innovation, improvement, and entrepreneurshipthrough vision and inspiration. Osland, Kolb, and Rubin (2001, p. 297) statethat “transformational leaders are value-driven change agents who makefollowers more conscious of the importance of task outcomes. They providefollowers with a vision and motivate them to go beyond self-interest for thegood of the organization.”Transformational leadership establishes subordinate effort andperformance that extends beyond that which occurs as a result oftransactional leadership. These two approaches to leadership are notmutually exclusive; most leaders exhibit both transactional and

transformational behaviors in different intensities and amounts (Bass,1990b; Luthans, 2002). According to Bass (1990b) and Luthans (2002, p.592), each leadership approach differentiates itself in the identification offour specific characteristics unique to each style:Transactional Leadership• Contingent Reward: Contracts exchange of rewards for effort; promisesrewards for good performance; recognizes accomplishments.• Management by Exception (an active approach): Watches and searchesfor deviations from rules and standards; takes corrective action.• Management by Exception (a passive approach): Intervenes only ifstandards are not met.• Laissez-Faire: Abdicates responsibilities; avoids making decisions.Transformational Leadership• Charisma: Provides vision and sense of mission; instills pride; gainsrespect and trust.• Inspiration: Communicates high expectations; uses symbols to focusefforts; expresses important purposes in simple ways.• Intellectual: Promotes intelligence, rationality, and careful problemsolving.• Individualized Consideration: Gives personal attention; treats eachemployee individually; coaches; advises.Transformational leadership elevates the level of insight about theimportance and value of outcomes through the growth of subordinates byencouraging followers to question their own way of doing things.Transactional leadership constitutes behavior that operates throughconsideration and covenants between the leader and the follower.TRANSFORMATIONAL LEADERSHIP: ACONTRADICTORY VIEWKotter (1995) provided a contradictory view as to the success ofincorporating transformational efforts. Kotter noted that transformationalchange (through transformational leadership) is conducted under manybanners: cultural change, reengineering, and total quality management, toname a few. The purpose of transformational leadership is to address theessential changes necessary to respond to an ever-changing, globally

competitive environment.Kotter (1995) added that transformational leadership resulting insuccessful change is best executed in phases and that failure to address eachphase to the fullest significantly diminishes the capacity to succeed. Asillustrated in Table 11–1, Kotter identified eight transformational phasesand associated transformational errors, which he accompanies withstrategies to enhance the success of the leader by addressing the errors.Tichy and Devanna (1986), cited in Luthans (2002, pp. 591–592), found thattransformational leaders shared the following seven characteristics:1. They identified themselves as change agents.2. They exhibited courage.3. They trusted people.4. They were value driven.5. They valued lifelong learning.6. They possessed the capability to face complexity, ambiguity, anduncertainty.7. They were imaginative, creative, innovative, and visionary.Table 11–1 Eight Specific Errors That Diminish the Transformational EffortPhaseTransformational ErrorsProcesses to Enhance Transformational Success1Failure to create a true sense ofurgencyEstablish a sense of urgency by examining market/competitive realities andconducting a SWOT analysis (strengths, weaknesses, opportunities, andthreats)2Failure to create a powerfulguiding coalitionForm powerful coalitions by assembling groups of teams with the power toeffect change3Failure to create a clearlyunderstood visionCreate a vision with direction and focus consistent with organizationalstrategies4Failure to adequatelycommunicate the visionUse all available channels of communication to convey the change and leadby example5Failure to remove obstacles inmoving towardtransformational changeRemove obstacles, change systems and structures, encourage creativityand innovation through empowerment6Failure to systematically plan foror create short-termsuccessesPlan for and recognize visible, short-term improvements through establishedreward systems7Proclaiming success prematurelyUtilize credibility to change systems, structures, processes, and policies toarrive at the vision8Failure to anchor thetransformational changeInstitutionalize the change by infusing appropriate behaviors that will lead todevelopment and succession in the organizational culture“Leading Change: Why Transformational Efforts Fail,” by J. P. Kotter, 1995. Harvard Business Review,73(2), 61. Reprinted with permission.THE IMPLICATIONS OF TRANSFORMATIONAL

LEADERSHIP ON THE HEALTH CARE INDUSTRYDue to the Affordable Care Act (2010) and other factors, health careorganizations will transform in many ways in the years to come. The healthcare manager must acquire the skills, abilities, and knowledge necessary tounderstand effective leadership processes and anticipate environmentalchange. Changes facing the health care manager necessitate a strongerfocus on results, creativity, and innovation (Gummer, 1995). The healthcare manager will experience increasing calls to demonstrate highperformance and quality outcomes while reducing costs in the midst ofdecreasing revenues. Leaders must demonstrate increasingtransformational skills while balancing the requirements of transactionalmanagement. However, as previously noted, the transactional leadershipmodel has been considered the most dominant leadership model used inhealth care (Schwartz & Tumblin, 2002).A 2003 study by Thyler provides interesting insight into the hold of thetransactional approach to health care leadership and its impact on nursingcare. In his study, Thyler reported that the healthcare transactionalleadership style may be causing nurses to leave the profession because theystruggle ideologically with the system in which they work. Numerous otherstudies have been conducted regarding the relationship between leadershipstyle and job satisfaction (or dissatisfaction). For example, Medley andLarochelle’s (1995) research reported that staff nurses view behaviorsassociated with transactional leadership (e.g., negative feedback)unfavorably in relation to their jobs. This study indicated that head nurseswith high transformational scores were more likely to have staff nurseswith higher job satisfaction scores and longer association with their staffnurses than transactional leaders. These results provide strong support thata transformational leadership approach advances retention efforts anddiminishes turnover rates—a conclusion that has significant fiscalimplications for health care facilities.Chaffee (2001) addressed the implications of transformational leadershipin a military health care environment. The purpose of Chaffee’s study wasto identify the ideal characteristics of a Navy health care executive of thefuture. Sixty-seven respondents reported most frequently the followingcharacteristics of an ideal, transformational leader:• Possesses an ability to organize teamwork.• Possesses a clear vision.• Teaches others to succeed and mentors others.

• Takes risks and encourages others to do so.• Develops and maintains excellent interpersonal relationship skills.• Possesses credibility, honesty, and integrity.• Embraces and drives change.• Strives for excellence and continuous improvement.• Possesses excellent communication skills.• Exhibits a passion for work.• Maintains a focus on the organizational mission.“The characteristics identified by respondents describe leadership traitsrather than management skills. None of the respondents identified thetraditional managerial skills of planning, organizing, coordinating,directing, and controlling. Additionally, the most frequently identifiedcharacteristics fit the definition of transformational leadership” (Chaffee,2001). These leadership characteristics support four managerialcompetencies sustained by successful leaders:1. Management of Attention: The ability to get the attention of a groupthrough a compelling vision that brings others to a place they havenot been before.2. Management of Meaning: The ability to make a vision clear to othersand the ability to communicate ideas and create meaning.3. Management of Trust: The ability to inspire trust through reliabilityand constancy.4. Management of Self: Knowing one’s skills and deploying themeffectively. (Bennis, 1984; Chaffee, 2001)Transformational leadership is, without question, very well suited to theneeds of today’s economic, social, political, and technological conditions.Why? Transformational leadership thrives on change and innovation.Transformational leadership provides the knowledge, skills, and abilities tofacilitate innovation and transformation, beyond that which is availablethrough a traditional approach. Doing things because that is the way theywere always done will be replaced with dynamic solutions to old and newproblems (Sofarelli & Brown, 1998; Trofino, 2000).Bennis and Nanus (1985), while noting the importance of bothmanagement and leadership, recognized a philosophical dissimilaritybetween the two approaches: “Managers are people who do things right andleaders are people who do the right things” (p. 21). The implications of thisstatement provoke questions as to how the health care industry will respond

to an environment where leadership focuses less on managing technicalskills and more on managing knowledge processes. Technical skills arecontrolled through clearly stated goals and measurable performanceobjectives. Mental processes have replaced the mechanistic tasks that mustbe carefully monitored and managed, meaning that critical decisions arearrived at through cognitive processes not controlled through clearly statedgoals and measurable performance objectives. The transformationalleadership approach is well suited to serve this new health servicesenvironment (Trofino, 1995).OTHER CONTEMPORARY LEADERSHIP APPROACHESMore than 50 years ago, the Office of Strategic Services published a booktitled The Assessment of Men, in which two types of leaders were described:(1) the leader in articulation, who was forceful and inspirational inexpression and who spelled out clearly what was needed and how it was tobe accomplished; and (2) the leader in action who, by setting him- or herselfin motion, demonstrated how to accomplish a goal and whose successesencouraged others to join in the pursuit of the goal(s). In either case, “theleader—by words or action—inspired others to achieve something beyondthe ordinary by appealing to a goal worthy of human effort” (Curtin, 1997,p. 7).Although the primary focus of this chapter is transformational leadership,other leadership styles and their respective characteristics also focus ontransformation or change. Recall that transactional leadership is directedtoward task accomplishment and good relations between the leader andsubordinates through consideration of performance and reward, whiletransformational leadership is directed toward the influence andmanagement of institutional change and innovation through revitalizationand vision (Dessler, 1998). Here we examine some other change styles andtheir conceptual similarities.Bolman and Deal (1997) offer for consideration the symbolic leader.Symbolic leaders interpret and reinterpret experiences, developing thecapacity to impart purpose and meaning. Symbolic leaders use symbols toseize attention. They frame experiences in an uncertain environment,providing reasonable interpretation and understanding of events. Symbolicleaders disseminate information through persuasive communication,especially through the use of stories, rites, and rituals, both current andpast. Symbolic leaders are consistent in their use of rules and customs

(Bolman & Deal, 1997).Another contemporary view of leadership is the superleadershipperspective. Because today’s leaders are required to function effectively inan ever-changing, fast-paced global environment, traditional leadershipapproaches lack the depth of knowledge, skill, and ability required of today’sleaders. As contemporary work environments increasingly develop andimplement new and innovative structural designs, there is anunprecedented level of employee participation, and the myriad of prevailingmanagement practices make it difficult, at best, to identify an appropriateleadership approach. In response to these issues, the superleader willinglyshares power and control with the employees, and instills a sense ofempowerment that redirects the basis of vision and direction from theleader to the follower. Like transformational leadership, superleadershipencourages followers to do or become more—to discover, use, and maximizetheir abilities. The superleader continues to lead, but recognizes the value ofvision and direction that can be assembled by individuals at all levels of theorganization. The superleader approach is effective in that the leadercreates a positive atmosphere, promotes self-leading teams, providesappropriate reward and constructive reprimand, and fosters a corporateculture that contributes to high levels of performance (Osland, Kolb, &Rubin, 2001).The Charismatic LeaderCharisma is a tricky thing. Jack Kennedy oozed it—but so did Hitlerand Charles Manson. Con artists, charlatans, and megalomaniacs canmake it their instrument as effectively as the best CEOs,entertainers, and Presidents. Used wisely, it’s a blessing; indulged, itcan be a curse. Charismatic visionaries lead people ahead andsometimes astray. (Sellers, 1996, pp. 68–72)Charismatic leaders are individuals who exhibit high levels of self-confidence and trust in subordinates, high expectations for subordinates,and ideological vision and purpose through personal example. In return,followers of charismatic leaders demonstrate loyalty to, confidence in, andtrust in the charismatic leader’s values, behaviors, and vision. Thisrelationship and connectedness are critical elements between the followersand the charismatic leader. The effect is profound, often producingperformance results that exceed established expectations (Luthans, 2002).Followers will transcend their own self-interests for the sake of the team,

department, or organization (Bass, 2008).In light of the high esteem in which the charismatic leader is held, onewould expect that the charismatic leader exhibits high ethical standards.This presumption, in most cases, would be correct. The ethical charismaticleader will, in general, exhibit the characteristics outlined in Exhibit 11–1(e.g., Mother Teresa and Martin Luther King Jr.). Yet, not all charismaticleaders are ethical (e.g., Adolf Hitler and Osama bin Laden). Howell andAvolio (1992) noted that charismatic leaders “deserve this label only if theycreate transformations in their organizations so that members aremotivated to follow them and to seek organization objectives not simplybecause they are ordered to do so, and not merely because they calculatethat such compliance is in their self-interest, but because they voluntarilyidentify with the organization, its standards of conduct and willingly seek tofulfill its purpose” (Luthans, 2002, p. 590).Exhibit 11–1 Characteristics Exhibited by the Ethical Charismatic LeaderThe ethical charismatic leader:• Uses power to serve others;• Aligns vision with followers’ needs and aspirations;• Considers and learns from criticism;• Stimulates followers to think independently and to question the leader’s view;• Uses open, two-way communication;• Coaches, develops, and supports followers; shares recognition with others;• Relies on internal moral standards to satisfy organizational and societal interests.Organizational Behavior (9th ed., p. 591), by F. Luthans, 2002. Boston, MA: McGraw-Hill BookCompany. Reprinted with permission.Though the components of transformational leadership and charismaticleadership differ somewhat (Yukl, 1999), these theories are often seen asequivalent. As discussed, research supports the position thattransformational leadership qualities can be learned as long as theindividual is comfortable and confident in the controlling and influencingroles. Thus, if one combines the desire to lead with learning andunderstanding the position and responsibility of a transformational leader,he or she may develop the capacity to transform organizations. Given thissupposition and the close association of transformational and charismaticleadership brings us to the question: Can an individual acquire charismaticcharacteristics sufficient to develop a following based on trust, expectations,

and purpose?Benton (2003) describes a six-step plan for developing executive charisma.He suggests that many people accept the fact that, given organizationalconstraints and the competition among organizational leaders, manypotential change agents acquiesce to acknowledge that they will onlyachieve a certain level of success. He suggests that the one missingcomponent to assuming charismatic positioning—beyond one’s exemplarycharacter, instincts, judgment, integrity, and positive energy—is executivecharisma. Benton defines executive charisma as “the ability to gain effectiveresponses from others by using aware actions and considerate civility inorder to get useful things done” (p. x). Benton’s (2003, p. 10) six steps todeveloping executive charismatic qualities are as follows:Step 1: Be the first to initiateStep 2: Expect and give acceptance to maintain esteemStep 3: Ask questions and ask favorsStep 4: Stand tall and straight, and smileStep 5: Be human, humorous, and hands-onStep 6: Slow down, shut up, and listenIt is important to recognize that being the first to initiate actionestablishes your willingness to accept uncertainty head-on; to acknowledgea situation can be either a problem or an opportunity to initiatetransformation. This first step requires a consistent willingness to act.Recognition, as both a giver and a receiver, fulfills the second step of theplan to provide a sense of esteem, to oneself and others. This provision ofesteem provides a cyclical optimism that can pervade others involved in thetransformative effort.The third step proffers an exchange of information as required to meetorganizational objectives. Choosing one’s words and tone carefully whilebeing specific and concise is important to ensuring that information istimely, relevant, and accurate. Do not be too timid to ask questions or solicitfavors. Be mindful to recall favors provided and extend thanks in return.Perception is important when exhibiting charismatic qualities. Step fourdemands that the executive leader not only play the role, but also “look” therole. Standing tall with a relaxed confidence enhances one’s charismaticappearance.Interestingly, step five mandates that charismatic leaders take onresponsibilities that others won’t—without overdoing it! By this Bentonsuggests that being human is imperative to being charismatic—but don’t be

too human. Be humorous with a sense of appropriateness. Do not crosssocial, ethnic, or gender boundaries; stepping across acceptable boundariesinto indefinable territory can quickly extinguish one’s effort to createcharismatic leadership qualities. The final step involves maintaining a pacethat permits decision making, implementation, and focus. Not talking (orshutting up) allows one the opportunity to listen. Listening allows one tohear what others have to say, develop a response to the information, andgain the trust necessary to initiate transformational efforts. “Executivecharisma isn’t as much about you as about your effect on others and thatcomes not just from what you say and do but from what you don’t say anddon’t do” (Benton, 2003, p. 153).Servant LeadershipSome scholars in the leadership area, such as Peter Senge, WarrenBennis, Peter Block, and Margaret Wheatley, see servant leadership as theemerging leadership paradigm for the 21st century for all corporations andinstitutions. The concept of servant leadership is captured in the followingquote from Disraeli: “I must follow the people. Am I not their leader?”The term “servant leadership” was first used by Robert K. Greenleaf in1969 as a way to describe a type of leadership that focuses on serving thehighest needs of others in an effort to help others achieve their goals.Servant leadership is an approach to managing people that “begins with aclear and compelling vision that excites passion in the leader andcommitment in those who follow” (Blanchard & Hodges, 2003). A servantleader values others’ strengths and talents and encourages the use of thesestrengths and talents for the betterment of the organization.Servant leadership focuses on the leader’s development throughawareness and self-knowledge. Spears (2004) identified the qualities andcharacteristics of servant leadership: listening, empathy, healing,awareness, persuasion, conceptualization, foresight, stewardship,commitment to the growth of people, and building community. Thesecharacteristics, along with a moral core, drive servant leaders to help peoplemeet their goals and overcome challenges (Trastek, Hamilton, & Niles,2014).As such, servant leadership recognizes the importance of performancecoaching while acknowledging that individual development and performanceare strongly related. According to Blanchard and Hodges (2003, p. A2),instrumental to the implementation of servant leadership are threecomponents of performance coaching:

1. Performance Planning: The setting of goals and objectives.2. Day-to-Day Coaching: Providing the resources and an environmentconducive to the accomplishment of established goals.3. Performance Evaluation: The timely and relevant evaluation ofindividual performance and the identification of professionaldevelopmental needs.Anderson (2003) believes that servant leadership can build effectivehospital–physician relationships. He states that servant leaders accept astheir responsibility the need to invest in the lives of their followers,believing that they are “not superior to the follower and also know that onany given day or in a given circumstance the follower may become theleader. It is the servant leader’s hope that the follower will indeed one daybecome a servant leader and, therefore, will make an investment in thefollower’s career to better ensure that indeed this happens” (Anderson, 2003,p. 45).Although empirical research in the area of servant leadership within thehealth care industry is still somewhat limited, Ornelas (2003) found apositive correlation between organizational outcomes and perception ofservant leadership characteristics among departmental leaders within alarge health system. The results of Ornelas’s study showed that employeesworking in departments that reported managers with servant leadershipcharacteristics reported lower turnover rates, higher job satisfaction, andincreased commitment to the organization than those employees working indepartments whose managers did not embrace the servant leadershipphilosophy. Jenkins and Stewart (2010) reported similar results. Theresearchers found a positive impact on individual nurse employee jobsatisfaction within departments where the nursing staff perceived that theirmanagers had higher servant leadership orientation.In their studies of health care leadership, Pelote and Route (2007)concluded that the most successful leaders, whom they refer to asmasterpiece leaders, displayed a form of servant leadership. These leadersviewed themselves as the leader-coach first and the leader-expert second.“Masterpiece leaders create, energize, and motivate the healthcare climate;exhibit a high level of passion, excitement, and drive to perpetuate theirsuccess” (p. 282).Many equate servant leadership with transformational leadership,however there are differences. The primary difference between the twoleadership styles is the focus of the leader (Stone, Russell, & Patterson,

2003). Stone, Russell, and Patterson (2003, p. 1) explain thatthe transformational lethe transformational leader’s focus is directedtoward the organization, and his/her behavior builds followercommitment toward organizational objectives, while the servantleader’s focus is on the followers, and the achievement oforganizational objectives is a subordinate outcome. The extent towhich the leader is able to shift the primary focus of leadership fromthe organization to the follower is the distinguishing factor inclassifying leaders as either transformational or servant leaders.Collaborative LeadershipIbarra and Hansen (2011, p. 73) define collaborative leadership as the“capacity to engage people and groups outside one’s formal control andinspire them to work toward common goals—despite differences inconvictions, cultural values, and operating norms.” Collaborative leadershipis complex because it requires a leader to achieve success by motivatingindividuals in multiple groups and/or organizations in addition to bringingtogether and aligning the goals of many stakeholders (Borkowski &Deppman, 2014). Al-Sawai (2013) states that collaborative health careleadership requires a synergistic work environment, wherein multipleparties are encouraged to work together toward the implementation ofeffective practices and processes. Such collaborations promoteunderstanding of different cultures and facilitate integration andinterdependency among multiple stakeholders, with individuals beingunified by shared visions and values.Borkowski and Deppman (2014) point out that as health care reformmoves the industry from segment-based delivery models to integratedsystems such as accountable care organizations (ACOs), collaborativeleadership becomes critical to organizational success. The leader of an ACOis expected to integrate and coordinate the various component parts ofhealth care, such as primary care, specialty services, hospitals, and homehealth care, and to ensure that all parts function well together to deliverefficient, high-quality, and cost-effective patient-centered care. Managers of21st-century health care organizations must be able to lead diverse groupsof people and facilitate their professional efforts and problem-solving bothwithin an organization as well as across formal organizational boundaries.According to Carter (2006), the collaborative leader should demonstrate:1. The confidence that the goals and objectives are achievable.

2. The skills to clearly communicate with the stakeholders regarding theissues needing to be addressed and the potential approaches toproblem solving.3. The ability to serve as an active listener.4. The ability to share knowledge and authority with the collaborators5. The ability to assess and handle varying levels of risk in decisionmaking and implementation.The good news is that these behaviors and the required skill set (seeExhibit 11–2) can be learned by dedicated leaders who commit thenecessary time and effort (Borkowski & Deppman, 2014).The Turning Point Leadership Development National ExcellenceCollaboration has identified six key practices that are unique to leading acollaborative process and the necessary steps for leaders to guide successfulcollaborations (see Exhibit 11–3).ANOTHER LOOK AT TRAITS AND BEHAVIORAs mentioned in the Overview section, many see contemporary theories ofleadership as a resurgence of interest in individual traits and behaviors.Two such theoretical constructs currently receiving considerable attentionare the Big Five personality factors (Judge et al., 2002) and emotionalintelligence (EI) (Salovey & Mayer, 1990). Following an examination ofthese constructs, we return to behaviors. Bass (1990a,b) emphasized thatleadership can be learned and suggested that one of the most significantapplications of transformational theory is in the training of individuals tobecome transformational leaders. The success of transformationalleadership training appears to be based on actual increases in leader uses oftransformational behaviors. Identifying behaviors that define competenttransformational health care leaders has captured the attention of bothscholars and practitioners.Big Five Personality FactorsThe Big Five personality framework posits that the multitude ofpersonality characteristics identified in theory and research can beorganized into five factors that underlie all others. These factors asidentified (DeHoogh, Den Hartog, & Koopman, 2005; Robbins, 2005)include:Extroversion: Extroverts tend to be social, assertive, active, and

gregarious.Agreeableness: Agreeable individuals are warm, generous, cooperative,and trusting.Conscientiousness: Conscientious individuals are dependable,responsible, achievement oriented, organized, and proficient.Emotional Stability: This dimension captures an individual’s ability towithstand stress. People with positive emotional stability are calm, self-confident, and secure. Some researchers measure this factor asneuroticism, which reflects the tendency to be anxious, insecure, anddefensive.Openness to Experience: Individuals open to experience arecharacterized by imagination, unconventionality, a range of interests,and fascination with novelty.Robbins (2005) suggests that the studies of the Big Five approach resultedin consistent and strong support for traits as predictors of leadership. Adifferent conclusion is drawn by DeHoogh, Den Hartog, and Koopman(2005). These authors suggest considerable variability in both the strengthand direction of the relationships between the personality factors andtransformational and transactional leadership. Such variances, theyconclude, result in weak support for the Big Five factors.The inconsistency of findings led DeHoogh, Den Hartog, and Koopman(2005) to suggest that it is not personality itself that is important inleadership style, but the interaction of personality characteristics and thecontext. Their research examined both the direct measure of the Big Fivepersonality factors and interactive relationship with emphasis on perceivedleader effectiveness (transformational and charismatic leader styles wereconsidered equivalent and contrasted with transactional). The contextvariable, the work environment, was defined as either dynamic (i.e.,characterized by a high degree of challenge and opportunities for change) orstable (i.e., more structured, and orderly). Results from this studyestablished that the relationships between personality and leadership styledid indeed differ depending on the context.Emotional IntelligenceEmotional intelligence (EI) is relatively new to the field of organizationalbehavior. Emotional intelligence involves assessing one’s own feelings, aswell as the feelings of others, then using those assessments to guide

personal thought and action. EI has five distinct characteristics:1. Self-awareness2. Self-management or regulation3. Self-motivation4. Empathy or social awareness5. Social skillsGoleman (1998, p. 318) describes self-awareness as involving self-understanding and knowledge of one’s true feelings at any given moment.Self-management ensures that a manager can control his or her emotions toassist with the task at hand while focusing on the problem’s solution. Self-motivation allows the manager to stay focused on the goal and desiredoutcome, overcoming negative emotional stimulus and accepting delayedgratification. Empathy is the possession of the sense of what others feel andwant while being sensitive to their needs. Finally, social skills relate to one’sability to read and react to social situations while interacting with othersand guiding and influencing the behavior of others.Goleman (1998), as cited by Luthans (2002, p. 306), noted that EI is notthe “end all” in determining leadership characteristics and competencies,but nonetheless, he concludes:• At the individual level, elements of emotional intelligence can beidentified, assessed, and upgraded.• At the group level, it means fine-tuning the interpersonal dynamicsthat make groups smarter.• At the organizational level, it means revising the value hierarchy tomake emotional intelligence a priority—in the concrete terms of hiring,training and development, performance evaluation, and promotions.Goleman (1998) believes that EI is more important than IQ, proposingthat EI is a better predictor of success in both personal and professionalendeavors. Gibbs (1995) provided the following evidence as to theimportance of EI: “IQ gets you hired, but EI gets you promoted” (p. 64).Druskat and Wolff (2001) have extended the concept of individualemotional intelligence to teams. The members of creative, productive teamsdemonstrate mutual trust, a sense of group identity, and a sense of groupefficacy. These emotional components enable effective participation,cooperation, and collaboration. They state (p. 83):Group emotional intelligence … [is] about bringing emotions

deliberately to the surface and understanding how they affect ateam’s work. It is also about behaving in ways that buildrelationships both inside and outside the team and that strengthenthe team’s ability to face challenges.Health care organizations are just beginning to recognize the importanceof developing employees’ EI (Grossman, 2000). Only select progressivehealth care facilities have recognized the value of EI training and haveincorporated programs that emphasize its principles. However, as Freshmanand Rubino (2002) point out, the applications of EI fit well within theindustry, as reflected in Table 11–2.Table 11–2 Health Care Administration Application to Emotional IntelligenceComponentDefinitionExamples of ApplicationSelf-awarenessHaving a deep understanding of one’semotions, strengths, weaknesses, needs,and drives1. Confidently making decisions when budgets mustbe trimmed in medical areas2. Knowing that the values of the health care systemare not congruent with yours3. Recognizing that the late-night committee meetingsare affecting your family relationsSelf-regulationA propensity for reflection, ability to adapt tochanges, saying no to impulsive urges1. Knowing when to step away if having an argumentwith a provider2. Acting to correct medical billing compliance issuesrather than ignoring them3. Accepting responsibility over additional health carefacilitiesSelf-motivationDriven to achieve, being passionate aboutenjoying challenges in the profession1. Setting up a senior manager retreat to allow thebest environment for planning2. Being optimistic even when consensus is low3. Embracing diverse populations of patients andemployeesSocialawarenessThoughtfully considering someone’s feelingswhen acting1. Thinking of the family’s perspective when involvedin bioethical decisions2. Being compassionate when dealing withemployees and their personal problems affectingtheir work3. Being patient-centeredSocial skillsMoving people in the direction you desire1. Being able to negotiate a favorable managed carecontract2. Having employees satisfied with their performanceevaluation3. Using good listening skills when talking withgoverning board members“Emotional Intelligence: A Core Competency for Healthcare Administrators,” by B. Freshman and L.Rubino, 2002, Health Care Manager, 20(4), p. 6. Reprinted with permission.Behavioral CompetenciesIn general, behavioral competencies define the skills, knowledge, abilities,

and actions that distinguish superior performance. Spencer and Spencer(1993) describe a competency as “what outstanding performers do moreoften, in more situations, with better results, than average performers.”There has been a growing interest in the development of competencies sinceMcClelland (1961, 1985) published his work on achievement and motivation.In the past decade, leadership competency models have proliferated inhealth care education and professional development. Numerous consultingorganizations, professional associations, health care organizations, andeducational programs have created leadership competency lists (Dye &Garman, 2006). The acceptance and implementation of competency-basededucation and training across health care systems may be viewed asacknowledgment that at least a significant portion of leadership may belearned, and as the desire to ensure exceptional leadership and performancein health care.The vast numbers of competency models preclude an exhaustive review.However, students in health care management programs should examinethe competencies incorporated into their programs of study. The NationalCenter for Healthcare Leadership (NCHL) in conjunction with the RobertWood Johnson Foundation has developed a framework to implementcompetency-based learning and assessment curricula in health caremanagement education. The NCHL project relies on academics and expertsin the field to define the technical and behavioral characteristics thatleaders must possess to be successful across the health professions. The fullmodel, which may be found on NCHL’s Web site at www.nchl.org, containslevels for each competency that distinguish leaders at each career stage(early careerist, midcareerist, and senior executive). Future and currenthealth care executives may be guided by the competencies set forth by theAmerican College of Healthcare Executives (ACHE), the internationalprofessional organization for the more than 30,000 health care executiveswho lead hospitals and health care organizations around the world (seewww.ache.org). ACHE offers a Healthcare Executive CompetenciesAssessment Tool derived from the Healthcare Leadership Alliance (HLA)(see www.healthcareleadershipalliance.org). The competencies weredeveloped by HLA through job analyses and research. Three hundredcompetencies are categorized under five major domains: (1) leadership, (2)communications and relationship management, (3) professionalism, (4)business knowledge and skills, and (5) knowledge of the health careenvironment. The ACHE self-assessment is designed to assist executives inidentifying areas of strength as well as areas in which they may wish to

improve performance.Do competencies create effective leaders? Dye and Garman (2006) suggestthat competency is most accurately described as the capacity to perform (p.xxxi). Translating competency into success requires both motivation andopportunity. Further, competencies are not just learned but “are moreaccurately described as improving slowly over time as a result of mindfulpractice, feedback, and more practice” (p. xx). Pelote and Route (2007) alsopresent a broader view of leadership competencies in the Healthcare CausalFlow Leadership Model. As the model demonstrates, individualcharacteristics do not exist in a vacuum and, of themselves, are not a sourceof success. Leadership competencies are viewed as one of the variableswithin a context (e.g., health care climate) that ultimately impactsperformance outcomes (i.e., patient outcomes, patient satisfaction, andfinancial results).SUMMARYContemporary theories recognize the complexity of leadership, and yetalso bring us back to examining the role of traits and behaviors as the moresimplistic, traditional leadership theories of the past. Today, leadershiptheorists acknowledge the presence of a symbiotic relationship between theleader’s traits and behaviors, the follower, the environment, the situation,and the strategic organizational objectives. In response to an ever-changing,external environment, contemporary leadership approaches allowinteractions between the leader and the follower that are not possible withtraditional leadership approaches. A common thread among contemporaryleadership models is an integration of ideological, moral, and valueapplications.It is important to recognize that organizations require both transactionaland transformational styles of leadership if strategic goals are to be met.One approach is not necessarily preferred over the other. Imagine anorganization that has only transactional leaders. Despite the fact that tasksand processes would be accomplished, it is unlikely that the organizationwould have the ability to transform itself to respond to an ever-changingenvironment or redirect its efforts into new markets. At the same time, anorganization that had only transformational leaders would certainly havethe vision to change and innovate, but would not have the capacity to do sobecause of an absence of transactional agreements between managers andemployees. Fortunately, this scenario is unlikely, but it does portray the

importance of balance of leadership styles within organizations.It is essential to create the proper blend of leadership that is flexible andadaptable to differing situational factors. The formula for balance isdifficult. In a time of crisis, which style of leadership is most important:transactional or transformational? You can see there is not a simple answerto this question because of the multitude of situational factors. One couldargue that in a time of crisis, transactional leadership would be moreeffective if control and efficiency were the primary concerns. Likewise,transformational leadership would be most effective in a time of crisis ifchange and innovation were the dominant interest.There is supportive research that suggests that transformational,charismatic, and other contemporary leadership attributes can be learned.This finding is valuable to individuals who find that they have reached aplateau in their professional development plan. Leaders at all levels of theorganization can enhance, modify, and develop leadership skills to increasetheir ability to influence, control, and manage by identifying personalleadership strengths and weaknesses.Today’s health care managers can move beyond transactional leadershipinto areas that create opportunities for ever-increasing levels ofperformance and connection to the workforce through visionary and servantapproaches to leadership. Contemporary managers should look closelywithin themselves to determine appropriateness of leadership styles on thebasis of situational, environmental, and personal factors. Understanding theneed for aligning one’s leadership approach with these factors can generatehigher levels of workplace commitment and performance.DISCUSSION QUESTIONS1. Identify the similarities and differences between transactional andtransformational leadership. Discuss the appropriateness of each styledependent upon situational factors.2. Discuss the type of leadership style—transactional, transformational,servant, and collaborative—that occurs in your specific professionalenvironment. List the positive and negative outcomes that exist as aresult of the leadership approach used.3. Debate the position that transformational and charismatic leadershipcan (or cannot) be learned. Be specific in your support (or opposition).4. Discuss Benton’s six-step plan for executive charisma. Would the plan

work for you in your current health care setting?5. Deliberate the need for transformational or collaborative leadershipin the next five years as the health care environment transforms as aresult of industry reform.EXERCISE 11–1It has been stated that to lead people through the complex changes facingthe health care industry, “transformational leadership” is required (i.e.,leaders creating an environment in which staff can best apply theirknowledge, skills, and efforts, engaging commitment and developingpotential). As such, you are engaged as the consultant for BeltwayHealthcare System to develop a management development program thatwill be the vehicle that managers can use to develop the necessary skills andknowledge to drive organizational change and improve the system’sperformance.What would you propose as the goals of the management developmentprogram?What learning methods would be best suited to achieve these goals?EXERCISE 11–2 ARE YOU A CHARISMATIC LEADER?If you were the director of a major department in a health care company,how important would each of the following activities be to you? Answer yesor no to indicate whether you would strive to perform each activity.1. Help subordinates clarify goals and how to reach them.2. Give people a sense of mission and overall purpose.3. Help get jobs out on time.4. Look for the new product or service opportunities.5. Use policies and procedures as guides for problem solving.6. Promote unconventional beliefs and values.7. Give monetary rewards in exchange for high performance fromsubordinates.8. Command respect from everyone in the department.9. Work alone to accomplish important tasks.10. Suggest new and unique ways of doing things.11. Give credit to people who do their jobs well.

12. Inspire loyalty to yourself and to the organization.13. Establish procedures to help the department operate smoothly.14. Use ideas to motivate others.15. Set reasonable limits on new approaches.16. Demonstrate social nonconformity.The even-numbered items represent behaviors and activities ofcharismatic leaders. Charismatic leaders are personally involved in shapingideas, goals, and direction of change. They use an intuitive approach todevelop fresh ideas for old problems and seek new directions for thedepartment or organization. The odd-numbered items are considered moretraditional management activities, or what would be called transactionalleadership.Managers respond to organizational problems in an impersonal way,make rational decisions, and coordinate and facilitate the work of others. Ifyou answered yes to more even-numbered than odd-numbered items, youmay be a potential charismatic leader.Data from “Have You Got It?,” a quiz that appeared in Patricia Sellers, “What Exactly IsCharisma?” Fortune (January 15, 1996): pp. 68–75; Bernard M. Bass, Leadership and PerformanceBeyond Expectations (New York, NY: Free Press, 1985); and Lawton R. Burns and Selwyn W. Becker,“Leadership and Managership,” in S. Shortell and A. Kaluzny (Eds.), Health Care Management (NewYork, NY: Wiley, 1986).Case Study 11–1 The Mall-Based Teen Services CenterThe Problem: Lack of accessibility of services for teens was an ongoing problem for key providersof health, social, and employment services. Services were funded and available, but those in greatestneed were not using them.The Solution: Co-locate a variety of teen-focused services at a popular teen hangout: a mall. Thestate health department signed a memorandum of understanding with the three local healthdepartments whose counties surrounded the mall area and the governor’s job training program. Onelocal health department hired a coordinator to develop and launch the project. Two stakeholdergroups were formed: an adult advisory council and a youth advisory council. The adult group wascomposed of school officials, representatives from youth service agencies, and social servicesagencies. Members of the youth advisory committee were drawn from the potential client group:middle- and high-school students. The coordinator enlisted the support of local construction groupswho agreed to donate labor for the build-out.The Outcome: There was much enthusiasm and support for the project from members of the adultand youth advisory committees. School officials, in particular, liked that they could support sensitiveteen services like family planning in an off-site location. Members of the youth advisory committeewere empowered by a process in which they were making decisions about how the clinic would beconstructed and promoted. However, the project ultimately failed. The mall owner, a resident ofanother state, refused to donate or rent at low cost space in the mall. Space in buildings surroundingthe mall was too expensive. An amendment to the host state’s constitution made it impossible for thelocal health departments to finance the initial startup costs.

As a collaborative leader, what would you have done differently?Reproduced with permission of the Turning Point Program, which was funded by the Robert WoodJohnson Foundation, Princeton, N.J.EXERCISE 11–3 WHAT IS YOUR EQ?A number of testing instruments have been developed to measureemotional intelligence, although the content and approach of each testvaries. See the About.com Psychology Website atpsychology.about.com/library/quiz/bl_eq_quiz.htm for a quiz that presents amix of self-report and situational questions related to various aspects ofemotional intelligence. Take the quiz to learn more regarding your quotient.Do you think you are at a higher or lower level than most people when itcomes to emotional intelligence?What might you be able to do to raise your level of emotional intelligence?How effective do you think this might be, considering that some researcherssuggest that emotional intelligence can be learned and strengthened, whileothers claim it is an inborn characteristic?EXERCISE 11–4Access a leadership competency assessment tool of your choice. Reviewyour scores to identify strengths as well as areas to further develop. Givenyour current strengths, how would you conceptualize your leadership style?REFERENCESAl-Sawai, A. (2013). Leadership of healthcare professionals: Where do westand. Oman Medical Journal, 28(4), 285–287.Anderson, R. J. (2003). Building hospital–physician relationships throughservant leadership. Frontiers of Health Services Management, 20(2), 45–47.Bass, B. M. (1990a). Bass and Stogdill’s handbook of leadership: Theory,research and managerial applications (3rd ed.). New York, NY: The FreePress.Bass, B. M. (1990b). From transactional to transformational leadership:

Learning to share the vision. Organizational Dynamics, 18(3), 19–31.Bass, B. M. (2008). The Bass handbook of leadership: Theory, research andmanagerial applications (4th ed.). New York, NY: The Free Press.Bennis, W. (1984). The four competencies of leadership. Training andDevelopment Journal, August, 144–149.Bennis, W., & Nanus, B. (1985). Leaders: The strategies for taking charge.New York, NY: Harper & Row.Benton, D. A. (2003). Executive charisma. New York, NY: McGraw-HillBook Company.Blanchard, K., & Hodges, P. (2003, May 12). The journey to servantleadership in work, life. San Diego Business Journal, A2.Bolman, L. G., & Deal, T. E. (1997). Reframing organizations: Artistry,choice, and leadership (2nd ed.). San Francisco, CA: Jossey-Bass.Borkowski, N., & Deppman, B. (2014). Collaborative leadership. In L.Rubino, S. Esparza, and Y. R. Chassiakos (Eds.). New leadership fortoday’s healthcare professionals: Concepts and cases. Burlington, MA:Jones and Bartlett Publishers.Bryman, A. (1992). Charisma and leadership in organizations. London, UK:Sage.Burns, J. M. (1978). Leadership. New York, NY: Harper & Row.Carter, M. (2006). The importance of collaborative leadership in achievingeffective criminal justice outcomes. Center for Effective Public Policy.Available at: www.cepp.comChaffee, M. W. (2001). Navy medicine: A health care leadership blueprintfor the future. Military Medicine, 166(3), 240–247.Curtin, L. L. (1997). How—and how not—to be a transformational leader.Nursing Management, 28(2), 7–8.DeHoogh, A., Den Hartog, D., & Koopman, P. (2005). Linking the Big Fivefactors of personality to charismatic and transactional leadership;perceived dynamic work environment as a moderator. Journal ofOrganizational Behavior, 26, 839–865.Den Hartog, D., & Koopman, P. (2001). Leadership in organizations. In N.Anderson, D. Ones, H. Kepir-Sinangil, & C. Viswesvaran (Eds.).International handbook of industrial, work & organizational psychology(Vol. 2). London, UK: Sage.Dessler, G. (1998). Management: Leading people and organizations in the21st century. Upper Saddle River, NJ: Prentice Hall.Digman, J. (1990). Personality structure: The emergence of the five-factor

model. Annual Review of Psychology, 41, 417–440.Druskat, V. U., & Wolff, S. B. (2001), Building the emotional intelligence ofgroups, Harvard Business Review, 79(3), 80–90.Dye, C. F., & Garman, A. N. (2006). Exceptional leadership: 16 criticalcompetencies for healthcare executives. Chicago, IL: HealthAdministration Press.Freshman, B., & Rubino, L. (2002). Emotional intelligence: A corecompetency for health care administrators. Health Care Manager, 20(4),1–9.Gibbs, N. (1995, October 2). The EQ factor. Time. Available at:www.time.com/time/magazine/article/0,9171,983503,00.htmlGoleman, D. (1998). Working with emotional intelligence. New York, NY:Bantam Books.Grossman, R. J. (2000). Emotions at work. Health Forum Journal, 43(5),18–22.Gummer, B. (1995). Go team go: The growing importance of teamwork inorganizational life. Administration in Social Work, 19, 85–100.Howell, J. M., & Avolio, B. J. (1992, May). The ethics of charismaticleadership: Submission or liberation. Academy of Management Executive,43–54.Ibarra, H., & Hansen, M. T. (2011). Are you a collaborative leader. HarvardBusiness Review, 89(7/8), 69–74.Jenkins, M., & Stewart, A. C. (2010). The importance of a servant leaderorientation. Health Care Management Review, 35(1), 46–54.Judge, T., Bono, J., Ilies, R., & Gerhardt, M. (2002). Personality andleadership: A qualitative and quantitative review. Journal of AppliedPsychology, 87, 755–768.Kotter, J. P. (1995, March/April). Leading change: Why transformationalefforts fail. Harvard Business Review, 73, 59–67.Luthans, F. (2002). Organizational behavior (9th ed.). Boston, MA:McGraw-Hill Book Company.McClelland, D. C. (1961). The achieving society. New York, NY: The FreePress.McClelland, D. C. (1985). Human motivation. Glenwood, IL: Scott-Foresman.Medley, F., & Larochelle, D. R. (1995). Transformational leadership and jobsatisfaction. Nursing Management, 26(9), 64JJ–64NN.Novick, L., Morrow, C., & Mays, C. (2008). Public health administration:

Principles for population-based management. Sudbury, MA: Jones andBartlett Publishers.Ornelas, J. (2003). The effect of servant leadership on organizationaloutcomes. Poster presentation at the American College of HealthcareExecutives 2003 Congress, Chicago, IL.Osland, J., Kolb, D., & Rubin, I. (2001). Organizational behavior: Anexperiential approach (7th ed.). Upper Saddle River, NJ: Prentice Hall.Pelote, V., & Route, L. (2007). Masterpieces in health care leadership.Sudbury, MA: Jones and Bartlett Publishers.Robbins, S. P. (2005). Organizational behavior (8th ed.). Upper SaddleRiver, NJ: Prentice Hall.Romm, C., & Pliskin, N. (1999). The role of charismatic leadership indiffusion and implementation of e-mail. Journal of ManagementDevelopment, 18(3), 273–291.Salovey, P., & Mayer, J. (1990). Emotional intelligence. Imagination,Cognition, and Personality, 9, 185–211.Schwartz, R. W., & Tumblin, T. F. (2002). The power of servant leadershipto transform health care organizations for the 21st-century economy.Archives of Surgery, 137(12), 1419–1427.Sellers, P. (1996). What exactly is charisma. Fortune, 133 (15), 68–72.Sofarelli, D., & Brown, D. (1998). The need for nursing leadership inuncertain times. Journal of Nursing Management, 6(4), 201–207.Spears, L. C. (2004). Practicing servant-leadership. Leader to Leader, 34, 7–11.Spencer, L., & Spencer, S. (1993). Competency at work models for superiorperformance. New York, NY: John Wiley & Sons.Stone, A. G., Russell, R. F., & Patterson, K. (2003, August). Transformalversus servant leadership: A difference in leader focus. ServantLeadership Research Roundtale: School of Leadership Studies, RegentUniversity. Available at:www.regent.edu/acad/global/publications/sl_proceedings/2003/stone_transformation_versus.pdfThyler, G. (2003). Dare to be different: Transformational leadership mayhold the key to reducing the nursing shortage. Journal of NursingManagement, 11(2), 73–79.Tichy, N. M., & Devanna, M. A. (1986). The transformational leader. NewYork, NY: John Wiley & Sons.Trastek, V. F., Hamilton, N. W., & Niles, E. E. (2014). Leadership models inhealth care—a case for servant leadership. Mayo Clinic Proceedings,

89(3), 374–381.Trofino, A. J. (1995). Transformational leadership in health care. NursingManagement, 26(8), 42–47.Trofino, A. J. (2000). Transformational leadership: Moving total qualitymanagement to world-class organizations. International Nursing Review,47(4), 232–242.Yukl, G. (1999). An evaluation of conceptual weaknesses intransformational and charismatic leadership theories. LeadershipQuarterly, 10, 285–305.OTHER SUGGESTED READINGAtchison, T. (2005). Leadership’s deeper dimensions: Building blocks tosuperior performance. Chicago, IL: Health Administration Press.Conger, J. A., & Kanungo, R. N. (1988). Behavioural dimensions ofcharismatic leadership. In J. A. Conger & R. N. Kanungo (Eds.).Charismatic leadership (pp. 79–91). San Francisco, CA: Jossey-Bass.Dixon, D. L. (1998). The balanced CEO: A transformational leader andcapable manager. Healthcare Forum Journal, 41(2), 26–29.Lee, F. (2008). If Disney ran your hospital: 9% things you would dodifferently. Chicago, IL: Health Administration Press.Yukl, G. (1989). Managerial leadership: A review of theory and research.Journal of Management, 15(2), 266.*We acknowledge and thank Dr. Gloria Deckard, who was the contributing author of an earlierversion of this chapter, which appeared in Organizational Behavior in Health Care (2011), Jones andBartlett Publishers.

PART IVIntrapersonal and InterpersonalIssuesIn Part IV, we explore various intrapersonal and interpersonal issues.Chapters 12 and 14 discuss stress and conflict and how the negative effectsof both can be avoided or at least miniminized. Having an optimal level ofstress and conflict in our lives is good. It can lead us to work efficiently andeffectively with creativity. However, when we experience too much of eitherstress or conflict, levels of productivity may decrease and problems may becreated with our physical and mental health.In Chapter 13, we discuss the various ways individuals approach decisionmaking. Managers face different types of problems (that cause stress andconflict) and therefore use different types of decision-making models–somemore effective than others!

CHAPTER 12Stress in the Workplace and StressManagementLEARNING OUTCOMESAfter completing this chapter, the student should be able to understand: The definition of stress. The process model of stress and coping. How stress can negatively affect individuals and organizations. The various forms of stress. The three stages of the General Adaptation Syndrome. How personalities, race, and gender affect an individual’s level ofstress. The definition and phases of burnout. The four categories of stress in the workplace. The various coping strategies available to organizations andindividuals. The concepts of learned optimism and hardiness training. The definition of stress management and the various programs used byorganizations.OVERVIEWStress is a complex and highly personalized process. As such, stress levelsin individuals can vary widely, even in identical situations, because ofpeople’s abilities to cope with different forms and levels of stress. The waysin which people are affected depend on a number of factors, such as theirlevel of self-efficacy, adaptability, and resources available.Cognitive-transactional theory defines stress as “a particular relationshipbetween the person and the environment that is appraised by the person astaxing or exceeding his or her resources and endangering his or her wellbeing” (Schwarzer, 2004, p. 343). Lazarus and his associates (Lazarus, 1991;Lazarus & Folkman, 1984; Lazarus, DeLongis, et al., 1985) argue that

individuals may perceive the same stressful situation differently on thebasis of their cognitive appraisal; some individuals see a specific situation asa threat, whereas other individuals see the same situation as a challenge oropportunity.Figure 12–1 The Process Model of Stress and CopingAdapted from Schwarzer, R. (2004). Manage stress at work through preventive and proactive coping. In E. A. Locke (Ed.),Handbook of Principles of Organizational Behavior. London: Blackwell Publishing, p. 344.

Table 12–1 Demand AppraisalsPhysical Demands• Indoor climate and air quality• Temperature• Illumination and other rays• Noise and vibrations• Office designTask Demands• Occupational category• Routine jobs• Job future ambiguity• Interactive organizational demands (e.g., interface with various constituencies, such as with boundary spanning)• Work overloadRole Demands• Role conflict• Interrole• Intrarole• Person/role (i.e., conflicting values or beliefs)• Role ambiguity• Work/home demandsInterpersonal Demands• Status incongruity• Social density (i.e., interpersonal need for space and distance)• Abrasive personalities• Leadership style• Team pressures• DiversitySource: Preventive Stress Management in Organizations (p. 22), by J. C. Quick, J. D. Quick, D. L. Nelson,and J. J. Hurrell, 1997, Washington, DC: American Psychological Association. Reprinted withpermission.As illustrated in Figure 12–1, an individual’s assessment of the situationincludes demand appraisals or resource appraisals. Demand appraisalsrelate to the person’s perception as to (1) physical demands, (2) taskdemands, (3) role demands, and (4) interpersonal demands (see Table 12–1).Resource appraisals may be material, personal, or social. Materialappraisals ask the question: Do I have the necessary resources to completethis task? Personal resource appraisal refers to an individual’s internalcoping options. Individuals who are affluent, healthy, capable, and self-confident are less vulnerable to stressful events. Social resource appraisalsrelate to external coping options available to an individual, such asavailability of obtaining assistance from others, receiving emotional support(reassurance), and/or advice or additional information necessary to completethe task (Lazarus, 1991; Schwarzer, 2004).As a result of the person’s appraisal of the situation, one of three

perceptual outcomes occurs. These perceptual outcomes are: challenge,threat, or harm/loss. When a situation is viewed positively, the person seesthe situation as a challenge and an opportunity to achieve personal growth.When the situation is viewed as a threat, the person perceives danger,either by physical injury or a blow to the self-esteem. For example, a taskdemand that is perceived to be difficult, ambiguous, unexpected, or time-consuming with an unrealistic deadline is more likely to induce a threatoutcome than an easy task that can be thoroughly prepared for and solvedat a convenient pace without time constraints. If the appraisal is viewed tobe harm or loss, the person has determined that damage has alreadyoccurred, such as loss of self-worth, social standing, or physical injury(Lazarus, 1991; Schwarzer, 2004). Building on Lazarus’s work, Schwarzer’s(2004) process model illustrates that, on the basis of an individual’sperception of the situation, he or she may engage in various copingstrategies to manage the experience of stress. The combination of anindividual’s perception of the situation (appraisals) and the coping strategiesemployed (reactive, anticipatory, preventive, or proactive) will determinethe resulting consequences, which may be behavioral, psychological,physiological, or combinations of the three (see Table 12–2).In this chapter, we first examine the factors that contribute to a personexperiencing stress in the workplace. Although many extraorganizationalfactors contribute to an individual’s experience of stress, such as a pendingdivorce, housing conditions, and the general economy, this chapter focusesprimarily on stress in the workplace. Second, we examine the variousmethods of coping with stress from both an organizational perspective andan individual perspective, which is referred to as stress management.WORK-RELATED STRESSStress is a common phenomenon in today’s workplace. Numerous surveysand studies confirm that occupation-related pressures are the leading sourceof stress for adults. Stress has been called the “health epidemic of the 21stcentury” by the World Health Organization and is estimated to costAmerican businesses up to $300 billion a year (Smith, 2012) in terms ofaccidents; absenteeism; employee turnover; loss of productivity; directmedical, legal, and insurance costs; workers’ compensation awards; as wellas tort and Federal Employers’ Liability Act judgments (American Instituteof Stress, 2004).The National Institute for Occupational Safety and Health (NIOSH), thefederal agency within the U.S. Department of Health and Human Services

responsible for conducting research and making recommendations for theprevention of work-related injury and illness, found that:• 40 percent of workers reported that their jobs were very or extremelystressful;• 25 percent viewed their jobs as the number-one stressor in their lives;• 75 percent of employees believed that workers have more on-the-jobstress than a generation ago;• 29 percent of workers felt quite a bit or extremely stressed at work;• 26 percent of workers said they were “often or very often burned out orstressed by their work”;• Job stress was more strongly associated with health complaints thanfinancial or family problems. (NIOSH, 1999)Table 12–2 Individual Distress: Behavioral, Psychological, and Physiological ConsequencesBehavioral Consequences• Tobacco use• Alcohol use• Drug abuse• Accident proneness• Violence• Eating disordersPsychological Consequences• Burnout• Family problems• Anxiety disorders• Sleep disturbances• Sexual dysfunction• Depression• Conversion reaction and somatizationPhysiological Consequences• Hypertension, heart disease, and stroke• Cancer• Back pain, arthritis, and other musculoskeletal conditions• Peptic ulcer disease and other gastrointestinal conditions• Headache• Diabetes mellitus• Liver cirrhosis and other alcohol-related diseases• Lung disease• Skin disease• Other diseases (e.g., HIV, chronic fatigue syndrome)SOURCE Preventive Stress Management in Organizations (p. 66), by J. C. Quick, J. D. Quick, D. L.Nelson, and J. J. Hurrell, 1997, Washington, DC: American Psychological Association 66. Reprinted withpermission.

Furthermore, stress may lead to physical violence in one out of 10 workenvironments. According to a study of “desk rage” by Integra RealtyResources (2001), almost half of those surveyed said yelling and verbalabuse were common in their workplaces. In a recent study, 51 percent ofBritish workers reported experiencing rage at work (The Telegraph, 2013).Desk or work rage can include behaviors or acts of aggression, hostility,rudeness, and physical violence. Workplace violence affects over 2 millionAmericans and costs an estimated $36 billion annually (Corporate Allianceto End Partner Violence, 2014) due to lost productivity, diminished image,insurance payments, and increased security costs. Integra’s survey reportedthat:• 65 percent of workers said that workplace stress had caused difficulties,and more than 10 percent described these as having major effects;• 10 percent said they work in an atmosphere where physical violencehas occurred because of job stress, and of this group, 42 percentreported that yelling and other verbal abuse is common;• 29 percent had yelled at coworkers because of workplace stress, 14percent said they worked where machinery or equipment had beendamaged because of workplace rage, and 2 percent admitted that theyhad actually personally struck someone;• 19 percent, or almost one in five respondents, had quit a previousposition because of job stress, and nearly one in four had been driven totears because of workplace stress;• 62 percent routinely found that they ended the day with work-relatedneck pain, 44 percent reported stressed-out eyes, 38 percent complainedof hurting hands, and 34 percent reported difficulty in sleeping becausethey were too stressed out;• 12 percent had called in sick because of job stress;• Over half said they often spent 12-hour days on work-related duties,and an equal number frequently skipped lunch because of the stress ofjob demands.Workplace rage is a common problem within the health care industry. Infact, a recent Securitas USA (2013) report reflected that workplace violenceprevention/response remained the top concern in the health care industryfrom 2010 to 2012. For example, almost one-third of physician executivesparticipating in a recent national study conducted by the American Collegeof Physician Executives reported that serious problems erupted within theirorganization on either a monthly or weekly basis as a result of disruptive

behavior by physicians (Weber, 2004). Furthermore, two-thirds of thenurses responding to a nurse/physician communication survey reported thatthey had suffered verbal, mental, or physical abuse by a physician. Themost common complaints related to physicians yelling, cursing, andabruptly hanging up on the nurse during telephone conversations. Othercomments cited were berating the nurse in front of patients, familymembers, or other staff. The highest number of desk rage responses camefrom nurses working in hospital operating rooms, and the incidents includedthrowing of surgical instruments (Homsted, 2003). Due to these types ofsituations, which undermine a culture of patient and workplace safety, TheJoint Commission issued a Sentinel Event Alert on the topic and developed aLeadership standard requiring all accredited hospitals to have a code ofconduct as well as a process for managing disruptive and inappropriatebehaviors (Wyatt, 2013).StressorsEveryone encounters stress in their daily lives, but the effects on anindividual depend on a number of factors. Causes or sources of stress,known as stressors, can take on a number of forms, such as positive ornegative, external or internal, or short-term (acute) or long-term (chronic).Positive and Negative StressorsA certain degree of stress is necessary for good mental and physicalhealth; it can be viewed as constructive stress, which compels us to act withoptimum performance, whereby we achieve our goals. Hans Selye (1956,1974), a Canadian physiologist referred to as the grandfather of stressresearch, coined the term “eustress” to describe good or positive stress.Eustress is from the Greek root eu for “good.” Selye suggested thinking ofeustress as euphoria + stress. It is only when stress is poorly managed orbecomes overwhelming that the negative effects appear, which is referred toas distress (see Figure 12–2).

Figure 12–2 Distress–Eustress (An Expanded Yerkes–Dodson Curve)Preventive Stress Management in Organizations (p. 156), by J. C. Quick, J. D. Quick, D. L. Nelson, and J. J. Hurrell, 1997.Washington, DC: American Psychological Association. Reprinted with permission.Distress refers to the unhealthy, negative, destructive outcomes ofstressful events (Quick et al., 1997). Distress may have behavioral,physiological, and/or psychological effects on the individual. For example, asearly as the 1930s, physiologists were studying the physiologic changes ofindividuals when confronted with a negative stimulus or environmental

change. This is referred to as an individual’s “fight-or-flight” response. Thefight-or-flight response is when the brain and certain chemicals within thebrain cause a reaction to potentially harmful stressors or warnings (e.g.,danger, harassment, noise). Selye (1956) studied the physiologic effects ofthe fight-or-flight response, which resulted in his description of GeneralAdaptation Syndrome (GAS). GAS describes the three phases an individualundergoes when a stressful situation is encountered: the alarm phase, theresistance phase, and the exhaustion phase.The first stage of GAS, the alarm phase, is when an individual’s fight-or-flight response is elicited for mobilization and geared for a fight or flight.The second stage, resistance, is when the individual fights the stressor andthe acute fight-or-flight response ceases. The third stage, exhaustion, iswhen the individual can no longer adapt to the stressor (Jacobs, 2001). Inthe first two stages, alarm and resistance, bodily responses are adaptive andbeneficial.It is only in the final stage, exhaustion, that an individual may reflectbehavioral, physiological, and/or psychological illnesses. Physiologicalillnesses may include chronic headaches or fatigue, hypertension, ulcers,and heart disease. Psychological illnesses or the emotional symptoms ofstress in the exhaustion stage relate to frustration and/or depression.According to von Onciul (1996), these emotional symptoms are thebehavioral consequences of the exhaustion stage, which may includeemotional outbursts, violent or antisocial behavior, eating disorders, andgeneral indifference and reduced attention to personal issues such asexercise and appearance. The individual may exhibit other mentaldysfunctions in the exhaustion stage, such as the inability to concentrateand poor memory retention. This leads to impaired performance, poorjudgment, and indecisiveness, as well as a negative attitude toward life andwork, with the possibility of this leading to the misuse of alcohol and drugs(von Onciul, 1996).Internal or External Stressors/Acute or ChronicIndividuals can experience two categories of stressors: external orinternal. External stressors can be physical conditions, such as excessivetemperatures, or psychological environments, such as abusive relationships.Internal stressors can be physical illnesses or psychological tendencies, suchas an individual’s personality type. These stressors can be described aseither short-term (acute) or long-term (chronic). Short-term acute stress isthe reaction to a real or perceived immediate threat (the fight-or-flight

response). Long-term chronic stressors are those that are continuous, suchas work pressures, relationship problems, and financial concerns (see Table12–3).Table 12–3 External and Internal Stressors (Acute and/or Chronic)ExternalInternalEnvironment—Noise, poor lighting or bright lights, extreme temperaturesof hot or cold, confined spaces, violence and other threats topersonal safety, general economy, globalization, technology, war,and terrorismOthers—Rude, domineering, aggressive,peer pressures, and discriminationWork—Excessive rules and policies, poor interpersonal relationships,lack of communication, mergers, downsizing, long and/or irregularhours, unrealistic deadlines, retraining, discrimination, and promotionor demotionMajor Life Events—Death of loved one, poor health and/or disability,loss of job, new job, marriage, divorce, bankruptcy or other financialworries, relocation, new baby, caring for aging parents, and pendingretirementEveryday Hassles—Commuting, misplacing keys or other importantitems, poor customer service, standing in lines, dealing withteenagers at homeLifestyle—Unhealthy lifestyles, such asexcessive caffeine, smoking, drinking,drugs, lack of sleep, trying to do too much(e.g., supermom)Mental State—Pessimistic, self-critical, self-helplessness, unrealistic expectations, andlack of flexibilityPersonality—Perfectionist, workaholic,perceived expectation of others andourselves, and other Type A personalitycharacteristicsINDIVIDUALS AND STRESSStress comes in all forms and affects all people. Although there are noexternal standards that can be applied to predict stress levels in individuals,research has provided us with some insight as to those who are more proneto experience higher levels of stress, such as certain personality types,belonging to a minority group, and gender.PersonalitiesRosenman and Friedman, along with their colleagues (Rosenman et al.,1966), discovered the first relationship between stress and personality bylinking coronary heart disease (CHD) and personality profiles. Starting inthe 1950s, the Mount Zion Harold Brunn Institute studied the role ofpersonality in CHD and found that participants with Type A behaviorpatterns (TABP), such as aggressiveness, anger/hostility, competitiveness,time urgency, impatience, tenseness, and intense commitment to goals,were at higher risk for developing CHD than people with Type B personalitytraits (e.g., patient, low-key, noncompetitive) (Young, 1974). Although TypeB individuals are equally intelligent and may be just as ambitious as thosewho are Type A, they approach life in a different way (Quick et al., 1997).Friedman and Rosenman (1974) define TABP as an “action-emotion complex

that can be observed in any person who is aggressively involved in achronic, incessant struggle to achieve more and more in less and less time,and if required to do so, against the opposing efforts of other things or otherpersons” (p. 84).Other studies suggest that rather than the entire set of Type Acharacteristics, only particular dimensions, such as tenseness, may berelated to CHD (Kim et al., 1998). For example, Barefort, Dahlstrom, andWilliams (1983) found that anger and hostility were the lethal dimensions ofTABP when they studied 255 physicians over a 25-year period. At this time,researchers are still unsure what component or components of TABPconstitute the greatest factor leading to CHD for Type A individuals.Another dimension of personality that is related to stress is the perceptionof control (Rotter, 1966). Employees with a high need for autonomy andcontrol over their environments, such as the personality traits displayed byType A individuals, will experience a higher degree of stress when theyperceive a lack of control. For example, Kushnir and Kasan (1991) foundthat high-demand jobs combined with high workload and low perceivedcontrol were stressful for Type A but not Type B individuals.Perceived control is defined as the amount of control that an individualbelieves he or she has over the environment, whether direct or indirect, tomake it less threatening or more rewarding (Ganster & Fusilier, 1989).Within the work setting, this concept is reflected in the extent to which anindividual is free to decide how to accomplish a task or the goals of the job.Very low levels of personal control have been found to be psychologicallyharmful, whereas greater control has been associated with better mentalhealth (Evans & Carrere, 1991; Ganster & Fusilier, 1989). High levels ofperceived control have been found to increase an employee’s job satisfaction,commitment, and performance (Spector, 1986).Much of the research on perceived control stems from Robert Karasek’s(1979) job demands–decision latitude model. This model proposes that theeffects of job demands (psychological stressors in the work environment) onemployee well-being are influenced by job decision latitude (i.e., the degreeto which the employee has the potential to control his or her work). Karasekfound that individuals in occupations with high demands and low decisionlatitude suffered the most severe psychosomatic complaints and the highestlevels of both depression, and job and life dissatisfaction. Other studies haveconfirmed that employees who perceive they are subject to high demands(job responsibility) but have little control over their environment (authorityand/or choices) are at increased risk for stress-related illnesses such as

cardiovascular disease (Karasek et al., 1981). For example, Fox, Dwyer, andGanster (1993) found that nurses employed in a medium-sized privatehospital in the Midwest who experienced high workloads/demands withperceived low controllability showed increased physiological problems andlower attitudinal outcomes (job satisfaction), with the physiologicalresponses continuing after the nurses left work. The researchers suggestedthat it was not the higher levels of workload or demands, but the nurses’perception of low controllability over the situation that caused the nurses todisplay symptoms of job stress (i.e., low job satisfaction, high blood pressure,and high cortisol levels). Simmons and Nelson (2001), however, found thatnurses with a high level of hope (the belief that one has both the will andthe way to accomplish one’s goals) had a significant, positive relationshipwith the perception of their health and ability to deal with the demands andstressfulness of their jobs.An employee’s sense of loss of control is an important form of emotionalstress; therefore, employers need to pay particular attention to this matterin the workplace. Middle managers are among those with the most highlystressed positions as related to the need to respond to others’ demands andproject deadlines, with little perceived control over their environments.Savery and Hall (1986) relate that “managers are beleaguered by demandsnot only from their superiors but also from government agencies, fromsubordinates and union representatives pushing for a greater say in therunning of the enterprise, and from community and other interest groupswith their many and rising expectations. Many of these demands are alsomutually exclusive” (p. 160). Savery and Hall also found that a significantrelationship existed between managers’ perceived lack of autonomy (i.e.,control) in decision making and stress-related illnesses. The researchersfurther found that middle managers under 30 years of age felt more stressthan older managers because of less autonomy, closer supervision, andconfusion over lines of authority within the organization.However, a perceived lack of control may not be stressful to someemployees. Some employees may want minimum control in their jobs. Theseemployees may not want the increased responsibility that is often connectedwith greater job autonomy. In such situations, a greater degree of jobcontrol would actually have the reverse effect on the employee’s well-being.MinoritiesThe nation’s workforce is becoming more culturally and ethnically diverse.Surprisingly, the literature is limited about the specific impact of workplace

diversity on organizations or about the stress that such diversity imposes onmembers of different cultural and ethnic groups (Keita & Hurrell, 1994;Quick et al., 1997). However, managers need to be attentive to the fact thatemployees from ethnic minority groups may be more prone to stress thanmajority (i.e., nonethnic minority) groups because of issues associated withprejudice and discrimination, whether perceived or real, potential languagedifficulties, and cultural values and attitudes.Quick et al. (1997) point out that “blatant prejudice is the most obvioussource of stress for those in minority ethnic groups” (p. 57). For example, inan early study, Kasschau (1977) found that the “overwhelming majority” of800 minority survey respondents identified prejudice and discrimination atwork. In a more recent national study, Roberts, Swanson, and Murphy(2004) found that American minorities reported perceptions ofdiscrimination at work at greater frequencies than nonminority Americans,and that whites, African Americans, and Hispanic Americans who reportedthat they had been discriminated against were found to have poorer mentalhealth outcomes than their same-race counterparts who did notacknowledge being discriminated against.James, Lovato, and Khoo (1994) argue that differences in cultural valuesand attitudes between minority workers and majority workers constitute amajor source of minority worker stress. For example, Cox, Lobel, andMcLeod (1991) found that Asian American, African American, and HispanicAmerican individuals have a more collectivist orientation than EuropeanAmericans as described by Hofstede’s four dimensions of national culture..Therefore, as a minority-culture member shifts from a work role in whichhe or she attempts to fit in with a majority-culture orientation, increasedstress levels may occur because this attempt to fit in, or assimilate, causes adeparture from the societal role within his or her collectivist community.Assimilation is the process by which an individual develops a new culturalidentity, whereby the individual may eventually lose identification with hisor her culture of origin in order to become successful in the dominantculture. Since minority cultures may have a more collectivist orientation,minority members may experience stress as they attempt to assimilate intothe majority culture dominating the workplace. As an example, Bell, ascited in Richard and Grimes (1996), found that African American womenwho were career-oriented experienced more stress than their counterpartswho were community-oriented or family-oriented. Since minority culturesmay differ in race, attitudes, and beliefs from the majority culture within anorganization, minority members would find the workplace to be more

stressful. Richard and Grimes (1996) point out that this is due to theminority members’ need to work harder to socialize, or assimilate, into thedominant organizational culture for a significant portion of their day.GenderOver the years, research has been conducted on the stress levels ofwomen, and considering that 92 percent of the 4.3 million nurses andnursing aides in the United States are female, health care employers needto be sensitive to the work-related stress issues experienced by women.Statistics from Roper Starch Worldwide’s Global 2000 Consumer Study of30,000 people between the ages of 13 and 65 in 30 countries showed thatincreased stress is felt worldwide, with women consistently reporting beingmore stressed than men. The most stressed women are: (1) mothers withchildren under the age of 13, (2) full-time working mothers, and (3) full-time working mothers with children under 13. In addition, one-fourth ofwomen executives and professionals say they feel “superstressed.”A second study, Creating Healthy Corporate Cultures for Both Genders,revealed that stress affects women differently from men (Peterson, 2004).The study indicated that women reported nearly 40 percent more healthproblems than their male counterparts and noticeably higher stress.Furthermore, Swanson (2000) found that:• Women face gender-specific work stress, such as sex discrimination andthe need to balance work and family demands, in addition to general jobstressors such as work overload, lack of control over their job, orunderutilization of their skills.• Barriers to financial and career advancement based on sexdiscrimination have been linked to more frequent psychological andphysical symptoms, such as depression and increased blood pressure.• Half of all working women will experience on-the-job sexualharassment at some point in their lives, and women who experiencesexual harassment report a range of psychological symptoms includingdepression, anxiety, fearfulness, and feelings of guilt and shame, as wellas physical symptoms such as headaches and sleep disorders. Sexualharassment is a particularly noxious stressor for women and has asignificant impact on psychological distress and absenteeism beyondthat attributable to regular job stressors (pp. 77–78).Burnout

Stress occurs when job requirements do not match the capabilities,resources, or needs of the employee. Studies show that stressful workingconditions are associated with increased absenteeism, tardiness, andturnover, which affects an organization’s productivity and profitability.An extreme case of job-related stress is known as burnout. Burnout, firstdiscovered in the 1970s, has been recognized as an occupational hazard forpeople-oriented professions such as health care, human services, andeducation (Maslach & Goldberg, 1998). Burnout symptoms includeoverwhelming exhaustion, feelings of frustration, anger and cynicism, and asense of ineffectiveness and failure. Sadly, health care professionals havereported substantially higher degrees of burnout than managers notemployed in the health care industry (Golembiewski & Boudreau, 1991).Maslach and Jackson (1981) identified three dimensions associated withburnout: emotional exhaustion, depersonalization, and diminished personalaccomplishment.• Emotional exhaustion results in apathy and loss of concern, a feelingthat one has reached the “end of the rope.” As emotional resources aredepleted, health care professionals feel they cannot give of themselvesat an emotional or psychological level.• Depersonalization is characterized by the development of negative andcynical attitudes toward the workplace, as well as toward people withwhom the employee interacts (patients and coworkers). Individualsdistance themselves and see others as things or objects.• Diminished personal accomplishment is characterized by the tendencyto evaluate oneself negatively, including viewing oneself as performingpoorly in the job—a job that is viewed as having no worth or meaning(low professional efficacy).Golembiewski and his associates (Golembiewski, 1986, 1990;Golembiewski & Boss, 1991; Golembiewski & Boudreau, 1991) studied over13,000 managers and health care professionals regarding burnout. Theresearchers found that varying degrees of burnout existed, with health careworkers experiencing the most advanced phases (Golembiewski &Boudreau, 1991). As illustrated in Table 12–4, Golembiewski’s phase modelsuggests that employees who are suffering from burnout first experiencedepersonalization, which induces feelings of inadequacy, followed bydiminishing personal accomplishment, and ending with emotionalexhaustion. Golembiewski and Boudreau relate that employees showgrowing deficits or deficiencies as they move from phase to phase, such as:

Table 12–4 Golembiewski’s Phases of Burnout“The Epidemiology of Progressive Burnout: A Primer,” by R. T. Golembiewski, 1986. Journal of Health andHuman Services Administration, 9(1), p. 18. Reprinted with permission.• Broad ranges of perceptions or attitudes about the worksite deteriorate;for example, satisfaction and job involvement fall and tension at workincreases.• Performance appraisals tend to decrease.• Physical symptoms increase.• Turnover grows.• Self-esteem falls.• Various clinical indicators of mental health deteriorate.• Declining quality of social and emotional life at work; for example,group cohesiveness is down and social support falls.In support of Golembiewski’s phase model, Kalliath, O’Driscoll, Gillespie,and Bluedorn (2000) found that nurses, laboratory technicians, andmanagers employed by a general community hospital in an urban Midwestcity who reported higher levels of burnout experienced (1) decreased jobsatisfaction, (2) decreased satisfaction with interpersonal relationships, and(3) lower levels of organizational commitment reflected by either jobturnover or increased intentions to leave their jobs.PresenteeismAs previously noted, symptoms of burnout may include lower jobperformance and satisfaction, higher job tension and turnover, andincreased absenteeism. However, increased absenteeism is not always anindicator that an employee may be suffering from burnout. A new buzzwordis “presenteeism,” which occurs when employees show up for work but areless productive because of illness. A study of 29,000 U.S. employees

estimated that absenteeism and presenteeism cost U.S. industry more than$60 billion a year and that more than three-fourths of lost productivity isexplained by presenteeism, not by absenteeism (Stewart et al., 2003). DowChemical Company estimates that presenteeism is its largest health-relatedeconomic impact, ahead of absenteeism, health insurance, and workers’compensation (Berry, Mirabito, & Berwick, 2004). A pilot study assessingthe impact of 28 medical conditions on workers’ productivity conducted byTufts–New England Medical Center researchers at Lockheed MartinCorporation found that employees who came to work sick during the studyyear—with ailments such as allergies, headaches, lower-back pain, arthritis,colds, and the flu—cost the organization approximately $34 million (Hemp,2004). (See Case Study 12–1: Presenteeism: A Public Health Hazard.)Case Study 12–1 Presenteeism: A Public Health HazardOn January 19, 2005 (day 1), three nursing home residents and one staff member at a 100-bed, two-floor urban facility developed symptoms of nausea, vomiting, and diarrhea. General infection controlmeasures were reinforced, including hand hygiene education for nursing home residents and staff,contact isolation for symptomatic residents, and new surface disinfection procedures. On days 2 and3 of the outbreak, seven more residents developed similar symptoms, as well as four additional staff.Two of these staff members reported diarrhea after arriving at work and were asked to go homeafter discussions with the infection control team. At this point, the public health department wasnotified and more restrictive measures were instituted, including closure of the dining room;suspension of group activities and outings; limitation of visitors, volunteers, and trainees;rescheduling of elective surgery and non-urgent clinic appointments; and discontinuation of newadmissions. Staffing strategies were also temporarily changed so that nursing staff did not float in orout of the unit. As per policy, supervisors were instructed to refer employees with signs orsymptoms of an infectious illness to Employee Health for diagnosis and determination of suitabilityto continue work. However, no daily systematic screening process took place to identify ill staffmembers at the start of their shift.Over the course of the next 10 days, 23 residents and 18 staff developed symptoms of nausea,vomiting, and diarrhea. Laboratory studies of affected staff and residents confirmed norovirusgenotype 2. By day 8 of the outbreak, it became increasingly clear that ill staff members continued towork despite strong recommendations to the contrary by management. Often, symptoms were notreported until employees had arrived for and sometimes completed their shifts. Several employeesalso reported ill family members with similar symptoms. Infection Control responded by contactingeach ill staff member to verify symptoms, provide education, and ask that they remain home. Severalnursing staff members who were symptomatic at work were asked to leave as soon as they reportedsymptoms and to not return until they received clearance from Employee Health. Staffing wasmanaged through the use of registry or per diem nursing coverage when appropriate.No new cases occurred from days 13 through 17 of the outbreak. However, on day 18, a staffmember arrived at work ill with gastrointestinal symptoms. On day 21, an additional two residentsdeveloped gastroenteritis. As voluntary measures to prevent presenteeism failed, the localdepartment of public health mandated enforcement of “back to work” rules. These rules requiredemployees with gastrointestinal symptoms to obtain clearance from Employee Health before beingallowed to return to work. This clearance was given only after 48 symptom-free hours had elapsed.The final case was identified 24 days into the outbreak, and gastroenteritis-specific infection control

measures were discontinued on day 34.Reproduced from: Widera, E., Chang, A., & Chen, H. L. (2010). Presenteeism: a public healthhazard. Journal of General Internal Medicine, 25(11), 1244–1247.CAUSES OF WORKPLACE STRESSWorkplace stress can be related to: (1) individual task demands, (2)individual role demands, (3) group demands, and (4) organizational demands(Kinicki & Williams, 2003) (see Table 12–5).• Individual task demands would include unrealistic deadlines, fear offailure, new technology, lack of necessary resources (e.g., poor physicalwork environment, such as noise, heat, and crowding), work overload,lack of control, and repetitive, unchallenging work (work underload).• Individual role demands include job ambiguity, role conflict, anddifficulty balancing work and family life.• Group demands include poor interpersonal relationships with coworkersand/or supervisors, inadequate support, and lack of participation indecisions.• Organizational demands encompass politics, communication problems,excess rules and regulations, organizational structure and culture, lackof career development activities, and change without clear strategicdirection.

Table 12–5 Job StressorsCategories of Job StressorsExamplesIndividual Task Demands (factors unique to thejob)• Workload (overload and underload)• Pace/variety/meaningfulness of work• Autonomy (e.g., the ability to make your own decisions about yourown job or about specific tasks)• Shift work/hours of work• Physical environment (noise, air quality, etc.)• Isolation at the workplace (emotional or working alone)Individual Role Demands (role in theorganization)• Role conflict (conflicting job demands, multiple supervisors ormanagers)• Role ambiguity (lack of clarity about responsibilities, expectations,etc.)• Level of responsibility• Difficulties balancing work and personal livesGroup Demands• Relationships at work with supervisors, coworkers, andsubordinates• Threat of violence, harassment, etc. (threats to personal safety)• Lack of participation in decision making• Inappropriate leadership/management styles (autocratic versusparticipatory)Organizational Demands (includingorganizational structure and climate)• Management/leadership styles• Communication patterns• Career development opportunities (under-/overpromotion)• Job security• Unplanned change• Overall job satisfactionSource: “Occupational Stress Management: Current Status and Future Directions,” by L. R. Murphy, 1995.In C. L. Cooper and D. M. Rousseau (Eds.), Trends in Organizational Behavior (Vol. 2, pp. 1–14). NewYork, NY: John Wiley & Sons. Reprinted with permission.How these various demands can affect employees’ stress levels isillustrated in Case Study 12–2.Case Study 12–2 Stress in Today’s WorkplaceThe longer he waited, the more David worried. For weeks he had been plagued by aching muscles,loss of appetite, restless sleep, and a complete sense of exhaustion. At first he tried to ignore theseproblems, but eventually he became so short-tempered and irritable that his wife insisted he get acheckup. Now, sitting in his primary care physician’s office and wondering what the verdict wouldbe, he didn’t even notice when Theresa took the seat beside him. They had been good friends whenshe worked in the billing office at the drug manufacturing facility, but he hadn’t seen her since sheleft three years ago to take a job as a member service representative at a local health maintenanceorganization. Her gentle poke in the ribs brought him around, and within minutes they were talkingand gossiping as if she had never left.“You got out just in time,” he told her. “Since the reorganization, nobody feels safe. It used to bethat as long as you did your work, you had a job. That’s not for sure anymore. They expect the sameproduction rates even though two people are now doing the work of three. We’re so backed up I’mworking 12-hour shifts six days a week. I swear I hear those machines humming in my sleep.Employees are calling in sick just to get a break. Morale is so bad they’re talking about bringing insome consultants to figure out a better way to get the job done.”

“Well, I really miss everyone,” she said. “I’m afraid I jumped from the frying pan into the fire. Inmy new job, the computer routes the calls and they never stop. I even have to schedule my bathroombreaks. All I hear the whole day are complaints from unhappy members. I try to be helpful andsympathetic, but I can’t promise anything without getting my supervisor’s approval. Most of the timeI’m caught between what the member wants and company policy. I’m not sure who I’m supposed tokeep happy. The other reps are so uptight and tense they don’t even talk to one another. We all go toour own little cubicles and stay there until quitting time. To make matters worse, my mother’shealth is deteriorating. If only I could use some of my sick time to look after her. No wonder I’m inhere with migraine headaches and high blood pressure. A lot of the reps are seeing the employeeassistance counselor and taking stress management classes, which seems to help. But sooner orlater, someone will have to make some changes in the way the place is run.”Job Conditions That May Lead to StressThe Design of Tasks: Heavy workload, infrequent rest breaks, long work hours, and shift work;hectic and routine tasks that have little inherent meaning, do not utilize workers’ skills, and providelittle sense of control.Example: David works to the point of exhaustion. Theresa is tied to the computer, allowing littleroom for flexibility, self-initiative, or rest.Management Style: Lack of participation by workers in decision making, poor communication inthe organization, lack of family-friendly policies.Example: Theresa needs to get her supervisor’s approval for everything, and her employer isinsensitive to her family needs.Interpersonal Relationship: Poor social environment and lack of support or help from coworkersand supervisors.Example: Theresa’s physical isolation reduces her opportunities to interact with her coworkers orreceive help from them.Work Roles: Conflicting or uncertain job expectations, too much responsibility, too many “hats towear.”Example: Theresa is often caught in a difficult situation trying to satisfy both the members’ needsand her employer’s expectations.Career Concerns: Job insecurity and lack of opportunity for growth, advancement, or promotion;rapid changes for which workers are unprepared.Example: Since the reorganization at the hospital equipment manufacturing facility, everyone,including David, is worried about their future with the company and what will happen next.Environmental Conditions: Unpleasant or dangerous physical conditions such as crowding, noise,air pollution, or ergonomic problems.Example: David is exposed to constant noise at work.MODIFIED from “Stress at Work,” DHHS (NIOSH) Publication No. 99–101, 1999. Washington, DC:National Institute for Occupational Safety and Health.COPING WITH STRESSCoping with stress at work can be defined as “an effort by a person or anorganization to manage and overcome demands and critical events that posea challenge, threat, harm or loss to that person and that person’sfunctioning or to the organization as a whole” (Schwarzer, 2004, p. 342).Coping is considered one of the top skills inherent in effective managers.With population samples from business, education, health care, and state

governments, Whetton and Cameron (1993) identified 402 effectivemanagers on the basis of responses from peers and superiors. Responsesfrom the participants revealed that coping with stress was second on a listof 10 skills attributed to effective managers.Stress is inevitable, but the degree of experienced stress can be modifiedin two ways: by changing the environment and/or by changing theindividual. This is referred to as stress management. Stress managementcan refer to a narrow set of individual-level interventions (e.g., relaxationtraining, biofeedback, meditation) or a broader meaning that includes anytype of stress intervention (Murphy, 1995). However, for stressmanagement interventions to be successful, they need to targetcharacteristics of the individual worker, the job, and the organization.Schwarzer (2004) provides managers with a model using four perspectivesfor assisting themselves and others to cope with job-related stress (refer toFigure 12–3). The distinction between each perspective is based on time-related stress appraisals and on the perceived certainty of critical events ordemands. The four perspectives are: (1) reactive coping, (2) anticipatorycoping, (3) preventive coping, and (4) proactive coping.• Reactive coping refers to efforts to deal with a stressful encounter thatis either ongoing or has already happened, such as a job loss ordemotion.• Anticipatory coping pertains to efforts to deal with an inevitable eventthat is certain to occur in the near future, such as public speaking, a jobinterview, or downsizing.• Preventive coping refers to an effort to “build up” resistance resources,whereby the level of stress felt by an individual is reduced (minimizingseverity of impact) if a critical event should occur in the future. Forexample, an individual returns to school to earn a master’s degree inhealth administration or completes the requirements to become a board-certified health care executive in case of a possible job loss due to amerger or buyout.• Proactive coping is defined as an effort to “build up” general resourcesthat facilitate movement toward challenging goals and personal growth,such as hardiness training and learned optimism (Schwarzer, 2004).

Figure 12–3 Four Coping PerspectivesReproduced from Schwarzer, R. (2004). Manage stress at work through preventive and proactive coping. In E. A. Locke (Ed.),Handbook of Principles of Organizational Behavior. London: Blackwell Publishing, p. 347.

Schwarzer (2004) points out, “The distinction between these fourperspectives of coping is highly useful because it moves the individual’sfocus away from mere responses to negative events towards a broader rangeof risk and goal management that includes the active creation ofopportunities and the positive experience of stress” (p. 349).Organizational Coping StrategiesAt the organizational level, when reactive or anticipatory coping occurs,managers’ efforts are involved with reducing the harm or loss to theorganization. Managers are concerned with putting out fires as opposed tousing their efforts to develop and implement preventive and proactivecoping strategies, which are more beneficial for both the organization andthe employee. For example, preventive coping is called for when no specificevent is envisioned but a more general threat in the distance comes intoview, such as an economic decline, a potential merger or downsizing, anaging workforce, or new technology (Schwarzer, 2004).The health care industry is using preventive coping strategies regardingthe envisioned future shortage of health care leaders due to an agingworkforce. For example, among its 191 hospitals, HCA, Inc., anticipatesthat many of its baby boom–generation chief executive officers (CEOs) willretire within the next 10 years. Furthermore, given the likelihood thatthose vacancies will be filled by incumbent chief operating officers (COOs),HCA anticipates that it will face a hospital leadership gap at the COO level.To address this challenge proactively, HCA created an intensive COOdevelopment program. This program is a development-in-place approachwhereby the program is not supplemental to the duties of a regular hospitaljob, but instead individuals are hired by HCA for the sole purpose ofparticipating in the program with the goal of developing critical, advancedexecutive-level skills. Participants are given the title of “associateadministrator” and assigned to an HCA hospital. The current CEO of thehospital serves as the associate administrator’s mentor and superior over atwo- to four-year period. After successfully completing the developmentprogram, the associate administrator would be promoted to COO for one ofHCA’s hospitals (HCA, 2004).Preventive and proactive coping are also referred to as primaryprevention or organizational prevention (Quick et al., 1997). Organizationalprevention is designed to enhance an employee’s health and performance atwork by eliminating the stressors that lead to distress. These methodsinclude modifying work demands and improving relationships in the

workplace (Schwarzer, 2004). Anticipatory coping is related to secondaryprevention; the goal is changing individual stress responses to necessarydemands. Reactive coping may be referred to as tertiary prevention, whichattempts to minimize the amount of individual and organizational distressthat results when organizational stressors and resulting stress responseshave not been adequately controlled (Quick et al., 1997) (see Figure 12–4).To illustrate these coping concepts, consider the following: A physiciandisplays inappropriate behavior* toward a nurse (a stressor), which leads tothe nurse experiencing anxiety (a stress response), and in turn, the nurseresigns (an organizational consequence of distress). Primary preventionwould attempt to eliminate the stressor by the hospital establishing a zero-tolerance policy regarding inappropriate physician behavior (preventiveand/or proactive coping). Secondary prevention would address the problemby providing programs to improve interpersonal relations betweenphysicians and nurses (anticipatory coping). These programs may includeimproving team building and communication skills, whereby the physicianrecognizes that nurses are an integral part of the patient’s health care teamand, as such, interactions are based on mutual respect and trust. Tertiaryprevention might include establishing an employee assistance programdesigned to assist nurses to cope with confrontational behavior that may bedisplayed by physicians.

Figure 12–4 Stages of Preventive Stress ManagementPreventive Stress Management in Organizations (p. 155), by J. C. Quick, J. D. Quick, D. L. Nelson, and J. J. Hurrell, 1997.Washington, DC: American Psychological Association. Reprinted with permission.The preceding example is based on a recent study that linked

inappropriate physician behavior with nurses leaving the nursingprofession. Rosenstein (2002) surveyed 1,200 nurses, physicians, andexecutive administrators at several hospitals affiliated with VHA, a nationalnetwork of community-owned hospitals and health care systems, to assesshow these disparate groups viewed nurse–physician relationships, disruptivephysician behavior, the institutional response to such behavior, and howsuch behavior affected nurse satisfaction, morale, and retention.Rosenstein found that daily interactions between nurses and physiciansstrongly influence nurses’ morale. All respondents indicated that they wereconcerned with the significance of nurse–physician relationships, and over90 percent of all respondents reported witnessing disruptive physicianbehavior and that they saw a direct link between this disruptive behaviorand nurse satisfaction and retention. In addition, 30 percent of the nurserespondents reported knowing at least one colleague who had resignedbecause of disruptive physician behavior.Subsequent research by Rosenstein and O’Daniel (2005, 2006, 2008) foundan almost equal amount of disruptive behavior in nurses and other hospitalemployees, but more disconcerting was the downstream negative impact ofdisruptive behavior on stress, loss of focus, concentration, communication,collaboration, and information transfer resulting in medical errors, adverseevents, and significant compromises in patient safety, quality, and evenmortality. As noted earlier, The Joint Commission issued a 2008 standardrequiring hospitals to develop a disruptive behavior policy and providenecessary education about this topic.Work SettingAs discussed previously, an employee’s work setting may create physicalstress because of noise, lack of privacy, poor lighting or ventilation, and soforth. As such, an organization should redesign employees’ physical settingsto minimize distressful effects (i.e., primary preventive and proactivecoping). For example, Williams (2003) found that the odds of feeling stressbecause of fear of accident or injury were 7.2 times higher for employeesworking in health occupations than those in the management, business,finance, or science fields. This high source of workplace stress by health careworkers may be caused by their constant exposure to risk of infection, longhours, and irregular shifts. Other studies have shown that the creation ofpleasant and suitable work areas can elevate an employee’s job satisfaction,job safety, and mental health, which may indirectly improve jobperformance.

Job DesignAnother important component of reducing work-related stress is jobdesign. Proper job design accommodates an employee’s mental and physicalabilities. According to the MFL Occupational Health Centre (2000), aCanadian community health center whose mission is to improve workplacehealth and safety conditions and eliminate hazards, employers can betterdesign jobs by:• Clearly defining jobs and responsibilities that reduce role conflict and/orrole ambiguity;• Giving workers a say in how they do their jobs;• Giving workers opportunities to learn new skills;• Allowing time for social interactions among workers;• Making work schedules flexible for responsibilities outside of work;• Clearly communicating about job security;• Training managers to apply participative-management styles as part ofa culture that emphasizes open communication, support, and mutualrespect;• Implementing effective performance-management systems with clearexpectations and procedures that are understood by managers and staff;• Ensuring that effective change management accompaniesorganizational change.INDIVIDUAL COPING STRATEGIESAt the individual level, one of the most well-documented techniques forreducing stress is through the relaxation response (see Exhibit 12–1).However, relaxation is a reactive coping strategy as a result of anindividual’s appraisal of a threat or harm/loss situation such as failing tomeet a work goal, conflict with a colleague or supervisor, or job loss.Reactive coping strategies do very little if anything to solve the underlyingproblems; therefore, employees need to learn to use preventive andproactive coping strategies so that the fight-or-flight response is notautomatically engaged at the first sign of stress (Schwarzer, 2004).Exhibit 12–1 How to De-stressOne of the most well-documented techniques for reducing stress is through the relaxationresponse, a term coined by Dr. Herbert Benson of Harvard Medical School to describe a state ofdeep, mindful rest that offsets the physical effects of stress by lowering heart rate, blood

pressure, and breathing rate. The relaxation response can be elicited at any time and in anyplace by sitting comfortably with your eyes closed, breathing slowly, letting your muscles relax,and repeating a certain word, sound, phrase, or prayer for 10 minutes while disregarding allother thoughts. The slow, repetitive movements and meditative thoughts involved in activitiessuch as yoga and T’ai Chi have also been found to evoke a similar physiological response, whichin turn can help you to think more rationally about your own predicament and how you can workto improve it.Reproduced from “Optimistic People Live Longer,” January 2003. Tufts University Health andNutrition Letter, 20(11), pp. 4–5.I. Friedman (1999) suggests training employees to cope with stressfulsituations by improving their abilities for problem solving and conflictresolution, and developing their leadership skills. For example, when anemployee is facing a stressful episode due to increasing workload, he or shecan be trained beforehand how to delegate tasks, use good timemanagement skills, and increase his or her social support system. Inaddition, employees need to learn how to maintain a healthy balancebetween work, family, and leisure activities, although this may be a difficultprocess for workaholics and individuals displaying other Type A personalitycharacteristics. It is known that healthy lifestyles (e.g., nutrition andexercise) provide a protective shield against the experience of stress(Schwarzer, 2004). In addition, the use of learned optimism and hardinesstraining has been shown to be successful in assisting employees toreinterpret perceived threats (i.e., stressful events) into challenges, therebytransforming distress into eustress.Learned OptimismFrom extensive research throughout his career as a psychologist, MartinSeligman (1991) developed the concept of learned optimism and applied itdirectly to workplace productivity. According to Seligman, when pessimisticpeople run into obstacles in the workplace, they give up. However, whenoptimistic people encounter obstacles, they try harder. Seligman’s learnedoptimism theory suggests that people can learn optimism by undoingpessimistic thinking by recognizing and then disputing negative thoughtsand beliefs.Optimism is not the same as the popular concept of “positive thinking.”Optimists and pessimists attribute the reasons for success and failuredifferently. Drawing on attribution theory, Seligman (1991) refers to how aperson interprets events as his or her explanatory style. Seligman identified

three primary elements of an individual’s explanatory style: stability,globality, and locus of control.• Stability refers to whether the event’s outcomes are temporary orpermanent. For example, if the outcome is negative, the optimist tendsto think it’s an isolated incident. If the outcomes are positive, theoptimist tends to think they will reoccur in the future. On the otherhand, the pessimist views positive outcomes as “one-time events” andnegative outcomes as more likely to occur in the future.• Globality refers to whether the event’s outcomes are specific to this onesituation or whether the outcomes apply to everything in a person’s life.For example, when a positive event occurs, the optimist is more likely toextend it to his or her whole life. With a negative event, the optimistwill tend to isolate the incident as specific to that situation. The oppositeholds true for the pessimist: positive events are viewed as “strokes ofluck,” and negative events are viewed as representative of his or herwhole life.• Locus of control refers to whether the individual believes the outcome isattributable to his or her actions or to factors in the environment. Forexample, when a positive event occurs, the optimist attributes thesuccess to his or her efforts. With a negative event, the optimist looks tocauses outside of his or her control to explain the outcome, such as badluck, whereas the pessimist will view positive events as attributable toluck, other people’s hard work, or something else outside of his or hercontrol, and will view negative events as being caused by his or herpersonal deficiencies.Pessimists tend to attribute failure and negative events to permanent,personal, and pervasive factors. Optimists tend to attribute bad events tononpersonal, nonpermanent, and nonpervasive factors. They attribute theirfailures to causes that are temporary rather than stable, specific to theattainment of a particular goal rather than all their goals, and see theproblem as a result of the environment or setting they are in, rather thanbeing inherent in themselves. Optimists have high self-efficacy; as such,they view setbacks, obstacles, and a noncontingent environment aschallenges that provide excitement in their life (Seligman &Csikszentmihalyi, 2000). The opposite is true for pessimists. Pessimists seeno relationship between their actions and goal attainment. Their lowoutcome expectancy causes deficits in future learning as well asmotivational disturbances such as procrastination and depression

(Seligman, 1991). Thus, even when the situation changes so that they canexert control over their environment so as to make progress toward theirgoal, pessimists do not try to do so, because they have learned that givingup is a rational response. This is because their attribution leads to what isreferred to as learned helplessness (see Exhibit 12–2) (Seligman, 1991). Anindividual’s habitual blaming of him- or herself undermines self-efficacy(Bandura, 1997).Exhibit 12–2 Learned HelplessnessHelplessness is a learned condition that has a negative impact on an individual’s physical,emotional, mental, and spiritual well-being. Learned helplessness is a phenomenon in whichpeople experience failure at a task, often numerous times. They determine that the task cannotbe accomplished, at least not by them, and thus they stop trying. They internalize their failures(self-blame) and develop a helpless attitude.A study on learned helplessness looked at stress levels in two groups subjected to the sameloud and unpleasant noise. One group was given a button that could turn the noise off, while thesecond group was not given any way to turn it off. The subjects who were denied control over thenoise experienced significant stress and called the noise “unbearable.” The first group that hadthe option of turning off the noise only considered the noise “unpleasant,” but chose not to turnoff the sound. Just knowing that they had the option of turning the noise off was enough.Following the sound session, the researchers observed that the group that had been subjectedto helplessness in the noise experiment tended to act helpless in subsequent situations, whereasthe group that had been given control to turn off the noise in the experiment looked for andchose to exercise control over subsequent situations. Both helplessness and empowerment arelearned conditions. Once learned, they are extended into other areas of life.Optimism may serve as a buffer against the physiological effects of stress.Research suggests that the immune function in optimists is better than inpessimists. It is not that optimists experience fewer stressful situations thanpessimists; they are just more adept at coping with such situations so theycan work through the problems and develop solutions rather than feelinghelpless or like victims.Hardiness TrainingThe hardiness concept has been applied frequently to prevent andalleviate stress at work (Schwarzer, 2004). The HardiTraining® program(see The Hardiness Institute, Inc., at www.hardinessinstitute.com)comprises building an employee’s attitudes of commitment, control, andchallenge.• Commitment refers to an individual’s belief that involving oneself in life

changes is the way to deepen meaning and purpose. Individuals high incommitment immerse themselves in a proactive coping process thattransforms the stressfulness of a problem so that it becomesmanageable and growth promoting.• Control refers to one’s belief that if he or she tries, he or she canpositively influence much of what happens in his or her life. Anindividual maintains that even when a personal or professional problemhas unchangeable aspects to it, if he or she is resourceful, there areways to use the stressful circumstance as an opportunity for newlearning. By constructively influencing outcomes, a person strengthenshis or her view of oneself as capable, hardy, and a participant in theworld.• Challenge refers to an individual’s attitude that everything thathappens to him or her, whether negative or positive, is an opportunityto enhance one’s performance, leadership, morale, conduct, and health.Individuals high in HardiAttitudes® engage fully in their personal andwork life, use life changes to promote learning and renewal, and reportgreater life meaning, purpose, and satisfaction (Maddi, 1998).HardiTraining® outcome studies have demonstrated their effectiveness instrengthening one’s ability to resist the stressful impact of personal andprofessional changes.Stress Management ProgramsOrganizations are developing comprehensive health promotion strategiesfor their employees, which include various types of individual-level stressmanagement programs (Schwarzer, 2004). Stress management programsoften consist of breathing and stretching exercises, yoga, meditation, and/ormassage. The programs’ goals are to lessen the adrenaline response tominor stress. For example, St. Paul Fire and Marine Insurance Companyconducted several studies on the effects of stress-prevention programs inhospital settings. Program activities included (1) employee and managementeducation on job stress, (2) changes in hospital policies and procedures toreduce organizational sources of stress, and (3) establishment of employee-assistance programs. In one study, the frequency of medication errorsdeclined by 50 percent after prevention activities were implemented in a700-bed hospital. In a second study, there was a 70 percent reduction inmalpractice claims in 22 hospitals that implemented stress-preventionactivities. In contrast, there was no reduction in claims in a matched group

of 22 hospitals that did not implement stress-prevention activities (Jones etal., 1988).Another example is Baptist Health South Florida (BHSF). Baptist Health,the largest nonprofit health care organization in South Florida, provides aholistic approach to the well-being of its staff. The organization sponsors ahealthy lifestyle program for its employees, called the Wellness Advantage.On-site fitness coaches are available to employees at each of the system’s sixhospital fitness centers to provide screening and personal training.Discounts are offered to employees who choose the designated “healthy”meals in the system’s cafeterias. For those facing life-threatening illnesses,the system offers flexible, reduced scheduling so that staff can maintainsome level of employment during stressful times. Senior managementbelieves that the organization’s success, as measured by patient satisfaction,physician satisfaction, employee satisfaction, clinical outcomes, andoperating profits, is directly owed to the “healthy” infrastructure of itsemployees. Baptist Health’s commitment to its employees is recognizednationally. The National Business Group on Health has recognized BaptistHealth’s longtime commitment to its employees by naming the healthsystem one of the Best Employers for Healthy Lifestyles for the past 10years (BHSF, 2015; May, 2004).Crampton and colleagues (1995) related that stress managementprograms need to contribute to the goals and needs of both the organizationand the individual. Organizations need to believe that the benefits of stressmanagement programs outweigh their costs. Employees need to perceivethat they will benefit from stress management programs or they will notvoluntarily participate. To meet both organizational and individual goals,Crampton and colleagues provide the following recommendations:Preventive and/or Proactive Coping (primary prevention)1. Identify the major stressors in the workplace and assess which onesare controllable. Organizations should do more than simply providestress management techniques. If the causes of stress can be reducedor eliminated, they should be. Organizational-level strategies mightinclude redesigning employees’ jobs, improving the selection,placement, and orientation of new employees, providing employeeswith more participation and autonomy in decision making,disseminating information, providing needed education and training,reducing workloads or the work pace, modifying work schedules to becompatible with demands and responsibilities outside of work,

conducting time management programs, clearly defining work roles,providing opportunities for career development, and providingemotional and task support.2. Communicate with employees about the benefits of stressmanagement. Explain what stress is, along with the healthimplications of excess stress or distress. Employees should beencouraged to lead healthier lives by lowering their stress on the jobas well as at home.Anticipatory Coping (secondary prevention)1. Assist employees to identify their stressors and stress-tolerancelevels. Before learning how to deal with stress, employees first haveto identify those stressors they react to, because not everyoneresponds the same way to the same stressors. To aid this process,organizations might conduct health-risk appraisals that test for theiremployees’ levels of stress.2. Develop individualized stress management programs that meet theneeds of the organization’s employees. Programs should be topic-specific and implemented in stages. If all aspects of a program areimplemented at one time and parts of the program fail, employeeswill lose faith in the program and in management. This will beanother cause of anxiety and stress for the employee. Stressmanagement programs may include learning relaxation andmeditation techniques, developing a good support system,undertaking outside hobbies, learning to set realistic goals, developingtime management skills, and learning when to say “no” rather thantaking on more than they can handle.3. Communicate with employees. Providing more information abouttheir jobs and other factors that affect them will help employees feelmore in control of their circumstances and can help build cohesion.Organizations must also communicate and describe the stressmanagement strategies available to employees and help them developpersonalized action plans.Reactive Coping (tertiary prevention)1. Make sure employees learn to recognize symptoms of distress. Forexample, symptoms may include gastrointestinal problems, rapidpulse, frequent illness, insomnia, persistent fatigue, irritability, lackof concentration, and increased use of alcohol and/or drugs. Commonmethods used to help identify stressors and symptoms include self-

report measures (e.g., interviews and surveys), behavioral measures(e.g., observation and performance measures), and physiologicalstress measures (e.g., heart rate and blood pressure).2. Exercise and maintaining a nutritious diet are two of the mostagreed-upon stress management techniques. Organizations can helpemployees by providing information and access to physical recreationfacilities or equipment by either establishing on-site facilities orproviding memberships to local health clubs. One type oforganizational stress management program available is to provideemployees with access to an employee assistance program, acorporate psychologist, a toll-free hotline, or some other form ofcounseling assistance. These programs can deal with a variety ofproblems that range from learning to cope to dealing with substanceabuse.3. Assist employees to keep a positive perspective on life and feel a senseof purpose. It is important for employees to feel they are making avaluable contribution to the organization.SUMMARYStress has become a widely used but misunderstood term. As a result, anumber of misconceptions about stress exist. The first misconception is thatall stress is negative. A certain degree of stress is necessary for good mentaland physical health; it can be viewed as positive or constructive stress,which compels us to act with optimum performance, whereby we achieveour goals. The second misconception is that nothing can be done to eliminateor diminish workplace distress. Organizations and individuals can usepreventive or proactive coping strategies (primary prevention) to changenegative events into positive experiences and growth opportunities.In the past, the phrase “healthy organization” almost always denoted afirm’s financial health. But recent studies of “healthy organizations” suggestthat policies benefiting workers’ health also benefit the organization’sbottom line. Today, the healthy organization means not only financialsoundness but also the physical and mental well-being of those who makeup the organization—its employees. Healthy employees create strongerbusinesses and healthier profits (Berry, Mirabito, & Berwick, 2004).DISCUSSION QUESTIONS

1. Define what stress means and the difference between eustress anddistress.2. Discuss the various components of the process model of stress andcoping.3. Discuss the negative effects of distress from both an organizationaland individual perspective.4. Describe the various forms of stress.5. Describe the three stages of the General Adaptation Syndrome andpositive and negative effects that occur within each stage.6. Discuss why personalities, ethnicity, and gender may affect anindividual’s level of stress.7. Discuss the symptoms of burnout using Golembiewski’s phase model.8. Discuss the four categories of causes of stress in the workplace.9. Discuss and provide examples of the various coping strategiesavailable to organizations and individuals.10. Discuss the concept of learned optimism and how it relates to copingwith stress by individuals.11. Discuss the concept of hardiness training and how it relates to copingwith stress by individuals.12. Discuss what is meant by the term “stress management” andavailable interventions for organizations and individuals.Case Study 12–3 Why Are All the Employees Leaving?The administrator of a large physician group practice is becoming alarmed about the growing levelof turnover the organization has recently been experiencing. It has already passed the industryaverage, and she is concerned about the practice’s capacity to staff the medical clinics for theupcoming flu season. In conducting exit interviews, she learned that the employees who are leavinggenerally like their work and they feel their salaries are fair; however, they are unhappy with theway their managers are treating them, and it is creating stress in their lives. They are leaving totake less stressful positions in other health care organizations.Discussion Questions1. How should the managers behave differently so the employees experience less stress on thejob?2. What strategies can the organization use so the employees experience less stress on the job?3. What could the individual employees do to help manage their own stress levels moreeffectively?Case Study 12–4 Scott’s DilemmaScott is a licensed physical therapist who works for a national rehabilitation company. The

rehabilitation facility in which Scott works is located in an urban Southwest city. He has worked atthis facility for four years, and up until recently was satisfied with his working environment and theinteractions he shared with his coworkers. In addition, Scott received personal fulfillment fromhelping his patients recover from their disabilities and seeing them return to productive lives.Last year the health system went through reorganization, with some new people being brought inand others reassigned. Scott’s new boss, George, was transferred from one of the system’s Midwestfacilities. Almost immediately upon taking his new position, George began finding fault with Scott’scare plans, patient interactions, and so on. Scott began feeling as if he couldn’t do anything right. Hewas experiencing feelings of anxiety, stress, and self-blame. Although his previous performanceevaluations had been above average, Scott was shocked by his first performance review underGeorge’s authority—George gave him an extremely low rating.Scott began trying to work harder, thinking that by working harder he could exceed George’sexpectations. Despite Scott’s working long hours and addressing George’s critiques, Georgecontinued to find fault with Scott’s work. Staff meetings began to be a great source of discomfort andstress because George would belittle Scott and single him out in front of his colleagues.Scott began to feel alienated from his family, friends, and colleagues at work. His eating andsleeping habits were adversely affected as well. Scott’s activities held no joy for him anymore, andthe career that he once loved and been respected in became a source of pain and stress. He began tocall in sick more often and started visualizing himself confronting and even hurting George, whichcreated even more guilt and anxiety for Scott.As time went on, George encouraged Scott’s coworkers to leave Scott alone to do his work. Theperception of the coworkers became more sympathetic to George’s point of view. Scott’s coworkersmused that perhaps Scott really was a poor worker and that George knew better because of hisposition as the supervisor of the rehabilitation department. Eventually, Scott’s coworkers began todistance themselves from him, in order to protect their own interests. They began to see Scott as anoutsider, with whom it was unsafe to associate.In an effort to resolve the situation, Scott spoke to George directly, stating his feelings andexpressing an interest in how they might improve the situation. Rather than making the situationbetter, what George perceived as Scott’s insubordination served to enrage George, and the personalattacks against Scott intensified. Feeling frustrated and helpless, Scott then decided to take hisproblem to the Human Resources Department (HRD). A human resources manager listened toScott’s complaints and suggested that Scott return with documentation evidence of what Scottperceived to be George’s mistreatment. In an effort to help ease the situation, the HRD managerdiscussed the issue with George, which only stirred the flames of George’s anger and his negativebehavior toward Scott.As a last resort, Scott decided to go to George’s boss, Rebecca. Rebecca met with George to get hisside of the story. George portrayed Scott as an unproductive employee with no respect for authority.The result was a strong letter of reprimand in Scott’s file for insubordination.Discuss the symptoms of stress that Scott is experiencing. What recommendations can you maketo Scott for coping with his stress?Reproduced from: “Case Discussion: Workplace Bully,” by J. Pinto, M. Vecchione, and L. Howard,October 2004. Presented at the 12th Annual International Conference of the Association onEmployment Practices and Principles, Ft. Lauderdale, FL.REFERENCESAmerican Institute of Stress. (2004). Job stress. Available at:www.stress.org

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39.OTHER SUGGESTED READINGGolembiewski, R. T., Hilles, R., & Daly, R. (1987). Some effects of multipleOD interventions on burnout and work site features. Journal of AppliedBehavioral Science, 23(3), 295–313.Hackman, J. R., & Oldham, G. R. (1980). Work design. Reading, MA:Addison-Wesley.Jick, T. D., & Mitz, L. F. (1985). Sex differences in work stress. Academy ofManagement Review, 10(3), 408–420.Keenan, A., & McBain, G. D. (1979). Effects of Type A behaviour,intolerance of ambiguity, and locus of control on the relationship betweenrole stress and work-related outcomes. Journal of OccupationalPsychology, 52, 277–285.Keita, G. P., & Jones, J. M. (1990). Reducing adverse reaction to stress inthe workplace. American Psychologist, 45(10), 1142–1145.Kowalski, R., Harmon, J., Yorks, L., & Kowalski, D. (2003). Reducingworkplace stress and aggression: An action research project at the U.S.Department of Veterans Affairs. Human Resource Planning, 26(2), 39–53.Kushnir, T., & Melamed, S. (1991, March). Work-load, perceived controland psychological distress in Type A/B industrial workers. Journal ofOrganizational Behavior, 12(2), 155–168.National Institute for Occupational Safety and Health. (2002, April). Thechanging organization of work and the safety and health of workingpeople. Available at: www.cdc.gov/niosh. Last accessed February 15, 2004.Noblet, A. (2003). Building health promoting work settings: Identifying therelationship between work characteristics and occupational stress inAustralia. Health Promotion International, 18(4), 351–359.Rahe, R. H., Meyer, M., Smith, M., & Kjaer, G. (1964). Social stress andillness onset. Journal of Psychosomatic Research, 8, 35–44.Savery, L. K., & Hall, K. (1986). Managers and decision making—”People”and “things”. Journal of Managerial Psychology, 1(2), 19–24.Sparks, K., Faragher, B., & Cooper, C. L. (2001, November). Well-being andoccupational health in the 21st century workplace. Journal ofOccupational and Organizational Psychology, 74(Pt. 4), 489–509.*Inappropriate physician behavior may be defined as “any inappropriate behavior, confrontation

or conflict, including verbal abuse to physical and sexual harassment” (Rosenstein, 2002, p. 26).

CHAPTER 13Decison MakingLEARNING OUTCOMESAfter completing this chapter, the student should be able to understand: The difference between the rational and the bounded rationalityapproach to decision making. The limitations of using intuitive decision making and the heuristics orbiases approach. How framing heuristics affects escalation of commitment. The four basic styles of decision making. The Vroom-Yetton Decision-Making Method and the relating factors.OVERVIEWManagers face different types of problems (i.e., well-structured and poorlystructured) and use different types of decision-making models. Whenmanagers confront a well-structured problem, defined as one that isstraightforward, repetitive, familiar, and easily defined, they use a routineapproach by relying on an organization’s policies and procedures. Forexample, two employees request the same vacation period. Because themanager must ensure adequate coverage in the workplace, he or she followscompany policy by granting the vacation request to the employee with themost seniority. However, middle and senior managers usually deal withpoorly structured problems, those that are new and complex, whereinformation is limited and incomplete.In the context of behavioral decision making, there are various meansthat an individual can use to choose the optimal or most desired outcome.Individuals use the rational approach to decision making when there issufficient time for an orderly, thoughtful process. However, because of time,resource, information constraints, and the complexity of today’s health careorganizations, managers are limited or “bounded” as to their rationaldecision making. The bounded rationality perspective takes into

consideration that managers, because of the complexity of problems, limitedtime, personal bias, and other factors, will not be able to weigh all possiblealternatives to a problem and, therefore, must sometimes rely on intuitivedecision making or the heuristics and biases approach.Rational ApproachThe rational approach to decision making, also referred to as the economicrationality model, is a systematic analysis of the problem followed by thechoice and implementation of a solution in a logical, step-by-step sequence(Daft, 2004). The rational model is considered the “ideal” method of decisionmaking. Daft (2004, pp. 449–450) explains the rational model using aneight-step approach, as illustrated in Figure 13–1.1. Monitor the Decision Environment: In the first step, a managermonitors internal (within the organization) and external (outside theorganization) information that will indicate deviations from plannedor acceptable behavior. The manager talks with colleagues andreviews financial statements, performance evaluations, industryindices, competitors’ activities, and the like.2. Define the Decision Problem: The manager responds to deviations byidentifying essential details of the problems: where, when, who wasinvolved, who was affected, and how current activities are influenced.3. Specify Decision Objectives: The manager determines whatperformance outcomes should be achieved by a decision.4. Diagnose the Problem: In this step, the manager digs below thesurface to analyze the cause of the problem. Additional data might begenerated to facilitate this diagnosis. Understanding the causeenables appropriate treatment.5. Develop Alternative Solutions: Before a manager can move aheadwith a decisive action plan, he or she must have a clearunderstanding of the various options available to achieve desiredobjectives. The manager may seek ideas and suggestions from otherpeople.6. Evaluate Alternatives: This step may involve the use of statisticaltechniques or personal experience to gauge the probability of success.The merits of each alternative are assessed, as is the probability thatthe alternative will reach the desired objectives.7. Choose the Best Alternative: This step is the core of the decisionprocess. The manager uses his or her analysis of the problem,

objectives, and alternatives to select a single alternative that has thebest chance for success.8. Implement the Chosen Alternative: Finally, the manager usesmanagerial, administrative, and persuasive abilities and givesdirections to ensure that the decision is carried out. The monitoringactivity (step 1) begins again as soon as the solution is implemented.However, under most circumstances, managers do not possess completeinformation about a problem and/or all the plausible alternatives. Inaddition, managers are constrained by limited time and resources, personalbias, and other factors, which make rational decision making unrealistic.Therefore, managers are bounded or limited regarding their rationaldecision making. The concept of bounded rationality embraces the realismthat evaluation of alternatives and decision making are constrained byhuman actions (Forest & Mehier, 2001).

Figure 13–1 Steps in the Rational Approach to Decision MakingSource: Organization Theory and Design (8th ed., p. 449), by R. L. Daft, 2004, Mason, OH: South-Western. Used withpermission.Bounded Rationality ModelThe bounded rationality model of decision making, proposed by Simon

(1957), recognizes that individuals have cognitive limitations, which prohibitthe processing of all the necessary or optimal information necessary fordecision making; as such, an individual will limit his or her search forinformation prior to decision making. Dequech (2001, p. 913) explains theconcept of bounded rationality in the following manner:1. Individuals often pursue multiple objectives, which may beconflicting. The alternatives from which to choose in order to pursuethese objectives are not previously given to the decision maker, whothus needs to adopt a process for generating alternatives.2. The limits in the decision maker’s mental capacity compared with thecomplexity of the decision environment usually prevent him or herfrom considering all the alternatives. Those limits are also presentwhen the decision maker has to consider the consequences of thealternatives, so that the decision maker employs some heuristicprocedure for that purpose.3. Finally, the decision maker adopts a “satisfying” rather than anoptimizing strategy, searching for solutions that are “good enough” orsatisfactory, given some aspiration levels.The expression “bounded rationality” is used to denote the type ofrationality that managers resort to when the environment in which theyoperate is too complex relative to their cognitive limitations. Because ofthese limitations, managers may employ the use of intuitive and/or heuristicstrategies for decision making.IntuitionIntuitive decision making can be understood as a cognitive “short-circuiting,” where a decision is reached even though the reason for thedecision cannot be easily described (Hall, 2002). In other words, intuitivedecision making involves using one’s professional judgment based on pastexperiences rather than sequential logic or explicit reasoning (Daft, 2004).Agor (1985, 1986a, 1986b) suggests that intuition is most useful tomanagers in situations of uncertainty. Agor advocates reliance on intuitionwhen a high level of uncertainty exists, when there is little precedent, whenvariables are not scientifically predictable and analytical data are of littleuse, when facts are limited and don’t clearly point the way to go, whenseveral alternatives seem plausible, and when time is limited and there ispressure to come up with the right answer.There is some debate as to the degree to which an individual’s intuitive

ability can be developed and improved (Bennett, 1998). Some argue intuitiveabilities are closely related to personality types (Myers, 1980). Others claimthat job characteristics or situational factors encourage managers to developand improve their intuitive abilities (Agor, 1986a, 1986b; Behling & Eckel,1991; Wally & Baum, 1994). In top-level decision-making environments, thisability is certainly an asset and has been shown to be a benefit to seniormanagers (Agor, 1986a, 1986b; Eisenhardt & Bourgeois, 1988; Hayashi,2001; Simon, 1987). For example, Agor (1985, 1986a, 1986b) conducted aseries of studies and found that senior managers always score higher thanmiddle- and lower-level managers in their abilities to use intuition to makedecisions on the job. In Maidique’s (2011) study of CEO decision making, hefound that intuition was a major or determining factor in 85 percent of the36 key decisions that were studied. Therefore, it is not surprising thatPeters and Waterman (1984) relate that the 10 best-run companies inAmerica encouraged the use of intuitive skills. In addition, business schoolsare designing courses to help develop MBA students’ intuitive skills fordecision making (Agor, 1985, 1986b).Heuristics or Biases ApproachIn addition to using intuition to deal with the problems of uncertainty andcomplexity, managers use judgmental heuristics strategies to simplify theirdecision making. Heuristics are guidelines or “rules of thumb” that helpmake our world manageable by simplifying complex tasks (Kahneman,Slovic, & Tversky, 1982; Tversky & Kahneman, 1974). Heuristic processingstrategies enable managers to cut through overwhelming data by applyingsimplifying assumptions to the information. Although the use of heuristicsmay result in accurate predictions by managers, it also can give rise to anarray of errors and biases. Tversky and Kahneman (1974) describe threecommonly used heuristics: (1) availability, (2) representativeness, and (3)anchoring and adjustment.Availability bias is an intuitive technique where the perceived probabilityof an event is influenced by the ease of recollection. More easily recalledevents are given a higher probability. More frequent events are often themost easily recalled, but the most easily recalled are not necessarily themost frequent (Hall, 2002). Ease of recall is also affected by salience (i.e.,the degree to which some information is perceived as being more relevant tothe decision being made) related to the emotional strength of a memory,with memories associated with strong emotions being recalled more easily.For example, performance appraisals of staff are affected by the use of

availability heuristics by managers while evaluating them. It is common tofind the most recent and vividly etched event—positive or negative—influencing the appraisal. (See Case Study 13–1: A Case of Abuse orNeglect?)Representativeness bias is an intuitive technique where probabilities areevaluated by the degree to which the given sample matches, or isrepresentative of, a class of samples or populations. In the workplace,representativeness heuristics can be traced as the reason behind many casesof employee discrimination. (See Case Study 13–1: A Case of Abuse orNeglect?)Anchoring and adjustment bias is an intuitive technique used when aseries of estimates is used to obtain a “proposed” answer to a currentproblem. People create the preliminary solution on the basis of initialinformation (anchoring), and thereafter modify the answer when moreinformation becomes available (adjustment). For example, when the salaryof a new employee is being set, the anchoring and adjustment heuristic isused. The employee’s starting salary is invariably set close to the last paidsalary, without regard to what the new job description may entail. In otherwords, the initial value significantly influences the process of theadjustment toward the new value, irrespective of the rationality in thechoice of the initial value. (See Case Study 13–2: A Case of Abuse orDependency?)Case Study 13–1 A Case of Abuse or Neglect?A significant portion of Dr. Smith’s private practice comprised clients who had been referred tohim from a psychiatric hospital. These included a former inpatient at the hospital, Ms. SarahJacobson. During the initial 20 minutes of the intake session, Sarah reported that she was 15 yearsold and was in her sophomore year in high school. Sarah told Dr. Smith that her parents weredivorced and that her mother had custody of her and her two younger sisters. The client reportedthat her mother repeatedly said that she was tired of taking care of her and her sisters and that shethought that her mother wanted the children out of the home. Sarah went on to say that she hadbeen placed in the hospital because of her aggressive and defiant behavior toward her mother. Inaddition, Sarah stated that she thought that her mother had become involved with another manprior to the divorce and that her mother liked him more than she liked her children. Sarahexpressed considerable anger toward her mother and the belief that her mother was trying to “getrid of her.”Dr. Smith’s case notes indicated that Sarah seemed agitated and felt persecuted by her mother. Ashe was conceptualizing the case, he recognized the similarity between this case and previousreferrals from the hospital and recalled that the diagnosis in those cases had been paranoidschizophrenia. The case notes indicated that Sarah seemed to be functioning at an adequate level tobe treated as an outpatient and that Dr. Smith regarded her as suffering from paranoidschizophrenia.Sarah attended only one other session, as she failed to keep subsequent appointments.

Approximately three weeks after his last meeting with Sarah, Dr. Smith received information fromthe Division of Family Services that Sarah’s mother had been charged with neglect and abandonmentof Sarah and her two younger siblings. Two weeks after Sarah had been released from the hospital,her mother had failed to pick up the younger children from day care and had left the city with hermale friend.DiscussionDr. Smith used the availability heuristic when formulating his diagnosis. Symptoms ofpsychopathology were very salient and accessible to Dr. Smith, because many of his cases werereferrals from the psychiatric hospital. Dr. Smith also used the representativeness heuristic bycomparing Sarah to former clients. Had Dr. Smith referred to DSM-III-R (American PsychiatricAssociation, 1987) criteria when forming his diagnosis in addition to relying on his previousexperience, he would have realized that Sarah’s symptoms did not meet the criteria forschizophrenia.SOURCE: “Bias in the Counseling Process: How to Recognize and Avoid It,” by K. A. Morrow andC. T. Deidan, 1992, Journal of Counseling and Development, 70(5), pp. 571–577. Reprinted withpermission.Case Study 13–2 A Case of Abuse or Dependency?Mr. Larson was a counselor employed by a community health clinic that offered both medical andpsychological care. Mr. Larson made a practice of reviewing all records on file at the center beforeseeing each new client. Prior to the initial session with Ms. Irma Busse, Mr. Larson reviewed herfile, which indicated no health problems and no previous visits for psychiatric reasons. The onlyremarkable entries were a broken arm sustained six months earlier and an indication that theattending physician suspected abuse. The physician’s notes indicated that Irma’s husband alwaysaccompanied her during examinations and that she deferred to him to answer the physician’squestions.During the initial session, Mr. Larson noticed that Irma had her collar buttoned to her neck, wasslightly stooped when she walked, and did not make immediate eye contact when she spoke. She hada quiet voice and indicated that she had come to counseling because she was having maritalproblems. During this interview, Irma discussed how important her marriage was to her and howdifficult it was for her to do things on her own, and indicated that all she wanted was to make herhusband happy. After the session, Mr. Larson reviewed the interview and concluded that the clientwas a victim of spouse abuse and was unable at this time to recognize the need to leave her husband.He decided that the course of counseling would be to help Irma become aware of the dangerousnature of the situation, provide information about the shelter for battered women, and attempt toconvince Irma that she needed to leave her husband for her own safety.As counseling progressed, Irma made other statements such as “I’m afraid to go anywhere withoutmy husband” and “I just don’t know if I could get along without him.” These seemed to support bothhis and the physician’s earlier conclusions that Irma was a battered wife. After speaking to severalfamily members, it became apparent that Irma had not been abused. Rather, it seems as though shewas a very dependent person and that her needs were directed primarily toward her husband,although others had experienced her dependency as well.DiscussionMr. Larson’s perceptions seem to have been skewed by the physician’s notes (anchor), whichsuggested that Irma may have been abused. Because of the dangerous nature of abusive situations,Mr. Larson focused on assisting the client to prepare to move out of her home and into a shelter. He

failed, however, to recognize that this client, through her verbal and nonverbal behavior, wasreflecting strong dependency. Mr. Larson maintained his initial impression of Irma (i.e., the“battered wife” label) until much later in the counseling process when he obtained substantialcontradictory information from family members (adjustment).SOURCE: “Bias in the Counseling Process: How to Recognize and Avoid It,” by K. A. Morrow andC. T. Deidan, 1992, Journal of Counseling and Development, 70(5), pp. 571–577. Reprinted withpermission.As illustrated by these two case studies, there are many similaritiesbetween clinical decision making and managerial decision making.Extensive literature exists regarding the use of intuition and heuristics inmedical decision making because of the high degree of uncertainty withinthe practice of medicine. As Sox et al. (1988, p. 17) point out, “medicine isthe art of making decisions without adequate information.” As such,decisions made by clinicians through the use of intuition or heuristics canhave a tremendous impact on health care managers. Clinicians make thedecisions as to the commitment of scarce resources to patients and theassociated care and treatment plans (Hall, 2002; C. Thompson, 2003).However, it is the responsibility of health care managers to provide theresources for clinicians to perform their work, and their health systems are“judged” on the clinical outcomes of the patient populations they serve. Assuch, health care managers need to appreciate not only how intuition andheuristics play a part in their own decision making but also how they affectthe decision making of clinicians because both impact the achievement oforganizational goals. (See Case Study 13–3: Cognitive Errors in ClinicalDecision Making.)Case Study 13–3 Cognitive Errors in Clinical Decision MakingHeuristic processing strategies enable individuals to cut through overwhelming data by applyingsimplifying assumptions to information. Heuristics are guidelines or “rules of thumb” that help makeour world manageable by simplifying complex tasks (Kahneman, Slovic, & Tversky, 1982; Tversky &Kahneman, 1974). As health care managers use heuristics strategies to simplify their decisionmaking, so do clinicians. Although the use of heuristics may result in accurate predictions byindividuals, it also can give rise to an array of errors and biases. Tversky and Kahneman (1974)describe three commonly used heuristics: (1) availability, (2) representativeness, and (3) anchoring.Consider the following clinical examples illustrating commonly used heuristics:Availability error occurs when clinicians misestimate the prior probability of disease because ofrecent experience. Experience often leads to overestimation of probability when there is memory ofa case that was dramatic or that involved a patient who fared poorly or a lawsuit. For example, aclinician who recently missed the diagnosis of pulmonary embolism in a healthy young woman whohad vague chest discomfort but no other findings or apparent risk factors might then overestimatethe risk in similar patients and become more likely to do chest CT angiography for similar patients

despite the very small probability of disease. Experience can also lead to underestimation. Forexample, a junior resident who has seen only a few patients with chest pain, all of whom turned outto have benign causes, may begin to do cursory evaluations of that complaint even amongpopulations in which disease prevalence is high.Representation error occurs when clinicians judge the probability of disease based on how closelythe patient’s findings fit classic manifestations of a disease without taking into account diseaseprevalence. For example, although several hours of vague chest discomfort in a thin, athletic,healthy-appearing 60-year-old man who has no known medical problems and who now looks andfeels well does not match the typical profile of a myocardial infarction (MI), it would be unwise todismiss that possibility because MI is common among men of that age and has highly variablemanifestations. Conversely, a healthy 20-year-old man with sudden onset of severe, sharp chest painand back pain may be suspected of having a dissecting thoracic aortic aneurysm because thoseclinical features are common in aortic dissection. The cognitive error is not taking into account thefact that aortic dissections are exceptionally rare in a 20-year-old, otherwise healthy patient; thatdisorder can be dismissed out of hand and other, more likely causes (e.g., pneumothorax, pleuritis)should be considered. Representation error is also involved when clinicians fail to recognize thatpositive test results in a population where the tested disease is rare are more likely to be falsepositive than true positive.Anchoring errors occur when clinicians steadfastly cling to an initial impression even asconflicting and contradictory data accumulate. For example, a working diagnosis of acutepancreatitis is quite reasonable in a 60-year-old man who has epigastric pain and nausea, who issitting forward clutching his abdomen, and who has a history of several bouts of alcoholicpancreatitis that he states have felt similar to what he is currently feeling. However, if the patientstates that he has had no alcohol in many years and has normal blood levels of pancreatic enzymes,clinicians who simply dismiss or excuse (e.g., the patient is lying, his pancreas is burned out, thelaboratory made a mistake) these conflicting data are committing an anchoring error. Cliniciansshould regard conflicting data as evidence of the need to continue to seek the true diagnosis (acuteMI) rather than as anomalies to be disregarded. There may be no supporting evidence (i.e., for themisdiagnosis) in some cases in which anchoring errors are committed.Reprinted from the Merck Manual of Diagnosis and Therapy, edited by Robert Porter. Copyright2013 by Merck Sharp & Dohme Corp., a subsidiary of Merck & Co, Inc, Whitehouse Station, NJ.Available at http://www,merckmanuals.com/professional.Escalation of Commitment and Framing HeuristicIn addition to Tversky and Kahneman’s (1974) three commonly usedheuristics, there is another area that may cause low-quality decisionmaking—escalation of commitment. Staw (1981) defines the problem ofescalation of commitment as when a manager continues to allocate moreresources to a losing proposition. One reason escalation of commitment mayoccur is because a manager does not want to admit that he or she has madea mistake (Staw & Ross, 1987). Research finds that if a manager feelspersonally responsible for an initial decision that is failing, he or she is morelikely to allocate additional resources than another person who was notresponsible for the initial decision (Staw, 1981). The expression “throwinggood money after bad” describes escalation of commitment, in a decision.

For example, one of the main reasons for the bankruptcy of the AlleghenyHealth System in Pennsylvania was the unwillingness of the top leaders ofthe organization to make midcourse corrections in their grand plans on thebasis of what was and was not working in hospitals and office practices inPhiladelphia and Pittsburgh (Bottles, 2001). Examples from the publicsector (Staw & Ross, 1987) include the city of Vancouver’s commitment toExpo ‘86, Chicago’s Deep Tunnel project, and the Washington Public SupplySystem.In the case of the World Exposition on Transportation andCommunication, or Expo ‘86, the fair was supposed to operate close tofinancial breakeven. But as the plans moved forward, the expected lossesburgeoned. The planners continued because politically it was too late to stopdue to various stakeholders. British Columbia had to create a lottery to copewith the $300 million deficit. The good news is that the fair did open asscheduled.Another reason escalation of commitment may occur is due to framingheuristic. Framing heuristic is a tendency to make a decision based on theform or manner in which information is presented. For example, Levin,Schnittjer, and Thee (1988) conducted a study where one group was given adescription of an experimental cancer treatment that was shown to have a40 percent success rate; the other group was told that the procedure had a60 percent failure rate. Although both statements are true, the way theresearchers worded the statements affected a person’s opinion of itseffectiveness and whether or not he or she would recommend the treatmentto a family member. The participants were more optimistic about thetreatment when its success rate was emphasized and less optimistic whenthe failure rate was emphasized.Staw and Ross (1987) suggest that to avoid escalation of commitment,managers can: (1) recognize that they may be biased toward escalation, (2)see escalation for what it is (i.e., an overcommitment to a strategy bydefining failure ambiguously, or by ignoring others’ concerns), and (3) avoidovercommitment by looking at the strategy from an outsider’s perspective.Decision-Style ModelManagers have different styles when it comes to making decisions andsolving problems. Rowe and Boulgarides (1983, 1998) developed a decision-style model that proposes that managers differ along two dimensions in theway they approach decision making: value orientation and tolerance forambiguity. Value orientation reflects the extent to which an individual

focuses on either task and technical concerns or people and social concernswhen making decisions. Tolerance for ambiguity reflects the extent to whicha person has a high need for structure or control in his or her life.As illustrated in Figure 13–2, the decision-style model encompasses fourbasic styles: directive, analytic, conceptual, and behavioral. Boulgarides andCohen (2001, pp. 59–60) describe the four basic styles as follows:Figure 13–2 Decision-Making Styles1. Directive: Low tolerance for ambiguity and low cognitive complexity.The focus is on technical decisions, and this style is generallyautocratic. The decision maker may adopt this style because of a highneed for power. Because of the use of little information and fewalternatives, speed and satisfactory solutions are typical. The decisionmakers tend to be focused and are frequently aggressive. Generallythey prefer structure and specific information, which is givenverbally. Their orientation is internal to the organization and shortrange. They tend to operate with tight controls. Although they areefficient, these decision makers have a high need for security andstatus. They have the drive required to achieve results, but they alsowant to dominate others.2. Analytic: This decision maker has a much greater tolerance forambiguity than the directive-style manager and also has a morecognitively complex personality that leads to the desire for moreinformation and the consideration of many alternatives. Because of

the focus on technical decisions and the need for control, the analyticstyle contains an autocratic bent. The analytic style is typified by theability to cope with new situations (but in a structured manner) andproblem solving. Position and ego are important to individuals whouse an analytic decision-making style. As such, these individuals oftenreach top positions within an organization or start their owncompanies. They are not particularly quick in their decision making,and they enjoy variety and prefer written reports. They also enjoychallenges and examine every detail in a situation.3. Conceptual: Including both high cognitive complexity and peopleorientation, this decision-making style tends to use data frommultiple sources and considers many alternatives. Similar toindividuals using the behavioral decision-making style, conceptual-style decision makers share goals with subordinates in trusting andopen relationships. These individuals tend to be idealists who mayemphasize ethics and values in their behavior. They generally arecreative and can readily understand complex relationships. Theirfocus is long range with high organizational commitment. They areachievement-oriented and value praise, recognition, andindependence. They prefer loose control over power and willfrequently encourage the participation of those they lead. They maybe characterized as thinkers rather than doers.4. Behavioral: Although low on the cognitive complexity scale, thisleader has a deep concern for the organization and the development ofpeople. Behavioral-style managers tend to be supportive and areconcerned with subordinates’ well-being. They provide counseling, arereceptive to suggestions, communicate easily, show warmth, areempathetic, are persuasive, and are willing to compromise and accepta looser style of control. With low data input, this style tends towarda short-range focus and uses meetings primarily for communicating.These managers avoid conflict, seek acceptance, and tend to be morepeople-oriented, but sometimes are insecure.Of the four decision-making styles, individuals have a tendency to resortto a single, dominant style (i.e., default mode of decision making). However,with training, managers can use all four styles effectively as differentsituations are presented.VROOM-YETTON DECISION-MAKING MODEL

A good decision-making method under one set of circumstances may notbe considered so under other conditions. A classic contingency model fordecision making was first described by Vroom and Yetton (1973). Fifteenyears later, Vroom and Jago (1988) replaced the decision tree system of theoriginal model (see Figure 13–3) with an expert system based onmathematics. As such, you will see the model referred to as Vroom-Yetton,Vroom-Jago, and Vroom-Yetton-Jago. The contingency model for decisionmaking suggests that individuals should consider choosing from five types ofdecision processes based upon a number of factors. Two are autocratic (AIand AII), two are consultative (CI and CII), and one is group-based (GII). Assuch, this decision-making model can be used to choose between individualand group decision-making strategies.Figure 13–3 Vroom-Yetton Decision-Making MethodModified from Vroom, V. H. and Yetton, P. W. (1973). Leadership and decision-making. Pittsburgh: University of PittsburghPress.The five decision processes are:

1. Autocratic I (AI): Completely autocratic. You solve the problem ormake the decision yourself using the information available to you atthe present time.2. Autocratic II (AII): Request specific information. You obtain anynecessary information from team members/subordinates, and thendecide on the solution to the problem yourself. You may or may nottell subordinates the purpose of your questions or give informationabout the problem or decision you are working on. The input providedby them is clearly in response to your request for special information.They do not play a role in the definition of the problem nor ingenerating or evaluating alternative solutions.3. Consultative I (CI): One-on-one discussion. You share the problemwith the relevant team members/subordinates individually, gettingtheir ideas and suggestions without bringing them together as agroup. Then you make the decision. This decision may or may notreflect your subordinates’ influence.4. Consultative II (CII): Group discussion. You share the problem withyour team members in a group meeting. In this meeting you obtaintheir ideas and suggestions. Then, you make a decision that may ormay not reflect your subordinates’ influence.5. Group (GII): Consensual group decision making. You share theproblem with your team members/subordinates as a group. Togetheryou generate and evaluate alternatives and attempt to reachagreement (i.e., consensus) on a solution. Your role is much like thatof facilitator, coordinating the discussion, keeping it focused on theproblem, and making sure that the critical issues are discussed. Youcan provide the group with information or ideas that you have, yetyou do not try to “press” them to adopt your solution and are willingto accept and implement any solution that has the support of theentire group.Many people find this contingency model for decision making helpfulwhen the following seven yes/no questions are answered in relation to thetree diagram, as shown in Figure 13–3. The seven questions must beanswered in order from 1 to 7 and followed across the tree diagram from leftto right:1. Is there a quality requirement? Is the nature of the solution critical?Are there technical or rational grounds for selecting among possiblesolutions?

2. Do I have sufficient information to make a high-quality decision?3. Is the problem structured? Are the alternative courses of action andmethods for their evaluation known?4. Is acceptance of the decision by subordinates critical to itsimplementation?5. If I were to make the decision by myself, is it reasonably certain thatit would be accepted by my subordinates?6. Do subordinates share the organizational goals to be obtained insolving this problem?7. Is conflict among subordinates likely in obtaining the preferredsolution?For example, in the case where the quality requirement is low (e.g., thenature of the solution is not critical), you would choose the upper branch atpoint 1. If you then consider, in reference to question 4, that acceptance ofthis decision by subordinates is also not critical, the method suggests thatyou should make the decision on your own (i.e., choose method AI).Alternatively, at point 4, if acceptance is critical, you would considerquestion 5 regarding certainty of acceptance if you made the decision onyour own. If people are likely to accept your decision, the method suggestsonce again making the decision on your own (i.e., AI). If, however,acceptance of your decision is not reasonably certain, the method suggests aconsensual group method (i.e., GII) to help overcome this.Situational factors that may influence the model are:• When decision quality is important and followers possess usefulinformation, then AI and AII are not the best methods.• When the leader sees decision quality as important but followers do not,then GII is inappropriate.• When decision quality is important, the problem is unstructured, andthe leader lacks information/skill to make the decision alone, then GII isbest.• When decision acceptance is important and followers are unlikely toaccept an autocratic decision, then AI and AII are inappropriate.• When decision acceptance is important but followers are likely todisagree with one another, then AI, AII, and CI are not appropriate,because they do not give opportunity for differences to be resolved.• When decision quality is not important but decision acceptance iscritical, then GII is the best method.• When decision quality is important, all agree with this, and the decision

is not likely to result from an autocratic decision, then GII is best.Some researchers relate that the model works best when there are clearand accessible opinions about the decision quality importance and decisionacceptance factors. However, these are not always known with anysignificant confidence.SUMMARYIn this chapter, we have discussed the various methods used by managersin their decision making processes. The rational approach is used whenthere is sufficient time for an orderly, thoughtful process. However, due tolimited resources, such as time and information, managers may be limitedin their rational decision making and will rely on intuitive or the heuristicsand biases approach.DISCUSSION QUESTIONS1. Explain the difference between the rational and bounded rationalityapproaches to decision making.2. Explain the limitations of using intuitive and the heuristics or biasesapproach to decision making.3. Describe how framing heuristics affects a manager’s escalation ofcommitment.4. Discuss the four basic styles of decision making.5. Explain the various situational factors that may influence the Vroom-Yetton decision making model.EXERCISE 13–1There are times when you have made good decisions. At the time of thedecision making you knew it was a good decision, when you look back on ityou recognize that, yes, that was a good decision, and even now you stillthink it was a good decision.There are also times when you have made poor decisions. At the time ofthe decision making you may have felt uneasy about it, and when you lookback on it you recognize that it was a poor decision.Analyze the factors that you think contributed to both your good and poor

decisions.EXERCISE 13–2You have 100 doses of a vaccine against a deadly strain of influenza thatis sweeping the country, with no prospect of obtaining more. Standing inline are 100 school children and 100 elderly people. The elderly are morelikely to die if they catch the flu than the school children are. But theelderly have fewer years left to live as compared with the school children,who have their whole lives ahead of them. Which group do you vaccinate?Describe each step in your decision-making process.REFERENCESAgor, W. H. (1985). Intuition as a brain skill in management. PublicPersonnel Management Journal, 14(1), 15–24.Agor, W. H. (1986a). How top executives use their intuition to makeimportant decisions. Business Horizons, 29(1), 49–53.Agor, W. H. (1986b). The logic of intuition: How top executives makeimportant decisions. Organizational Dynamics, 14(3), 5–18.Behling, O., & Eckel, N. (1991). Making sense out of intuition. Academy ofManagement Executive, 5(1), 46–54.Bennett, R. H. (1998). The importance of tacit knowledge in strategicdeliberations and decisions. Management Decision, 36(9), 589–600.Bottles, K. (2001). The good leader—Management skills. PhysicianExecutive, 27(2), 74–76.Boulgarides, J. D., & Cohen, W. A. (2001). Leadership style vs. leadershiptactics. Journal of Applied Management and Entrepreneurship, 6(1), 59–73.Cross, J. (1969). The economics of bargaining. New York, NY: Basic Books.Daft, R. L. (2004). Organization theory and design (8th ed.). Mason, OH:South-Western.Dequech, D. (2001). Bounded rationality, institutions, and uncertainty.Journal of Economic Issues, 35(4), 911–929.Eisenhardt, K., & Bourgeois, L. (1988). Politics of strategic decision makingin high velocity environments: Towards a mid-range theory. Academy ofManagement Journal, 31, 737–770.

Forest, J., & Mehier, C. (2001). John R. Commons and Herbert A. Simon onthe concept of rationality. Journal of Economics, 3(35), 591–605.Hall, K. H. (2002). Reviewing intuitive decision-making and uncertainty:The implications for medical education. Medical Education, 36, 216–224.Hayashi, A. M. (2001). When to trust your gut. Harvard Business Review,79(2), 59–65.Kahneman, D., Slovic, P., & Tversky, A. (Eds.). (1982). Judgment underuncertainty: Heuristics and biases. Cambridge, UK: Cambridge UniversityPress.Levin, I. P., Schnittjer, S. K., & Thee, S. L. (1988). Information framingeffects in social and personal decisions. Journal of Experimental SocialPsychology, 24, 520–529.Maidique, M. A. (2011). Decoding intuition for more effective decision-making. Harvard Business Review Blog Network. Available at:http://blogs.hbr.org/2011/08/decoding-intuition-for-more-ef/Morrow, K. A., & Deidan, C. T. (1992). Bias in the counseling process: Howto recognize and avoid it. Journal of Counseling & Development, 70(5),571–577.Myers, I. (1980). Introduction to type. Palo Alto, CA: ConsultingPsychologists, Inc.Peters, T. J., & Waterman, Jr., R. H. (1984). In search of excellence: Lessonsfrom America’s best-run companies. New York, NY: Warner Books.Rowe, A. J., & Boulgarides, J. D. (1983). Decision styles: A perspective.Leadership & Organization Development Journal, 4(4), 3–9.Rowe, A. J., & Boulgarides, J. D. (1998). Managerial decision making. NewYork, NY: Macmillan Publishing Company.Simon, H. A. (1957). Administrative behavior (2nd ed.). New York, NY:Macmillan Publishing Co.Simon, H. A. (1987). Making management decisions: The role of intuitionand emotion. Academy of Management Executive, 1, 57–64.Sox, H. C., Marshal, A. B., Higgins, M. C., & Marton, K. I. (1988). Medicaldecision-making. New York, NY: Butterworths.Staw, B. M., (1981). The escalation of commitment to a course of action.Academy of Management Review, 6(4), 577–587.Staw, B. M., & Ross, P. (1987). Knowing when to pull the plug. HarvardBusiness Review, 65(2), 68–74.Thompson, C. (2003). Clinical experience as evidence in evidence-basedpractice. Journal of Advanced Nursing, 43(3), 230–237.

Tversky, A., & Kahneman, D. (1974). Judgment under uncertainty:Heuristics and biases. Science, 185, 1124–1131.Vroom, V. H., & Jago, A. G. (1988). The new leadership: Managingparticipation in organisations. Englewood Cliffs, NJ: Prentice Hall.Vroom, V. H., & Yetton, P. W. (1973). Leadership and decision-making.Pittsburgh, PA: University of Pittsburgh Press.Wally, S., & Baum, R. (1994). Personal and structural determinants of thepace of strategic decision making. Academy of Management Journal, 37,932–956.OTHER SUGGESTED READINGAgor, W. H. (1984). Intuitive management: Integrating left and right brainmanagement skills. Upper Saddle River, NJ: Prentice Hall.Ashford, B. E. (2001). Role transitions in organizational life: An identity-based perspective. Mahwah, NJ: Lawrence Erlbaum Associates.Bates, B. (1975). Physician and nurse practitioners: Conflict and reward.Annals of Internal Medicine, 82, 702–706.Brett, J. F., Northcraft, G. B., & Pinkley, R. L. (1999). Stairways to heaven:An interlocking self-regulation model of negotiation. Academy ofManagement Review, 24(3), 435–451.Davis, M. H., Capobianco, S., & Kraus, L. (2004). Measuring conflict-relatedbehaviors: Reliability and validity evidence regarding the conflictdynamics profile. Educational and Psychological Measurement, 64(4),707–731.Elangovan, A. R. (2002). Managerial intervention in disputes: The role ofcognitive biases and heuristics. Leadership & Organization DevelopmentJournal, 23(7), 390–399.Friedman, R. A., Tidd, S. T., Currall, S. C., & Tsai, J. C. (2002). What goesaround comes around: The impact of personal conflict style on workconflict and stress. International Journal of Conflict Management, 11(1),32–55.Gigerenzer, G. (2007). Gut feelings: The intelligence of the unconscious.New York: Penguin Group.Kahneman, D. (1991). Judgment and decision making: A personal view.Psychological Science, 2(3), 142–154.Kilmann, R. H., & Thomas, K. W. (1977). Developing a forced-choicemeasure of conflict-handling behavior: The mode instrument. Education

and Psychological Development, 37, 309–325.Kolb, D. M., & Putman, L. L. (1992, May). The multiple faces of conflict inorganizations. Journal of Organizational Behavior, 13, 311–324.McWilliams, C. (2003). Healthcare decision making for dementia patients:Two problem cases. Internet Journal of Law, Healthcare and Ethics, 2(1),12–19.O’Connor, K. M., DeDreu, C. K., Schroth, H., Barry, B. Lituchy, T. R., &Bazerman, M. H. (2002). What we want to do versus what we think weshould do: An empirical investigation of intrapersonal conflict. Journal ofBehavioral Decision Making, 15, 403–418.Shelton, C. D., & Darling, J. R. (2004). From chaos to order: Exploring newfrontiers in conflict management. Organization Development Journal,22(3), 22–41.Thomas, K. W. (1992). Conflict and conflict management: Reflections andupdate. Journal of Organizational Behavior, 13, 265–274.

CHAPTER 14Conflict Management andNegotiation SkillsLEARNING OUTCOMESAfter completing this chapter, the student should understand: The definition of conflict. The four basic types of conflict. The five levels of conflict. The five conflict-handling modes. The three major negotiation models.OVERVIEWConflict is inevitable and unavoidable because it is a natural part ofhuman relationships. It is a part of our everyday professional and personallives, and therefore, it is inherent in any type of work setting (Thomas,1976). Although there are numerous definitions of conflict, Thomas (1992)suggests that there are three common components to most definitions: (1)perceived incompatibility of interests, (2) some interdependence of theparties, and (3) some form of interaction. For example, Rahim (1985)defined conflict as an “interactive state” manifested in disagreement ordifferences, or incompatibility, within or between individuals and groups.For our discussions, we will define conflict as occurring when an individualor group feels negatively affected by another individual or group.No organization is exempt from conflict; however, the health care settinghas been referred to as one of the highest conflictual environments becauseof factors such as high stress, high emotions, scarce resources, competition,downsizing, mergers, excessive regulations, diversity and cultural issues,and multiple stakeholders’ demands. These factors increase conflict inorganizations (Gardner, 1992; Johnson, 1994). For example, research hasshown that managers, both health care and non–health care, spend an

average of 30 percent of their time dealing with conflict, and this isfrequently cited as one of the least enjoyable aspects of their leadershiproles (McElhaney, 1996; Robbins, 1990; Shelton & Darling, 2004; Thomas &Schmidt, 1976).It is important to note that conflict does not necessarily lead toineffectiveness. Conflict, like stress, can be either positive or negative.Positive conflict can act as a stimulus for positive change. Positive orconstructive conflict can lead to creative problem solving and alternatives,increased motivation and commitment, high-quality work, and personalsatisfaction (i.e., functional outcomes) (Cosier & Dalton, 1990). However,negative or unconstructive conflict can be counterproductive for anorganization by diverting efforts from goal attainment (i.e., dysfunctionaloutcomes). Negative conflict may also affect the psychological well-being ofemployees. If they are severe, unconstructive conflicts may result inemployee resentment, tension, and anxiety, which may lead to low-qualitywork, personal stress, and possible sabotage. For example, it is estimatedthat over 65 percent of performance problems result from strainedrelationships and that conflict accounts for up to 50 percent of involuntaryemployee departures (Dana, 2000; Watson & Hoffman, 1996). Negativeconflict may create an organizational culture of competition versuscooperation, thereby eliminating the sustainability of supportive andtrusting relationships, which are necessary for successful organizations(Baron & Richardson, 1990). For example, Forte (1997) points out that inclinical environments, conflict among health care professionals can becounterproductive with respect to patients, which can result in increasedmortality and morbidity rates due to medical errors.Lewicki, Weiss, and Lewin (1992) identify six major areas in conflictresearch: the microlevel (psychological) approach, the macrolevel(sociological) approach, the economic-analysis approach, the labor-relationsapproach, the bargaining and negotiation approach, and the third-partydispute approach. The microlevel approach includes research on factors thataffect intrapersonal and interpersonal conflict (i.e., within and amongindividuals), whereas the macrolevel approach focuses on factors affectingconflict among and within groups, departments, and organizations (i.e.,intragroup, intergroup, and interorganization). Economic analysis refers toeconomic rationality and how it applies to individual decision making. Theresearch areas of labor relations, bargaining and negotiation, and third-party resolution relate to studies that deal with the effects of workplace andconflict resolutions and/or conflict management.

Using this framework, we first discuss the various types and levels ofconflict. Second, we examine the various methods to deal with conflicteffectively, referred to as conflict resolution or conflict management. Thisdiscussion includes individual decision making and the negotiation skillsnecessary for effective conflict management.TYPES OF CONFLICTThere are four basic types of conflict: goal, cognitive, affective, andprocedural (Kolb & Bartunek, 1992). Goal conflict occurs when two or moredesired or expected outcomes are incompatible. It may involveinconsistencies between individual or group values and norms (e.g.,standards of behavior). Cognitive conflict occurs when the ideas andthoughts within an individual or between individuals are incompatible.Affective conflict emerges when the feelings and emotions within anindividual or between individuals are incompatible. Procedural conflictoccurs when people differ over the process to use for resolving a particularmatter. As illustrated in Case Study 14–1, the different types of conflictare not mutually exclusive.Case Study 14–1 Who’s the Boss?“Dr. Jordan on line three for you, Mary.” When Mary Jones pressed the blinking button, she knewDr. Jordan was not calling to set up their next tee time. As chief of surgery, Dr. Jordan had fullaccess to the board of directors, and Mary, the chairperson of the board, noticed he took fulladvantage of it. Lately, Dr. Jordan’s calls were mostly about Harriet Briggs, the hospital’sadministrator. Today was no different.“Mary, as chief of surgery, I have authority over all issues that affect the quality of patient care.When something or someone is compromising that quality, it is my prerogative, not the prerogativeof some layman [Dr. Jordan’s word for anyone not holding an MD] to do what I deem necessary tocorrect the situation. Don’t you agree?”Mary mentally ran through job descriptions and the hospital’s charter and she could remember noclause that explicitly gave the chief of surgery this authority. Implicitly though, his stance wasprobably correct. “I’ll reserve comment on that, Alex, until you tell me the specific situation that hasyou this upset.”The problem that concerned Dr. Jordan involved the nursing supervisor, Judith Brady, RN. Ms.Brady scheduled the hospital’s surgical nurses according to her interpretation of establishedhospital policy. Surgeons were frustrated with her attitude that maximum utilization must be madeof the hospital’s operating time for training purposes. She therefore scheduled in such a way thatnurses were often assigned to procedures they had not seen before. Surgeons complained that thisscheduling method often added to the time it took to perform an operation. This caused problemsbecause the operating room was run at full capacity. Surgeons already felt they must hurry tocomplete a procedure because another procedure was scheduled directly following theirs. Having towait because a nurse did not automatically know what instrument is needed next only exacerbatedthis problem and did not permit them sufficient time to complete a surgical procedure in the propermanner. The surgical staff were concerned that this scheduling system was impacting quality of care.

Furthermore, some of the surgeons had complained that Ms. Brady clearly favored some physiciansover others and tended to assign more experienced nurses to their procedures.The situation came to crisis earlier in the morning when Dr. Jordan, following a confrontationwith Ms. Brady, told her she was fired. Ms. Brady then made an appeal to Harriet Briggs, thehospital administrator. Harriet overturned Ms. Brady’s dismissal and then instructed Dr. Jordanthat discharge of nurses was the purview of the hospital administrator and only she had theauthority to do so. Dr. Jordan vehemently disagreed. The conversation ended with Dr. Jordanyelling, “This is clearly a medical problem, and I am sure the board of directors will agree with me.”Dr. Jordan then called Mary.After listening to Dr. Jordan, Mary decided to call Harriet Briggs to get her side of the story.Harriet told Mary, “I cannot be responsible for improving patient care if the board will not supportme. I must be able to make decisions and develop policies and procedures without worrying whetheror not the board will always side with the physicians. As you already know, Mary, I am legallyresponsible for the care that patients receive here at the hospital. And another thing, the next timeDr. Jordan tells me that I should restrict my activities to fund raising, maintenance, andhousekeeping, I will not be responsible for my actions!”The severity of the problem was obvious, but the answers were not. All Mary knew was she neededto fix the situation quickly.Discuss the goal, cognitive, affective, and procedural conflicts illustrated in this case.SOURCE: “Musical Operating Rooms: Mini-Cases of Health Care Disputes,” by R. Friedman, 2002.International Journal of Conflict Management, 13(4), pp. 419–420. Reprinted with permission.LEVELS OF CONFLICTThere are five levels of conflict: intrapersonal conflict (within a person),interpersonal conflict (between or among individuals), intragroup conflict(within a group), intergroup conflict (between or among groups), andinterorganizational conflict (between or among organizations).Intrapersonal ConflictIntrapersonal conflict occurs within the individual and may involve someform of goal, or cognitive or affective conflict. Intrapersonal goal conflicthappens when several alternative courses of action are available and whenthe outcome is important to the individual, whether positive or negative(Locke et al., 1994). Brehm and Cohen (1962) identified three types ofintrapersonal conflict, which may develop involving alternative courses ofaction:• Approach/Approach: The approach/approach type occurs when anindividual must choose among two or more alternatives, each of whichis expected to have a positive outcome. For example, Judy Lewis, arecent graduate of a local university’s master of health servicesadministration (MHSA) program, has been offered job positions in two

different health care organizations. The first is a managed carecoordinator position with a national, publicly held laboratory company.The second is a network analyst position with a fast-growing third-partyadministrator. The salary levels of both positions are comparable.• Avoidance/Avoidance: The avoidance/avoidance type occurs when anindividual must choose among two or more alternatives, each of whichis expected to be or result in a negative outcome. For example, afterJudy Lewis accepted the position as the managed care coordinator withthe laboratory company, management announced that because of arecent merger, the company is in the process of rightsizing. Two optionswere presented to Judy: to retain her position by relocating to theorganization’s headquarters, which is 1,000 miles away from herhometown, or be laid off.• Approach/Avoidance: The approach/avoidance type occurs when anindividual must choose an alternative that is expected to have bothpositive and negative outcomes. Judy Lewis chooses the relocationoption. Although Judy realizes she will gain valuable experienceworking in the organization’s corporate headquarters with opportunitiesfor advancement, she is saddened by the fact that she must leave herfamily, friends, and familiar surroundings.Intrapersonal conflict may also be a consequence of cognitive dissonance,which occurs when individuals recognize inconsistencies in their thoughtsand behavior. Individuals seek consistency among their beliefs and/oropinions (i.e., cognitions), and when an inconsistency arises between anindividual’s attitude or behavior (i.e., dissonance), something must changeto eliminate or lessen the conflict. When there is a discrepancy between anindividual’s attitude and behavior, it is more likely that the individual’sattitude will change to accommodate his or her behavior, thereby reducingor eliminating the intrapersonal conflict (Brehm & Cohen, 1962).In the workplace, dissonance occurs most often within the context of roleconflict. The three types of role conflict are: (1) the person and the role, (2)intrarole, and (3) interrole. Person–role conflict occurs when theexpectations associated with a work role are incompatible with theindividual’s needs, values, or ethics—for example, a pharmaceuticalrepresentative who believes that making untested claims about a new drugis unethical, but whose work role requires him or her to do so. Intraroleconflict occurs when an individual experiences different expectations fromhis or her role. For example, a hospital’s purchasing manager reporting

administratively to the vice president of operations and functionally to themedical director may face conflicting expectations, as the former may,because of decreasing reimbursements, stress cost efficiency by restrictingchoices of prosthesis devices in the surgery department, whereas the lattermay emphasize having available whatever prostheses the surgeons prefer touse without regard to cost. Interrole conflict occurs when there is a clashbetween work and nonwork role demands. For example, if an individualmust travel extensively or work excessive hours, it may conflict with familyneeds or demands to spend time together.Interpersonal ConflictInterpersonal conflict is a natural outcome of human interaction.Interpersonal conflict involves two or more individuals who believe thattheir attitudes, behaviors, or preferred goals are in opposition. Kottler(1996) relates that there are three major sources of interpersonal conflict:(1) personal characteristics and issues, (2) interactional difficulties, and (3)differences around perspectives and perceptions of the issues. Porter-O’Grady and Epstein (2003, p. 36) summarize these components as follows:Personal Characteristics and Issues: As a result of the diversity of today’sworkplace, an extensive range of differences exists between persons andcultures. These differences are embedded with a kind of emotionalcontent related to variations in beliefs, behaviors, roles, andrelationships. Individuals function in the context of these diversecharacteristics, further validating differences others see in us.Interactional Difficulties: As we mature and socialize, we learn effectivecommunication and relational skills. A lack of communication skills,combined with our personal and cultural differences, creates powerfuldeficits in our ability to relate to one another. Because of this broad-based inadequacy, relational conflicts regularly emerge.Perspective and Perceptive Differences: When combined with personaldifferences and communication inadequacies, dissimilarity in the waypeople view issues and interactions is a common source of interpersonalconflict. This source of interpersonal conflict may include erroneousperceptions based on incomplete information, disparate interpretationsof meaning, or personal bias.Many interpersonal conflicts involve goal conflict or role ambiguity. Roleambiguity involves a lack of clarity or understanding regarding expectationsabout an individual’s work performance. Often, the misunderstanding is the

result of perceptual differences regarding an issue or process. Unclearperformance expectations may easily intensify interpersonal conflicts andundermine sustainability of healthy relationships. Role ambiguity maycause stress reactions, such as aggression, hostility, and withdrawalbehavior (Jackson & Schuler, 1985).Intragroup ConflictIntragroup conflict involves clashes among some or all of a group’smembers, which often affect the group’s processes and effectiveness. Jehnand Mannix (2001) suggest that there are three types of intragroup conflict:(1) relationship, (2) task, and (3) process.• Relationship conflict is an awareness of interpersonal incompatibilities.It includes affective components such as feeling tension and friction.Relationship conflict involves personal issues such as dislike amonggroup members and feelings such as annoyance, frustration, andirritation.• Task conflict is an awareness of differences in viewpoints and opinionspertaining to a group task. Similar to cognitive conflict, it pertains toconflict about ideas and differences of opinion about the task. Taskconflicts may coincide with animated discussions and personalexcitement but, by definition, are void of the intense interpersonalnegative emotions that are more commonly associated with relationshipconflict.• Process conflict is an awareness of controversies about aspects of howtask accomplishment will proceed. More specifically, process conflictpertains to issues of duty and resource delegation, such as who shoulddo what and how much responsibility different people should beassigned. For example, when group members disagree about whoseresponsibility it is to complete a specific duty, they are experiencingprocess conflict.Intergroup ConflictIntergroup conflict involves opposition and clashes between groups. Underextreme conditions of competition and conflict, the groups develop attitudestoward one another that are characterized by a failure to communicate,distrust, and a self-interest focus (see Case Study 14–2). Nulty (1993)relates that there are four categories of intergroup conflict: (1) verticalconflict, (2) horizontal conflict, (3) line-staff conflict, and (4) diversity-based

conflict.• Vertical conflict occurs between employees at different levels in anorganization. For example, when supervisors attempt to controlsubordinates, subordinates may resist because they believe that thecontrols infringe too much on their autonomy to perform their jobs.Vertical conflict may also arise because of poor communication, goal orvalue incompatibility, or role ambiguity (Pondy, 1967).• Horizontal conflict occurs between groups of employees at the samehierarchical level in an organization. It occurs when each department orteam strives only for its own goals, disregarding the goals of otherdepartments and teams, especially if those goals are incompatible (seeCase Study 14–3; also Pondy, 1967).• Line-staff conflict occurs over authority relationships. Most managersare responsible for the processes that create the organization’s servicesor products. Staff managers often serve an advisory or control functionthat requires specialized technical knowledge. Line managers may feelthat staff managers are imposing on their areas of legitimate authority.Staff personnel may specify the methods and partially control theresources used by line managers. Line managers often believe that staffmanagers reduce their authority over employees, although theirresponsibility for the outcomes remains unchanged (March & Simon,1993).• Diversity-based conflict relates to issues of race, gender, ethnicity, andreligion. These conflicts may encompass all five levels of conflict—intrapersonal, interpersonal, intragroup, intergroup, andinterorganizational.Case Study 14–2 Turf BattlesAndrea Bevans, chief operating officer of Holy Name Hospital, knew it was a matter of when, notif. The memo she had just read was the first salvo in what promised to be another turf battle withinthe medical staff organization. In the memo, the hospital’s vascular surgeons demanded thatradiologists not be allowed to perform balloon angioplasty. Bevans knew that this treatment used aballoon at the end of a catheter and that after the catheter had been threaded into an artery in theperipheral vascular system, the balloon was inflated to break up deposits that narrowed thearteries.The memo stated that vascular surgeons had the background, training, expertise, and provenoutcomes using surgical skills and that they could best learn and apply the new techniques, if thosetechniques were appropriate at all. To allow radiologists to work inside the peripheral vascularsystem would violate previously tried and tested relationships and would cause other, unspecified,disruptions. The memo ended with a chilling, thinly veiled threat: “Should the hospital allowradiologists to perform balloon angioplasty, it may not be possible for members of the surgical staff

to be available to treat untoward events, should they occur as the result of a procedure done byradiologists.”Bevans reread the memo and mused about the path of modern medicine. It was reaching the pointwhere many conditions were treated without a scalpel. She thought fleetingly about “Bones,” theStar Trek physician, who had only to pass a device over a patient’s body to make a diagnosis. “Is thiswhere we’re headed?” she thought. “But, enough of science fiction,” she said to herself. “How do Isolve yet another turf battle without too many casualties, not the least of whom could be me?”Discuss the intergroup conflicts reflected in the Turf Battle case study.Reproduced from “The Developing Crisis in Medical Staff Organization,” by K. Darr, 1996.Hospital Topics, 74(4), pp. 4–6. Reprinted with permission.Case Study 14–3 The Managed Care FactorCedars-Sinai is a 400-bed community hospital located in a major East Coast metropolitan area.The hospital has a reputation as a high-quality, low-cost provider. The medical staff at Cedars-Sinaicomprises board-certified physicians who are predominantly solo practitioners or are part of two- orthree-physician practices. No single- or multispecialty group practices are affiliated with Cedars-Sinai. Medical staff matters are handled cautiously and conservatively by the hospitaladministration.Nine years ago a large West Coast health maintenance organization (HMO) established a presenceon the East Coast and grew rapidly. Because of its fine reputation, Cedars-Sinai has become a majorprovider of services for the HMO, and many of the HMO’s physician-employees have admittingprivileges. Almost 20 percent of Cedars-Sinai’s inpatient days come from the HMO.Following a review of the HMO’s utilization patterns, a West Coast consultant noted the largedifference in hospital inpatient days per 1,000 enrollees between East and West Coast branches ofthe HMO. The HMO’s clinical director was asked to assess how many days of care and, consequently,how many premium dollars could be saved with various levels of progress toward the West Coastutilization patterns.Word of this study came to the attention of Cedars-Sinai’s chief executive officer (CEO), who wasimmediately alarmed by the implications. He knew that if the HMO’s physicians reduced the lengthsof stay for their patients by moving utilization patterns toward the West Coast experience,shockwaves would run through the majority of the members of his medical staff—the voluntary, fee-for-service physicians. The consequences of such a disparity in patient-day utilization patterns couldbe a decision by the medical staff leadership not to reappoint the HMO’s physician-employees to themedical staff because the voluntary medical staff would judge that the lengths of stay wereinappropriately short and risked patient morbidity and mortality.Discuss the horizontal conflict reflected in the Managed Care Factor case study.Reproduced from “The Developing Crisis in Medical Staff Organization,” by K. Darr, 1996.Hospital Topics, 74(4), pp. 4–6. Reprinted with permission.Interorganizational ConflictInterorganizational conflict occurs between organizations as a result ofinterdependence on membership and divisional or system-wide success. Forexample, as Longest and Brooks (1998) point out, health care organizations

participate in a variety of forms of organizational integration. The mostextensively integrated organizations are integrated delivery systems (IDS).As integration levels increase due to health reform, senior managersincreasingly become involved in interorganizational conflict. Integrationthat involves extensive linking of providers at different points in the patientcare continuum—and even more so when IDSs are linked with insurers orhealth plans and perhaps with suppliers in very highly integrated situations—brings into close interactive proximity what are often quite disparateorganizations. Conflicts are unavoidable; knowledge and skills useful inmanaging them effectively are imperative. Interpersonal/collaborativecompetence is, of course, required of senior managers in all settings, but inan IDS, such competence becomes more complex overall, especially giventhe new dimension of managing interorganizational conflict (Longest &Brooks, 1998).CONFLICT MANAGEMENTWinder (2003, p. 20) points out that:Disagreements between people are an inherent and normal part oflife. These disagreements can stem from differences in perceptions,lifestyles, values, facts, motivations or procedures. Differing goals,expectations or methods can turn disagreements into conflict, whichcan be damaging to both parties. Conflict may also be positive andbeneficial in that it can force clarification of policy or procedures,relieve tensions, open communications and resolve problems. In itsnegative form, conflict can direct energy from real tasks, decreaseproductivity, reduce morale, prevent cooperation, produceirresponsible behavior, break down communication, and increasetension and stress, all resulting in loss of valuable human resources.Understanding how conflict arises in the workplace is helpful foranticipating situations that may become conflictual. However, individualsalso need to understand how they cope with or handle these conflictualsituations. Thomas and Kilmann (1974), building on Blake and Mouton’s(1964) work in the area of leadership, identified five conflict-handlingmodes. Thomas and Kilmann describe the five conflict-handling modeswithin two dimensions: (1) assertiveness (i.e., attempt to satisfy one’s ownconcern) and (2) cooperativeness (i.e., attempt to satisfy others’ concerns).The five conflict-handling modes are: (1) competition, (2) avoidance, (3)

compromise, (4) accommodation, and (5) collaboration (see Figure 14–1).

Figure 14–1 Thomas and Kilmann’s Two-Dimensional Taxonomy of Conflict-Handling ModesCompetition involves assertive and uncooperative behaviors and reflects awin–lose approach to conflict. A dominating or competing person goes all outto win his or her objective and, as a result, often ignores the needs,concerns, and expectations of the other party (Rahim, Garrett, &Buntzman, 1992). When dealing with conflict between subordinates ordepartments, competition-style managers use coercive powers such asdemotion, dismissal, negative performance evaluations, or other

punishments to gain compliance (Winder, 2003). When conflict occursbetween peers, a competition-style manager will try to get his or her ownway by appealing to his or her supervisor in an attempt to use thesupervisor to force the decision on his or her peer (Blake & Mouton, 1984b).However, in some situations competition-style management isappropriate. For example, when the issues involved in a conflict are trivialor when emergencies require quick action, this style may be appropriate. Itis also appropriate when unpopular courses of action must be implementedfor long-term organizational effectiveness and survival (e.g., cost cutting,dismissal of employees for poor performance). This style is also appropriatefor implementing the strategies and policies formulated by higher-levelmanagement (Dewine, Nicotera, & Perry, 1991; Rahim, Garrett, &Buntzmann, 1992).Collaboration involves highly assertive and cooperative behaviors andreflects a win–win approach to conflict. A collaborating-style managerattempts to find a solution that maximizes the outcomes of all partiesinvolved. Managers who use the collaborating style see conflict as a meansto a more creative solution, which would be fully acceptable to everyoneinvolved (Winder, 2003). This involves openness, exchange of information,and examination of differences to reach an effective solution acceptable toall parties. Rahim et al. (1992) suggest that when issues are complex, thecollaboration conflict-handling mode emphasizes the use of skills andinformation possessed by different employees to arrive at creativealternatives and solutions. This style may be appropriate for dealing withthe strategic issues relating to objectives and policies, long-range planning,and so forth. However, as Winder (2003) points out, this style requiressufficient interdependence and parity in power among individuals so thatthey feel free to interact candidly, regardless of their formalsuperior/subordinate status. In addition, this style requires expending extratime and energy; therefore, sufficient organizational support must beavailable to resolve disputes through collaboration (Winder, 2003).Compromising is the “middle ground,” with managers displaying bothassertive and cooperative behaviors. It involves give-and-take, whereby bothparties give up something to reach a mutually acceptable agreement.According to Rahim, Garrett, and Buntzmann (1992), it may mean splittingthe difference, exchanging concessions, or seeking a middle-ground position.Compromising may be appropriate when the goals of the conflicting partiesare mutually exclusive or when both parties, who are equally powerful (e.g.,labor and management), have reached a deadlock in their negotiation.

According to Winder (2003), heavy reliance on this style may bedysfunctional because the compromising style may create several problemsif used too early in trying to resolve conflict. First, the people involved maybe encouraged to compromise on the stated issues rather than on the realissues. The first issues raised in a conflict often are not the real ones, sopremature compromise may prevent full diagnosis or exploration of the realissues. Second, accepting an initial position presented is easier thansearching for alternatives that are more acceptable to everyone involved.Third, compromise may be inappropriate for all or part of the situation,because it may not be the best decision available.Compared with the collaborating style, the compromising style does notmaximize optimal outcomes for all involved parties. Compromise achievesonly partial satisfaction for each person. Kabanoff (1991) points out thatthis style is likely to be appropriate when agreement enables each person tobe better off or at least not worse off than if no agreement were reached,achieving a total win–win agreement is not possible, and conflicting goals oropposing interests block agreement on one person’s proposal.Accommodating involves cooperative and unassertive behaviors and is theopposite of competing. Accommodations may represent an unselfish act, along-term strategy to encourage cooperation by others, or a submission tothe wishes of others (Winder, 2003). This style is associated with attemptingto play down the differences and emphasizing commonalities to satisfy theconcern of the other party. An obliging person neglects his or her ownconcern to satisfy the concern of the other party; as such, accommodating-style managers may be perceived as weak and submissive because theseindividuals try to reduce tensions and stress by reassurance and support(Rahim, Garrett, & Buntzmann, 1992; Winder, 2003).According to Lee (1990), accommodating is generally ineffective if used asa dominant style, but it may be effective on a short-term basis whenindividuals are in a potentially explosive emotional conflict situation, andsmoothing is used to defuse it; when keeping harmony and avoidingdisruption are especially important in the short run; and when the conflictsare based primarily on the personalities of the individuals and cannot beeasily resolved. In addition, this style is useful when an individual believesthat he or she may be wrong or the other party is right and the issue ismuch more important to him or her. It can be used as a strategy when aparty is willing to give up something with the hope of getting something inexchange from the other party when needed (Rahim, Garrett, &Buntzmann, 1992).

Avoiding involves unassertive and uncooperative behaviors and is theopposite of collaborating. It is associated with withdrawal, buck-passing, orsidestepping situations (Rahim, Garrett, & Buntzmann, 1992). Thisapproach often reflects a decision to let the conflict work itself out, or it mayreflect an aversion to tension and frustration. Because ignoring importantissues often frustrates others, consistent use of the avoidance conflict-handling mode usually results in frustration by others. When unresolvedconflicts affect goal accomplishment, the avoiding style will lead to negativeresults for the organization (Winder, 2003).Conflict Negotiation ModelsRubin and Brown (1975) define negotiation as the process by which two ormore parties decide what each will give and take in an exchange. Since the1960s, there has been extensive research in the field of conflict resolution orconflict management. From this research, three major negotiation modelshave been developed: (1) distributive, (2) integrative, and (3) interactive.Each of these models is associated with different goals and indicators ofsuccess, and each may be most appropriately applied in different contexts(Winder, 2003).Distributive ModelThe distributive model originated within the field of labor negotiations(Lewicki, Weiss, & Lewin, 1992; Stevens, 1963; Walton & McKersie, 1965)and can be described as a set of behaviors for dividing scarce resources.Distributive negotiation is often referred to as “hard-bargaining” or a win–lose, zero-sum approach. The negotiators are viewed as adversaries whoreach agreement through a series of concessions with the goal of obtainingthe greater “piece of the pie.” Tactics used in the distributive negotiationmodel are withholding information, guarded communications, powerpositioning, limited expressions of trust, use of threats, and distortedstatements and demands (Walton & McKersie, 1965). Brett and Shapiro(1998) referred to distributive negotiations as a tug-of-war game with eachparty trying to tug the other to its own side. The winner wins when theopponent’s strength gives out and the opponent is pulled across the midline.The result is a one-sided agreement, where resolved issues favor one sidemore than the other.Winder (2003) outlines the four win–lose strategies practiced bynegotiators using the distributive approach. The first negotiating strategy isthe “I want it all” tactic. This tactic involves making extreme offers and

then granting concessions grudgingly, if at all. One party hopes to weardown the resolve of the other by pressuring the other to make significantconcessions and forcing the other party into a position of nonreciprocation.The second negotiating strategy is “time warp.” The time-warp tacticcommunicates an arbitrary deadline for acceptance of the offer. Forexample, the negotiators will relate to the other party that an offer is onlygood until a certain date and time. If not accepted by the arbitrarily setdeadline, the offer will be withdrawn. The third negotiating strategy is the“good cop, bad cop” scenario. In this scenario, one party attempts to swaythe negotiator by alternating sympathetic with threatening behavior. Thefourth negotiating strategy is the “ultimatum” tactic, which is designed totry to force one party to submit to the will of the other. In this negotiationapproach “take it or leave it” offers are presented, and one party overtlytries to force acceptance of demands—one party is unwilling to make anyconcessions, and the other party is expected to make all of the concessions(Fisher, Ury, & Patton, 1991).Integrative ModelThe integrative negotiation model, similar to the distributive model,evolved primarily within the field of labor negotiations (Follett, 1940, 1942;Lewicki, Weiss, & Lewin, 1992; Walton & McKersie, 1965). It is currentlyone of the most frequently used models of conflict resolution because of itscollaborative versus confrontational approach.Integrative negotiation is a cooperative, interest-based, agreement-oriented approach to dealing with conflict that is viewed as a “win–win” ormutual-gain dispute. Integrative negotiation is a process by which partiesattempt to explore options to achieve mutual gains versus unilateral gains.Parties recognize and define a problem, search for possible solutions to it,evaluate the solutions, and select one that maximizes joint gains (Lewicki,Weiss, & Lewin, 1992).Filley (1975), building on the work of Walton and McKersie (1965),developed an integrative decision-making model. Filley’s six-step approach isas follows:1. Create an environment that promotes equality, cooperation,communication, and information sharing2. Review and adjust perceptions3. Review and adjust attitudes (i.e., create processes that maximizeinformation sharing and “clear the air” of past hostilities and negativeattitudes)

4. Define the problem5. Search for alternatives6. Achieve consensusThe concept of integrative negotiation is based on a value system thatstresses interpersonal trust, cooperation, a willingness to share informationcombined with open communication, and a search for mutually acceptableoutcomes (Lewicki, Weiss, & Lewin, 1992). This model looks beyond theexisting resources and aims to expand the alternatives and increase theavailable payoffs to both parties through joint problem solving (Winder,2003).Fisher and Ury (1981) and Fisher, Ury, and Patton (1991) defineintegrative negotiation as “principled negotiation.” The researchers suggestthat negotiations should be grounded in substantive concerns when theparticipants:• Separate the people from the problem. In other words, separate theissues in conflict from the personal relationships. Negotiators should behard on the issues, but do so in a cooperative relationship with the otherparty.• Focus on interest or need rather than position. In other words, do notallow individual egos to negate the negotiation process. This requirestrust, respect, and open communication by both parties.• Identify the best alternative to a negotiated agreement (BATNA) forboth parties. By identifying BATNAs, the parties’ goal will be to achievebetter outcomes than their BATNA through negotiations.• Invent options or alternatives that provide mutual gain. Brainstorming,prior to and during meetings, will assist in developing creativealternatives.• Insist on using only objective criteria to judge solutions. Whennegotiations are based on objective versus subjective criteria,discussions focus on equitable solutions, not false assumptions.The integrative-conflict model encourages equitable solutions to problems.Negotiators are viewed as partners who cooperate in searching for a fairagreement that meets the interests of both sides and seeks to maximize thegain for all the parties involved (Winder, 2003). (See Case Study 14–4:Creating a Win–Win Situation.)Case Study 14–4 Creating a Win–Win Situation

A hospital anesthesiology department is deeply financially troubled. Department leadersapproach senior hospital administrators seeking additional funds. Department leaders say thatwithout funding they will lose staff and be forced to close operating rooms. The administrators takethe position that if they provide funding to the anesthesiology department, every department willdemand it. Furthermore, the anesthesiology department has enjoyed the privilege of having anexclusive contract. If rooms are closed, the hospital may entertain looking at other anesthesiologypractices. The senior vice president for medical affairs (i.e., VPMA) is called in to mediate. Ameeting is set up to negotiate a solution.Applying Fisher’s principled negotiations, how should the VPMA proceed?The first component of principled negotiation is to attack the problem over which the parties arenegotiating. The further apart the positions, the more likely emotions will obscure the objectivemerits of the problem. Most negotiations are as much about emotion as they are money. Thenegotiation process will deteriorate rapidly if both sides firmly settle into their respective positions.If the anesthesiology group and hospital administration settle into their respective positions ofclosing rooms and denying the anesthesia group their exclusive contract, the negotiation soon willbecome a series of personal attacks.The first step is for the VPMA to acknowledge that negotiation is an emotional undertaking. Asmediator, he or she should encourage both parties to consider what they would be thinking if theywere on the other side of the table. The point is to get both parties to address the problem and not toreact immediately to emotional outbursts.Relationship building and the “spirit of the deal” are important factors to keep in mind. The wayto accomplish this relationship building is simple. Lay down the ground rules so that each partyagrees to show the same degree of honesty, respect, and fairness that it would demand from others.The ultimate objective of any negotiation is to satisfy the underlying interests of each side in thebest way possible. As mediator, the VPMA must get each party to recognize the importance of eachother’s interests.What are the interests of each group in this example? For the anesthesiologists, it may beincreasing salaries to retain current staff and recruit new staff, while not having to workunreasonable or unsafe amounts of time to achieve this goal. For the hospital, it may be maintainingor even increasing operating room time to retain and attract high-volume surgeons.The point is that each side has multiple interests. Positions such as “We will close down anoperating room” obscure the underlying interests. Both parties must be cautioned to recognize andavoid any preconceived perceptions they may have about the other party.For example, not all anesthesiology groups seeking stipends are greedy. Not all hospitaladministrators are clueless to clinical issues. No attempt should be made to discard any solutionsuntil there has been a discussion of the problem and interests at hand.With the interests articulated and understood, the VPMA should begin to look at options, lookingfirst for shared or common interests. In this example, it is a common interest for both theanesthesiology group and hospital to keep the operating rooms open and running, since both deriverevenue from the cases (i.e., common ground).Unfortunately, it may be difficult or impossible to find common ground in many situations. As aresult, capitalizing on differences may hold the key to developing options for achieving agreement.For example, the hospital may state that in order to provide a stipend, the anesthesiology groupmust be willing to expand operating room coverage in the evenings. The anesthesiology group mayclaim it does not have the staff to expand coverage and there is no need for expansion.Could there be a solution in the disagreement? If both sides agree to look at both decreasing roomturnover time and more accurate posting of procedure times by surgeons on the basis of historicaldata, the interest of the hospital in providing time for high-volume surgeons, and theanesthesiologists’ interest in not expanding evening coverage, might be achieved. Remember thatagreement often can be based on disagreement.Once the parties begin looking at options, the problem can be discussed on the basis of objectivecriteria. The VPMA must have both parties prepare objective data to present prior to negotiating a

solution. The anesthesiology group should be prepared to have benchmarks as to current salaries,workload, and operating room staffing models. The hospital should know how other institutionshandle stipends, the legal implications, and objective criteria used to judge performance.SOURCE: “The Role of the Physician Executive in Negotiation,” by D. P. Tarantino, 2004.Physician Executive, 30(5), pp. 71–73. Reprinted with permission.Interactive ModelWhen negotiations become locked into a win–lose situation, a third partymay be invited to assist in resolving the issues (Schwarz, 1994). Interactiveproblem solving is a form of third-party consultation or informal mediation.Third-party facilitators can be mediators, arbitrators, or consultants.Depending on the situation, a third-party facilitator may have high or lowcontrol of either the conflict-resolution process and/or the outcomes. Forexample, the third party in intraorganizational conflicts is most often theperson in the hierarchy to whom the contesting parties report (Lewicki,Weiss, & Lewin, 1992). In this situation, the mediator/supervisor wouldhave high control of both the conflict-resolution process and the outcomes.Mediators usually have high control of the conflict-resolution process andlow control of the outcomes (as demonstrated by the VPMA in Case Study14–4), whereas arbitrators have low control of the conflict-resolution processand high control of the outcomes.In general, interactive negotiation is designed to facilitate a deeperanalysis of the problems and issues forcing the conflict. According to Winder(2003), interactive negotiation usually begins with an analysis of the needsof each of the parties and a discussion of the constraints faced by each sidethat make it difficult to reach a mutually beneficial solution to the conflict.After the analytical dialogue, the parties engage in joint problem solvingversus a fight to be won. Interactive negotiation is less focused on directlyhelping parties reach binding agreements (excluding arbitration) and ismore devoted to improving the process of communication, increasingperspectives and understanding, enabling the parties to reframe theirsubstantive goals and priorities, and engaging in more creative problemsolving. Other goals include improving the openness and accuracy ofcommunication, improving intergroup expectancies and attitudes, reducingmisperceptions and destructive patterns of interaction, inducing mutualpositive motivations for creative problem solving, and ultimately, building asustainable working relationship between the parties (Winder, 2003).Managers need to understand and appreciate that negotiation is not azero-sum game. Managers who demonstrate effective conflict-resolution

skills are often seen as competent, effective leaders (Gross & Guerrero,2000; Stamato, 2004). A study by Eckerd College’s ManagementDevelopment Institute (2003) found a significant link between a person’sability to resolve conflict effectively and his or her perceived effectiveness asa leader and suitability for promotion. The sample for the study consisted of172 employees (90 male, 82 female) from five different types oforganizations. Approximately one-half of the participants were middle-levelmanagers or higher in their organization; all of them participated in aprogram focusing on workplace conflict. The study revealed a strongcorrelation between certain conflict-resolution behaviors and perceivedeffectiveness as a leader and promotion potential. Employees who wereperceived as good at creating solutions, expressing emotions, and reachingout were considered more effective. Destructive behaviors, on the otherhand, such as winning at all costs, displaying anger, demeaning others, andretaliating were found to be the worst career advancement and leadershipbehaviors. Avoidance behaviors were found to be particularly problematicfor would-be negotiators because individuals who are uncomfortable withnegotiating, or perceive themselves to be unskilled or ineffective innegotiating, often avoid conflict and thus fail to manage differenceseffectively. Of particular significance is the study’s finding that negotiationskills are an important aspect of leadership.SUMMARYIn this chapter, we have discussed the positive and negative outcomes ofconflict, and that conflicts originate from a variety of sources. Conflict-handling behavior can be learned, and managers should adapt theirbehavior to the situation to be resolved. Collaborative behavior is stronglydesired as a way to manage conflict.DISCUSSION QUESTIONS1. Explain the definition of conflict.2. Describe the four basic types of conflict.3. Discuss the five levels of conflict.4. Describe the five conflict-handling modes.5. Describe the three major negotiation models.

CASE STUDIESCase Study 14–5 Musical Operating RoomsDr. John Wilkins sat staring at the phone message in front of him. Dr. Peter Mikelson, chief oforthopedics, had called again wanting to discuss the current system used to schedule operating roomtimes. As chief of medicine, technically, Dr. Wilkins had the power to dictate who would use theoperating resources and when. Up to now he had been reluctant to use that power, relying insteadon scheduling administrators to handle the schedule for operating room use. Perhaps the time hadcome to review that system and implement changes if necessary.Mercy Hospital, a not-for-profit hospital located in the Northeast, employed 1,000 doctors in 30different departments. The facility had an outstanding reputation as a teaching hospital. About 40percent of its doctors were full-time faculty, while the remaining 60 percent were volunteer staff(those doctors who, while not employees of the hospital, worked with residents and had access tohospital resources). The hospital currently had 25 operating rooms located throughout the hospital.Operating rooms were not assigned to any particular department, but doctors tried to use the roomsclosest in proximity to their department wing. In some more extreme cases, it was simplyunderstood that the operating rooms in certain wings were to be used only by certain departments.Dr. Wilkins decided to have some informal discussions with different department chairs to gaugehow dire the situation really was. His first stop was with Dr. Steve Daly, chief of urology. “Youknow, John,” Dr. Daly explained, “I understand urology is not a high-profile glamour specialty, but Iam having a very difficult time attracting both volunteer staff and the best residents because of thetrouble I have scheduling procedures. We have 20 doctors in three different departments sharingfour operating rooms. I know to you this may sound like an inability on my part to plan, but let meput this in terms that may mean something to you. The operating room is where we make our money.If my doctors and I can’t easily schedule time in the OR, we can’t continue to build the department. Ihave already seen a decline in the number of referrals from primary care physicians. If this keepsup, this hospital will have a hard time maintaining this specialty at a competitive level.”Next on Dr. Wilkins’s list was Dr. Jack Palmer, chief of neurosurgery. Jack Palmer was a bit of alegend in the region. This was due to a combination of the high-profile nature of his specialty, hislong tenure at the hospital, and his impressive client list, which included many of the people who saton Mercy Hospital’s board of directors as well as their families and friends. As John walked throughthe department, he noticed that all three of the ORs in the Neurosurgery wing were not in use.When he mentioned this to the department secretary, she replied that this was always the case onFriday mornings. For as long as she could remember, Neurosurgery held a weekly teachingconference from 7:00 to 12:00 every Friday. The secretary then informed John that Jack could notfree up any time to speak with him, but she did relay the message that all was fine in Neurosurgeryas far as OR time.Dr. Wilkins next spent some time with Dr. Sheehan, chief of ophthalmology. After reviewing theOR schedule for the next month, Dr. Wilkins was astounded at the number of procedures Dr.Sheehan and members of her department were scheduled to perform. Dr. Sheehan explained, “Well,John, I’ve actually put a little cushion in there to make sure I have the time I need. At the beginningof the month I sign up those surgeries I am sure we will perform as well as some ‘phantom’ patients.That way, if surgery runs over because I’m teaching the procedure to a resident, or if a patient showsup in a condition under which I cannot operate, I can easily reschedule him or her. Patients getquickly rescheduled, doctors’ office hours aren’t disrupted, and everyone is happy. The name of thegame is customer service. Peter [Dr. Mikelson] is new and will learn the system like everyone elsedid. I’m feeling particularly charitable today. Send Peter my way and we’ll see if we can’t negotiatefor some of my scheduled time.”Dr. Wilkins spoke with Dr. Mikelson last. Dr. Mikelson said, “John, I know I’m the new kid on the

block, but this system is simply unacceptable. Six months ago when I took this position, you and theboard made it very clear to me the importance of building the practice. I’ve done as much as I can,but my capacity analysis shows that if my growth continues, I’ll need four operating rooms instead ofthe one I am currently allocated. The bottom line is the bottom line, and you and I both know themoney Orthopedics brings into the hospital. If I have to beg and plead with Susan Sheehan everytime an unexpected change in my schedule pops up or rely on the grapevine to figure out when theOR is available, I can’t keep my patients happy. The game has changed, John. Unhappy patientssimply go elsewhere for surgery.”Dr. Wilkins knew Dr. Mikelson was right. How would he fix the situation in a way that madeeveryone happy, including patients, doctors, administrators, and the board of directors? What wasthe proper criteria to use: longevity, political clout, fiscal impact? How was he going to allow foremergency surgeries? How much control did he really want to take away from the physicians inscheduling their procedures?Discussion Questions1. What is this conflict about?2. Why is there a conflict over these issues?3. How are each of the doctors doing now at managing the conflict? What should they have done?Would you do what they did?4. As Dr. Wilkins, who is asked to resolve this dispute, what source of leverage do you have?What options are possible? What impact would each option have? What are your overall goals?Reproduced from Musical operating rooms: Mini-cases of health care disputes, by R. Friedman,2002. International Journal of Conflict Management, 13(4), pp. 421–422. © Emerald Group PublishingLimited all rights reserved.Case Study 14–6 What Went Wrong?Tim Hardwood, CEO of Community Health System, hung up the phone with a heavy sigh. Tim hadjust received the news from Mary Martin, vice president of human resources, that negotiations hadstalled between the health system and the service employees’ union. Mary related, “As of now, the2,000 service employees at our three hospitals are without a contract and threatening to strike. Butdon’t worry, Tim. I told the union negotiators that the health system is prepared to handle a strike.”“A strike! The media will have a field day with this!” Tim wondered, “What went wrong?”Jim Brentward, one of the union negotiators, sat across the table from Mary Martin. Jim relatedthat his members understood that the health system was having financial difficulties because of thecurrent state of the industry with decreasing reimbursements and increasing regulations, but theunion members were not pleased with the health system’s proposed offer for salary increases andbenefits package over the next four years. He related that “unless the health system signed acontract by 5:00 p.m. Friday with acceptable salary and benefit increases, members of the union arethreatening to strike.” Jim continued, “The union plans to hold an informational picket on Thursday,and although the union doesn’t want to strike, it’s a strong possibility. After the informationalpicket, we will hold a strike vote and see what our members have to say about the situation.”Mary was shocked by Jim’s comments. She simply could not believe thatCommunity’s service employees would threaten to strike! Because of herposition as vice president of human resources, Mary knew that the serviceemployees represented by Jim’s union were in the bottom end of the healthsystem’s pay scale. These employees included patient transporters,

housekeeping, and cafeteria workers. Mary also knew that union benefitspaid during a strike represented only 50 percent of the employee’s/member’sweekly salary. Mary felt confident that because of financial restraints, theemployees would never vote to strike; they had too much to lose. Inaddition, she knew that Community Health System was consideringoutsourcing its dietary departments to Thomson Healthcare Food Services.If the employees did strike, although Mary considered it very unlikely, thataspect of services would continue without interruption. Knowing this insideinformation, Mary decided she wasn’t going to let Jim and the other unionnegotiators bully her. Mary responded by stating that the health systemwould not give in to the union’s demands and it was prepared for a strike.Explain to Tim Hardwood what went wrong. If you were hired as themediator, how would you go about resolving the situation to achieve a win–win agreement?Case Study 14–7 Healthy Conflict Resolution“Cindy, please reschedule my afternoon clinic; I am going to be out for the rest of the day,” says Dr.Jones, a senior physician in a hospital-owned multispecialty group.“But, Dr. Jones,” Cindy says, while whipping off her telephone headset and turning away from theopen patient registration window, “you are double booked for most of the afternoon because youcanceled your clinic twice this month already. Many of these patients have been waiting more thanthree months to see you!”Jones glances furtively at the waiting room, and already half turned and heading toward the clinicexit, says, “I’m sure you will be able to smooth things over. Just tell them that I got called to anemergency.”Cindy has a suspicion that, because the weather is nice, Jones is taking off with a couple ofcolleagues to go sailing or play a round of golf. After all, he always sports a darn tan, comes to cliniclate, and often leaves early. Cindy does not relish having to call and reschedule these patients, someof whom have already been rescheduled at least once in the past couple of months.Cindy decides enough is enough. She calls her manager and requests a meeting as soon as possible.Her manager can sense that Cindy is upset and offers to have someone cover for Cindy so that theycan talk privately.Cindy tells the manager about the situation with Jones that happens “all the time,” and how she is“sick of it,” and will not “work another day under these conditions.” After calming Cindy down, themanager promises to bring the matter up with the chief of the department.To make a long story shorter, suffice it to say that this conflict continues to mushroom to involveseveral more individuals (the chief medical officer, the executive director of the clinic, the directorof human resources, and the union representative) before Jones is ever made aware that Cindy hasfiled a formal complaint about him. When he is finally confronted, in a meeting with the chiefmedical officer and the director of human resources, he is caught completely off guard.After all, the incident happened several weeks ago, and Cindy did not mention anything to himabout it. They have continued to work together, in his opinion, as if nothing were wrong. He is alsosurprised to find out that Cindy has been keeping a tally of the number of times that he has canceledhis clinic, left early, or started clinic late.Jones goes from astonishment to red-faced anger in a few minutes. It is clear to all that the

relationship between Cindy and the doctor is irreparable. Jones is labeled as a disruptive physician.Cindy is not welcome in any department because the other physicians are fearful of being targeted.Cindy eventually resigns, and Jones feels betrayed and unappreciated by his staff and his employer.If you were the manager in this case, how would you have handled the situation?Reproduced from Pierce, K. P. (2009, January/February). Healthy conflict resolution. PhysicianExecutive, 35(1), 60–61.Case Study 14–8 Conflict-Handling StylesFor each of the five scenarios that follow determine the most appropriate conflict-handlingstyle(s).Scenario OneA radiologist on the staff of a large community hospital was stopped after a staff meeting by acolleague in internal medicine. On Monday of the previous week, the internist referred an elderlyman with chronic, productive cough for chest X-ray, with a clinical diagnosis of bronchitis. OnThursday morning, the internist received the radiologist’s written X-ray report with a diagnosis of“probable bronchogenic carcinoma.” The internist expressed his dismay that the radiologist had notcalled him much earlier with a verbal report. Visibly upset, the internist raised his voice, but did notuse abusive language.How should the radiologist handle this conflict with the internist?Scenario TwoThe Family and Community Medicine Division of a large-staff model HMO serves a populationthat is ethnically diverse. The senior management team of the HMO, spurred by repeated complaintsfrom representatives of one racial group, has encouraged the division, all of whose physicians arewhite, to diversify. Several black and Hispanic physicians with strong credentials apply for the openpositions, but none are hired. Weeks later, a young female family physician learns from severalcolleagues that the division director has identified her as racist and the obstructionist to recruiting.The comments attributed to her are not only false but are also typical of discriminatory statementsthat she has heard the division chief utter. The rumors about her “behavior” have circulated widelyin the division.How should the young female family physician handle this conflict with the division chief?Scenario ThreeA manager who reports to the vice president for clinical affairs (VPCA) of a tertiary-care hospitalhired a young woman to supervise development of a large community outreach program. During thefirst four months of her employment, several behavioral problems came to the VPCA’s attention: (1)complaints from community physicians that the coordinator criticizes other physicians in public; (2)concerns from two community leaders that the coordinator is not truthful; and (3) complaints aboutwritten reports about the project that label and blame others, sometimes in language that isdisrespectful. The VPCA spoke several times to the manager about these problems. The managerreported other dissatisfactions with the coordinator’s performance, but he showed no sign of dealingwith the behavior. Two more complaints come in, one from an influential community leader.How should the VPCA handle this conflict with the manager?Scenario FourThe medical school in an academic health center recently implemented a problem-based

curriculum, dramatically reducing the number of lectures given and substituting small-grouplearning that focuses on actual patient cases. Both clinical and basic science faculty are feelingstretched in their new roles. In the past, dental students took the basic course in microanatomy withmedical students. The core lectures are still given, but at different times that do not match with thedental-curriculum schedule. The anatomists insist that they don’t have time to teach another coursespecifically for dental students. The dean has informed the chair of the Department of Anatomy andCell Biology that some educational revenues will be redirected to the dental school if the faculty donot meet this need.How should the dean handle this conflict with the chair of the Department of Anatomy and CellBiology?Scenario FiveThe partners in a medical group practice are informed by the clinic manager that one physicianmember of the group has been repeatedly upcoding procedures for a specific diagnosis. This issuefirst came to light six months ago. At that time the partners met with him, clarified the Medicareguidelines, and outlined the threat to the practice for noncompliance. He argued with their view, butultimately agreed to code appropriately. There were no infractions for several months, but now hehas submitted several erroneous codes. One member of the office staff has asked whether Medicarewould consider this behavior “fraudulent.”How should the partners handle the situation with the other physician partner?SOURCE: “Managing Low-to-Mid Intensity Conflict in the Health Care Setting,” by C. A.Aschenbrener-Siders, 1999, Physician Executive, 25(5), pp. 44–50. Reprinted with permission.REFERENCESBaron, R. A., Fortin, S. P., Frei, R. L., Hauver, L. A., & Shack, M. L. (1990).Reducing organizational conflict: The role of socially induced positiveaffective. International Journal of Conflict Management, 1, 133–152.Baron, R. A., & Richardson, D. R. (1990). Human aggression (2nd ed.). NewYork, NY: Plenum Books.Blake, R. R., & Mouton, J. S. (1964). The managerial grid. Houston, TX:Gulf Publishing.Blake, R. R., & Mouton, J. S. (1984a). Solving costly organizationalconflicts. San Francisco, CA: Jossey-Bass.Blake, R. R., & Mouton, J. S. (1984b). The managerial grid III (3rd ed.).Houston, TX: Gulf Publishing.Brehm, J., & Cohen, A. (1962). Explorations in cognitive dissonance. NewYork, NY: John Wiley & Sons.Brett, J. M., & Shapiro, D. L. (1998). Breaking bonds of reciprocity innegotiations. Academy of Management Journal, 41(4), 410–424.Cosier, R. A., & Dalton, D. R. (1990). Positive effects of conflict: A fieldassessment. International Journal of Conflict Management, 1, 81–92.

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11(5/6), 423–432.Robbins, S. (1990). Organization theory (3rd ed.). Englewood Cliffs, NJ:Prentice Hall.Rubin, J. Z., & Brown, B. R. (1975). The social psychology of bargaining andnegotiation. New York, NY: Academic Press.Schwarz, R. M. (1994). The skilled facilitator: Practical wisdom fordeveloping effective groups. San Francisco, CA: Jossey-Bass.Shelton, C. D., & Darling, J. R. (2004). From chaos to order: Exploring newfrontiers in conflict management. Organization Development Journal,22(3), 22–41.Stamato, L. (2004, July/August). The new age of negotiation. Ivey BusinessJournal Online. Available at: www.iveybusinessjournal.com/archivesStevens, C. M. (1963). Strategy and collective bargaining negotiation. NewYork, NY: McGraw-Hill Book Company.Tarantino, D. P. (2004). The role of the physician executive in negotiation.Physician Executive, 30(5), 71–73.Thomas, K. W. (1976). Conflict and conflict management. In M. Dunnette(Ed.), Handbook of industrial and organizational psychology (pp. 889–935). Chicago, IL: Rand McNally College Publishing Company.Thomas, K. W. (1992). Conflict and negotiation processes in organizations.In M. Dunette (Ed.), Handbook of industrial and organizationalpsychology (2nd ed., Vol. 3, pp. 651–717). Palo Alto, CA: ConsultingPsychologists Press.Thomas, K. W., & Kilmann, R. H. (1974). Thomas-Kilmann conflict modeinstrument. Tuxedo, NY: Xicom, Inc. (Currently available throughConsulting Psychologist’s Press.)Thomas, K., & Schmidt, W. (1976). A survey of managerial interests withrespect to conflict. Academy of Management Journal, 19(2), 315–318.Thomas, K. W. (1992). Conflict and conflict management: Reflections andupdate. Journal of Organizational Behavior, 13, 265–274.Walton, R. E., & McKersie, R. B. (1965). A behavioral theory of labornegotiations: An analysis of a social interaction system. New York, NY:McGraw-Hill Book Company.Watson, C., & Hoffman, L. R. (1996). Managers as negotiators. LeadershipQuarterly, 7(1), 63–85.Winder, R. (2003). Organizational dynamics and development. Futurics,27(1/2), 5–30.

OTHER SUGGESTED READINGAgor, W. H. (1984). Intuitive management: Integrating left and right brainmanagement skills. Upper Saddle River, NJ: Prentice Hall.Ashford, B. E. (2001). Role transitions in organizational life: An identity-based perspective. Mahwah, NJ: Lawrence Erlbaum Associates.Bates, B. (1975). Physician and nurse practitioners: Conflict and reward.Annals of Internal Medicine, 82, 702–706.Brett, J. F., Northcraft, G. B., & Pinkley, R. L. (1999). Stairways to heaven:An interlocking self-regulation model of negotiation. Academy ofManagement Review, 24(3), 435–451.Davis, M. H., Capobianco, S., & Kraus, L. (2004). Measuring conflict-relatedbehaviors: Reliability and validity evidence regarding the conflictdynamics profile. Educational and Psychological Measurement, 64(4),707–731.Elangovan, A. R. (2002). Managerial intervention in disputes: The role ofcognitive biases and heuristics. Leadership & Organization DevelopmentJournal, 23(7), 390–399.Friedman, R. A., Tidd, S. T., Currall, S. C., & Tsai, J. C. (2002). What goesaround comes around: The impact of personal conflict style on workconflict and stress. International Journal of Conflict Management, 11(1),32–55.Gigerenzer, G. (2007). Gut feelings: The intelligence of the unconscious.New York, NY: Penguin Group.Kahneman, D. (1991). Judgment and decision making: A personal view.Psychological Science, 2(3), 142–154.Kilmann, R. H., & Thomas, K. W. (1977). Developing a forced-choicemeasure of conflict-handling behavior: The mode instrument. Educationand Psychological Development, 37, 309–325.Kolb, D. M., & Putman, L. L. (1992, May). The multiple faces of conflict inorganizations. Journal of Organizational Behavior, 13, 311–324.McWilliams, C. (2003). Healthcare decision making for dementia patients:Two problem cases. Internet Journal of Law, Healthcare and Ethics, 2(1),12–19.O’Connor, K. M., DeDreu, C. K., Schroth, H., Barry, B., Lituchy, T. R., &Bazerman, M. H. (2002). What we want to do versus what we think weshould do: An empirical investigation of intrapersonal conflict. Journal ofBehavioral Decision Making, 15, 403–418.

Shelton, C. D., & Darling, J. R. (2004). From chaos to order: Exploring newfrontiers in conflict management. Organization Development Journal,22(3), 22–41.

PART VGroups and TeamsAs we learned in Chapter 5, people are social beings and require satisfyinga need for affiliation or achieving a sense of belonging. Groups help satisfythis need. In Chapter 15, we examine group dynamics. Group dynamics is aterm, created by Kurt Lewin, used to describe the subfield of organizationalbehavior that attempts to understand the nature of groups, how theydevelop, and how they interact with the members, other groups, and theirenvironments. In Chapter 16, we discuss the various types of groups andtheir related functions. Chapter 17 examines the use of teams in today’scomplex health service organizations. Health care delivery “takes a village.”Few jobs can be performed start to finish by one person. To complete a taskrequires resources from many individuals. Today, we see the widespread useof interdisciplinary teams to deliver effective and efficient health care.

CHAPTER 15Overview of Group DynamicsLEARNING OUTCOMESAfter completing this chapter, the student should understand: The importance of group dynamics. The characteristics that define a group. The meaning of group interaction and methods to measure it. What motivates individuals to join and remain in groups. The various roles members assume in groups and the importance ofthese roles. The meaning of group norms and how they are formed and sustained. The factors that contribute to or inhibit group cohesiveness. The impact of conformity on group performance. The impact of groupthink on group decision making.OVERVIEWHuman beings are social animals. Although we are born into and leavethe world in a singular manner, we spend the majority of our time working,worshiping, learning, and playing in groups. Because we spend so much ofour time in groups, there is great interest in understanding the innerworkings of groups and their members. This research is referred to as thestudy of group dynamics, which is the attempt to understand the behaviorin which people interact with, influence, and are influenced by others withingroups.Why is understanding group dynamics important to managers? It isimportant to the success of an organization. More and more organizationsare moving toward a stronger emphasis on their employees working ingroups and/or teams. A study by Blackburn and Rosen (1993) found thatFederal Express had 4,000 employee teams, Motorola used 2,200 problem-solving teams, and at any given time 75 percent of Xerox’s employees serveon some type of task force or on advisory teams. It is estimated that, on

average, managers spend 50 to 80 percent of their working day in one sortof group or another. In the health care setting, this estimate is notsurprising. Health care managers, both clinical and administrative,participate in numerous work groups and teams on a daily basis, such asoperating room teams, disease management teams, patient safetycommittees, biomedical ethics committees, patient care teams, traumateams, and emergency-preparedness and disaster-management teams. Themovement toward accountable care organizations and patient-centeredmedical homes will give further impetus to the growing importance of teamsin health care (Taplin, Foster, & Shortell, 2013). Therefore, managers needto understand the variables involved relating to groups: (1) formation anddevelopment, (2) structure, and (3) interrelationships with individuals, othergroups, and the organizations within which they exist, so that they mayeffectively manage them (Turner, 2000).Our discussion of groups is divided into three sections. We define what agroup is, discuss why individuals join groups, and then examine theinteractions and behavior of members within a group. Although many usethe terms “groups” and “teams” interchangeably, there are differences. Theconcept of groups is broader than the concept of teams. Katzenbach andSmith (1993) point out that teams are a special form of groups that havehighly defined tasks and roles and demonstrate high group commitment.Because of these characteristics, we discuss the nature of teams separately.WHAT IS A GROUP?Social scientists usually define a group using four characteristics: (1) twoor more people in social interaction, (2) a stable structure, (3) commoninterests or goals, and (4) the individuals perceiving themselves as a group.For example, two patients waiting to be treated in a hospital’s emergencydepartment are not a group. This collection of two individuals is not a groupbecause: (1) there is no interaction between the two patients, nor are theyattempting to influence each other; (2) patients in an emergencydepartment constantly change, and therefore, a stable environment does notexist for future interactions; (3) although patients may share similar goals(e.g., restoring their healthy status, alleviation of pain), they are notworking in a coordinated effort to achieve a common goal; and (4) they donot perceive themselves as a group, only as individuals occupying space inthe same location at the same time. However, a group exists whenvolunteer members of the local chapter of the American Heart Associationmeet to plan the next fundraising event, or when a multidisciplinary

medical team convenes for the purpose of developing evidence-basedguidelines for patients admitted to the hospital with congestive heartfailure. These groups represent collections of individuals with a commoninterest or goal in a stable environment (although members may join andleave the group at various times), wherein members interact with oneanother with the intent of influencing the other(s). One important factorrelating to group dynamics is understanding the interactions that occurbetween a group’s members.GROUP INTERACTIONTubbs (2001) defines group interaction as the process by which membersof a group exchange verbal and nonverbal messages in an attempt toinfluence one another. Therefore, interaction includes talking, listening,nonverbal gestures, and any other behavior to which people assign meaning.Can we observe these interactions to better understand the dynamics withina group? Yes, we can. On a formal level, researchers may use a sociogram torecord their observations of the interactions between members of a group(see Figure 15–1).A sociogram is a pictorial method of mapping out and recording thecontributions of members to a group interaction. In the example shown inFigure 15–1, the number of inputs is recorded as lines in the circles, each ofwhich represents a participant in the interaction. The arrows show thedirection of the contributions made, and their thickness indicates theintensity of the traffic. Where an arrow points outward, that indicates acontribution made to the group as a whole, rather than to an individualmember. Where a member addresses the group in general, rather than aparticular member, arrows are shown pointing outward to reflect that.

Figure 15–1 A Typical SociogramHowever, a sociogram is limited to documenting the direction andintensity of communication, not the content of what was communicated bythe members in their attempt to influence one another. Therefore,researchers can use other assessment tools, such as Bales’s InteractionProcess Analysis, that can provide insight about the content of the members’communication (see Figure 15–2).As noted by Sprott (1958), there are 12 categories of interactions withBales’ Interaction Process Analysis; these interactions are classified asrelating to either emotion or task. The emotional responses are eitherpositive (items 1 to 3) or negative (items 10 to 12). Task responses areeither giving (items 4 to 6) or asking for information (items 7 to 9). The 12

categories are also grouped into pairs, as noted in Table 15–1. Theinteractions of these 12 categories greatly influence the roles assumed bymembers and group norms.

Figure 15–2 Bales’s Interaction Process Analysis

Reproduced from Bales, R. F. (1950). Interaction process analysis: A method for the study of small groups. Chicago:University of Chicago Press.WHY DO PEOPLE JOIN GROUPS?Individuals join groups for many reasons, and many of these reasons areexplained with Maslow’s Hierarchy of Needs. Individuals join groups tosatisfy their need for belonging (i.e., the need to have close contact withothers and to be accepted by them), in addition to social and affection needs.Groups can satisfy an individual’s need for safety by reducing the sense ofpowerlessness and anxiety, which one may experience in ambiguous orthreatening situations. Members may join because group affiliation can bean important part of an individual’s self-esteem as well as social identity.People need to have a positive opinion of themselves, which arises in partfrom acceptance by others in a group and evidence that other groupmembers share their views and values. Furthermore, a group can helpmembers achieve stated goals that the member, by himself or herself, couldnot have achieved alone. Group membership can satisfy a number of needsfor an individual, in addition to the member contributing to other membersand the group achieving objectives. However, deciding whether to join agroup or to continue membership with a group poses an approach/avoidanceconflict for people. As such, an individual will perform a cost/benefit analysisof the relationship. Members will continue with their association as long asthe rewards (satisfaction of needs) outweigh or are equal to the costs ofbeing a member, such as required time to participate and financialcommitment. This cost/benefit analysis is analogous to Adams’s EquityTheory of Motivation.

Table 15–1 Bales’s Interaction Process Analysis: Twelve Categories PairedItemsDescriptionExample1 and12OrientationHow well do the group members cohere? Bales gives the example of a man who makes anoffensive remark directed at another member (item 12); however, the laughter that follows isclassified under item 2.2 and11EmotionalresponseonlyBales gives the example of a member sighing heavily and examining his fingernails.3 and10Acceptanceor rejection4 and9ControlAsking for suggestions such as “I think we should do this” or “How do you think we ought totackle this?” By asking for suggestions, a member is getting the others to committhemselves. By committing themselves, members limit their future choices. This is a methodof bringing other members under control, which may or may not lead to resentment.5 and8Opinion“Have we done that?” “We ought to make sure that we do this.” Any comments that involvesummarizing the issues.6 and7OrientationSetting out the problem and giving factual information.Source: Interaction Process Analysis: A Method for the Study of Small Groups, by R. F. Bales, 1950,Chicago: University of Chicago Press. Reprinted with permission.ROLES OF GROUP MEMBERSFunctional Role Theory, as introduced by Benne and Sheats (1948),identified the functional roles they observed individual group membersassuming in small group interactions. The three roles identified were task,maintenance, and individual (sometimes called “self-centered”) roles (seeExhibit 15–1). Task-oriented roles focus on goal accomplishment,maintenance roles focus on relationships, and individual roles focus onindividual needs, which may in the long run be harmful to the group’soverall success. Benne and Sheats’s task and maintenance roles are similarto the two communication patterns, task-oriented and socioemotional, thatwere identified by Bales (1950, 1953, 1970, 1999) with his research on groupmembers’ interactions. Bales’s task role relates to a member’s activities thathelp the group accomplish its goals (e.g., concern for production), and themember’s socioemotional role is described as the activities that he or sheperforms to promote harmonious relations within the group (e.g., concernfor people) (refer to Figure 15–2).Exhibit 15–1 Benne and Sheats’s Functional Roles of Group MembersTask Roles—Groups have members who play roles relating to job completion:• Initiator-contributor: Generates new ideas.• Information-seeker: Asks for information about the task.

• Opinion-seeker: Asks for the input from the group about its values.• Information-giver: Offers facts or generalization to the group.• Opinion-giver: States his or her beliefs about a group issue.• Elaborator: Explains ideas within the group, offers examples to clarify ideas.• Coordinator: Shows the relationships between ideas.• Orienter: Shifts the direction of the group’s discussion.• Evaluator-critic: Measures group’s actions against some objective standard.• Energizer: Stimulates the group to a higher level of activity.• Procedural-technician: Performs logistical functions for the group.• Recorder: Keeps a record of group actions.Maintenance Roles—Groups also have members who play certain social roles:• Encourager: Praises the ideas of others.• Harmonizer: Mediates differences between group members.• Compromiser: Moves group to another position that is favored by all group members.• Gatekeeper/expediter: Keeps communication channels open.• Standard setter: Suggests standards or criteria for the group to achieve.• Group observer: Keeps records of group activities and uses this information to offer feedbackto the group.• Follower: Goes along with the group and accepts the group’s ideas.Individual Roles—Member roles that can be counterproductive to the group accomplishingits task or goals:• Aggressor: Attacks other group members, deflates the status of others, and shows otheraggressive behavior.• Blocker: Resists movement by the group.• Recognition seeker: Calls attention to himself or herself.• Self-confessor: Seeks to disclose non-group-related feelings or opinions.• Dominator: Asserts control over the group by manipulating the other group members.• Help seeker: Tries to gain the sympathy of the group.SOURCE: “Functional Roles of Group Members,” by K. Benne and P. Sheats, 1948. Journal ofSocial Issues, 4, 41–49. Reprinted with permission.Members may assume different roles depending on the needs of theindividual or group. However, Bales found that some members engaged inmore task and socioemotional activities than others and, as a result, wereoffered leadership status in the group. But Bales also found that the personwho engaged in the most task activities was not the same person whoperformed the most socioemotional activities. Therefore, two leadersemerged: the task leader, who was rated as having the best ideas, offeringthe most guidance, and being most influential in forming the group’sopinions, and the socioemotional leader, who was the best liked. The usualexplanation for the emergence of the second leader is that a task leader’ssense of purpose gives rise to activities (e.g., unpopular orders, sharpcriticism) that hurt group members’ feelings. The second leader emerged to

smooth things over and restore harmony to the group.Belbin (1981, 1993, 2004) studied the performance of a team and howperformance was directly affected by the roles that members play. Belbindeveloped the Team Role Theory, which proposes that for optimal operationof a management team, nine (originally eight) personality-related teamroles needed to be fulfilled. The roles are: chairman/coordinator, shaper,plant, teamworker, completer/finisher, company worker/implementator,resource investigator, monitor/evaluator, and specialist. Belbin’s nine rolescan be categorized as either task/task-oriented, maintenance/socioemotionalpositive, or individual/socioemotional negative with Benne and Sheats’sFunctional Role Theory and Bales’s Interaction Analysis (see Table 15–2).All groups need task leadership as well as attention to details and a concernfor people for effectiveness. Understanding the various members’ roles isimportant to understanding the interactions that either push toward orhinder a group from meeting its goals, including member satisfaction withthe interactions. The role(s) a member assumes and the resultinginteractions greatly influence the group’s norms.GROUP NORMSEvery group has a set of norms, which is an implied code of conduct aboutwhat is acceptable and unacceptable member behavior. Norms can bewritten or unwritten, positive, negative, or neutral and applied to allmembers of the group or only to certain ones. In addition, groups will apply“punishment” or sanctions to members if their behavior deviates from thegroup’s norms. Norms can dictate the performance level of groups (e.g.,high- or low-productivity work groups), the appearance of group members(e.g., bankers wear dark suits), or the social arrangement within the group(chair of the committee sits at the head of the conference table).If written, norms become the formal rules of conduct for group members(see Exhibit 15–2). Most organizations have formal rules of conduct, whichare delineated in their policies and procedures manuals. For example, ahospital would have written policies as to clinical research protocols;infection-control procedures for handling blood and other body fluids; theproper attire to be worn in operating room suites; and processes to ensurethat the correct patient (and correct body part) is operated on.However, in most instances group norms are unwritten and learned bymembers through their interactions with others. For example, Crandall(1988) studied groups of cheerleaders, dancers, and female sorority

members with high rates of eating disorders and noted that these groupsadopted the behaviors of binging and purging as normal methods of weightcontrol. The most popular members of the group binged and purged at therate established by the norms of the group, and those who did not binge andpurge when they first joined the group were more likely to take up thepractice the longer they were members of the group. This alignment ofbehavior within a group is part of an individual’s socialization process. Thisprocess of socialization explains how unwritten norms become the“standards” for the group, as members begin to internalize the group’snorms as their own behavior standards. As such, norms do not just maintainorder within the group; they also maintain the group itself (Youngreen &Moore, 2008).Table 15–2 Comparison of Members’ Roles

 

Since most group norms are unwritten, they are usually not easilyidentified until violated. When group norms are violated, members of thegroup will attempt to convince the “deviant” to conform to the group’sstandards of behavior. If the use of persuasion is not successful, the groupmay punish the member by withdrawing any “special” status that he or shemay hold, or psychologically reject (e.g., ignore) the member. The finalconsequence for a member who refuses to conform would be dismissal fromthe group. Through this process, members learn the range or boundaries ofacceptable behavior within a group. For example, Feldman (1984) describesthe norms about productivity that frequently develop among piece-rateworkers. A person produces 50 widgets and is praised by his coworkers; aperson produces 60 widgets and receives a sharp teasing from them; aperson produces 70 widgets and is ostracized by the group. Not all behaviordeviations will be enforced, only those violations that have some significanteffect on the group meeting its goals (see Table 15–3). Norms are powerfulforces not only over the behavior of group members, but also in determiningthe degree of cohesiveness and conformity of the group.Exhibit 15–2 Formal Rules of ConductNotice of Monthly Meeting of the Biomedical Ethics Committee of Glen Haven Hospital• Monthly meetings are held on the first Tuesday of each month.• Meetings begin at 5:00 p.m. and end at 7:00 p.m.• If you are unable to attend the meeting, please notify the Secretary of the committee.• No item will be discussed unless noted on the agenda. If you wish to add an item for discussion,please notify the Chair of the committee no less than two weeks prior to the scheduledmeeting. The Chair must approve all agenda items.• Issues requiring a vote of committee members will pass by a majority (hand) vote.• New business will be discussed during the last 15 minutes of the meeting (no exceptions!).

Table 15–3 Why Norms Are EnforcedFour Conditions Under Which Group Norms AreMost Likely to Be EnforcedExampleIf norms facilitate group survivalMembers do not discuss internal problems with members of otherorganizational unitsIf norms simplify, or make predictable, whatbehavior is expected of group membersNegative comments on presentations or proposals will be made on anindividual basis, not during large, formal meetingsIf norms help the group avoid embarrassinginterpersonal problemsMembers do not discuss romantic involvement so that differences inmoral values do not become salientIf norms express the central values of thegroup and clarify what is distinctive aboutthe group’s identityLevels of productivity should remain relatively stable because thegroup is more concerned with maximizing group security than aboutindividual profitsSource: “The Development and Enforcement of Group Norms,” by D. C. Feldman, 1984. The Academy ofManagement Review, 9, pp. 47–53. Reprinted with permission.COHESIVENESSThe degree of cohesiveness (e.g., camaraderie) of a group is determined byvarious factors, which may include members’ dependence and physicallocation/proximity. The more significant factors tend to be: (1) the size ofthe group, (2) experience of success by the group, (3) group status, and (4)outside threats to the group.Size of the GroupResearchers have determined that the size of the group has a directimpact on the cohesiveness of a group. When there are too many members,it becomes too difficult for members to interact. Luft (1984, p. 23) concludedthat “cohesion tends to be weaker and morale tends to be lower in largegroups than in comparable smaller ones.” What is the acceptable group size?Kameda et al. (1992) suggest that five members appears to be the optimumgroup size. Five-member groups are small enough for meaningfulinteraction yet large enough to generate an adequate number of ideas(Tubbs, 2001). Small groups may also avoid the problem of social loafing.Social LoafingSocial loafing refers to the decreased effort of individual members in agroup when the size of the group increases (Tubbs, 2001). Ringelmann(1913) identified this social phenomenon when he noticed that as more andmore people were added to a group pulling on a rope, the total force exertedby the group rose, but the average force exerted by each group memberdeclined. The reason is that some members’ performance became mediocre

because they assumed that other members would pick up the slack. Karauand Williams (1993) found that social loafing occurs across work populationsand tasks. However, the researchers noted that if the participants’dominant culture emphasized collectivism versus individualism as describedby Hofstede’s four dimensions of national culture, the degree of socialloafing decreased.Subsequent studies revealed that when an individual’s contribution isidentified, and the person is held directly accountable for and rewarded forhis or her behavior, social loafing may be eliminated (Kerr, 1983; Kerr &Bruun, 1981; Shepperd, 1993; Szymanski & Harkins, 1987). Beyerlein et al.(2003) stress that personal accountability by each group member for his orher role and responsibilities is required to achieve an effective collaborativeteam. When accountability is lacking, members will usually act in supportof their own self-serving interests. For example, members will sometimeshold back if they believe other members of their group are not extendingequal efforts toward accomplishing the task.Experience of SuccessPrior success of a group reaching its goals has a direct impact on thedegree of cohesiveness. No one wants to stay on a losing team! When agroup fails to obtain its goals, members display a lack of unity by infighting,finger pointing, and, finally, disassociation.Group StatusCohesiveness is more prominent when admission into the group is moredifficult to obtain because of various barriers or high criteria—for example,education levels. This perception of status, whether real or not, creates afeeling of being in the “in-group” for those individuals who were able toovercome the barriers for admission into the group—for example, aphysicians’ group.Outside Threats to the GroupThe cohesiveness of a group will increase if members perceive that anexternal force may prohibit the group from obtaining its goals. Members ofthe group will unite to display a unified front to the opposing force. Inaddition, cohesive groups will unite against nonconforming members whothreaten the esprit de corps of the group. As such, cohesive groups exertpressure on members of the group to conform.

Managers should assist their subordinates’ development into cohesivework groups because research has shown that cohesive units demonstrate ahigher level of productivity when compared with less cohesive groups.However, managers need to be aware that group norms may mediate therelationship between cohesiveness and performance. On the one hand, ifnorms support performance-related activities, then cohesiveness is likely toimprove performance. If, on the other hand, norms support limited outputor engagement in irrelevant tasks, cohesiveness may undermineperformance (Berkowitz, 1954).In conclusion, group cohesiveness is a product of social identification.According to Hogg and Abrams (1990), the more positive a member feelsabout his or her group, the more motivated the person is to promote in-group solidarity, cooperation, and support. In turn, the more cohesive agroup is, the more likely its members will socially interact and influence oneanother (Turner, 1987). Because of these interactions, we find that morecohesive groups have a tendency to pressure their members toward a higherdegree of conformity, and a high degree of conformity may lower theperformance level of the group.CONFORMITYStrong group norms and high degrees of group cohesiveness can hamperthe performance of a group because of conformity pressures. Conformityinvolves the changing of an individual’s perceptions or behaviors to matchthe attitudes or behaviors of others. This “normative social influence” iswhen we conform to what we believe to be the norms of the group in orderto be accepted by its members.One of the earliest studies in the conformity area was Sherif’s (1936)experiment that involved the autokinetic effect. Sherif pointed a light in adark space that, although stationary, appeared to move. Subjects wereasked to estimate the amount of movement they observed both asindividuals and as a member of a group. When in groups, the subjectschanged their original estimates to more closely fit the answers of the othermembers. This experiment demonstrated the individual’s urge to conform.Asch (1952) also conducted conformity studies. In Asch’s experiments,eight people were seated around a table. Of these eight people, seven wereactually the experimenters or confederates. However, the eighth person wasunaware of this situation. The group was shown two cards; each cardcontained different lengths of vertical lines (i.e., no two lines matched inlength on either card). The participants were asked to say which of the lines

matched the length of another. One after another, the participantsannounced their decisions. The confederates had been asked to give theincorrect response. The eighth subject sat in the next to last seat so that allbut one participant had given an obviously incorrect answer before thesubject gave his or her answer. Even though the correct answer was obvious(i.e., no two lines matched in length on either card), Asch found that one-third of the subjects conformed to the majority, one-third never conformed,and the remaining one-third gave conforming responses at least once. Thisexperiment was designed to create pressure on subjects to conform toothers, which in fact they did.Although Asch’s experiment has been criticized for being unrealistic (i.e.,in the real world, individuals would be making decisions on subjects morecomplex and more important than the length of a line), it did confirm that“humans have the tendency to conform to the goals and ideas of a smallgroup and tend to be unwilling to go against the group even if they knowthe group is wrong” (Asch, 1960).Not all people conform. There is evidence that those who do not conformtend to have a healthy level of self-esteem and to have mature socialrelationships, as well as being fairly flexible and open-minded in theirthinking. For example, Crutchfield (1955) and Tuddenham (1958) found thatthere is a correlation between high intelligence and other personality traitsand low conformity. Another important aspect of conformity is that it maylead to “groupthink.”GROUPTHINKStrong conformity pressures reflect members’ attempts to maintainharmony within the group. However, conformity may hamper a group’sperformance by decreasing innovation and increasing faulty decisionmaking. Janis (1982) referred to this situation as “groupthink.” Groupthinkrefers to conditions under which efforts to maintain group harmonyundermine critical thought and lead to poor decisions (Janis, 1982; Janis &Mann, 1977). Janis, as cited in Tubbs (2001, p. 236), identified eightsymptoms of groupthink:Type I: Overestimation of the group—its power and morality1. An illusion of invulnerability, shared by most or all of the members,which creates excessive optimism and encourages taking extremerisks.

2. An unquestioned belief in the group’s inherent morality, inclining themembers to ignore the ethical or moral consequences of theirdecisions.Type II: Closed-mindedness3. Collective efforts to rationalize in order to discount warnings or otherinformation that might lead the members to reconsider theirassumptions before they recommit themselves to their past policydecisions.4. Stereotyped views of enemy leaders as too evil to warrant genuineattempts to negotiate or as too weak and stupid to counter whateverrisky attempts are made to defeat their purposes.Type III: Pressures toward uniformity5. Self-censorship of deviation from the apparent group consensus,reflecting each member’s inclination to minimize to him- or herselfthe importance of his or her doubts and counterarguments.6. A shared illusion of unanimity concerning judgments conforming tothe majority view (partly resulting from self-censorship of deviations,augmented by the false assumption that silence means consent).7. Direct pressure on any member who expresses strong argumentsagainst any of the group’s stereotypes, illusions, or commitments,making clear that this type of dissent is contrary to what is expectedof all loyal members.8. The emergence of self-appointed mindguards—members who protectthe group from adverse information that might shatter its sharedcomplacency about the effectiveness and morality of its decisions.Was groupthink the downfall of HealthSouth? (See Exhibit 15–3.) Manyformer senior managers of HealthSouth, a nationwide provider ofrehabilitative services headquartered in Birmingham, Alabama, wereindicted and/or found guilty of fraudulently and systemically inflating thecompany’s earnings and assets by approximately $4 billion during the 1990s.Exhibit 15–3 Five HealthSouth Officers Charged with Conspiracy to Commit Wire and SecuritiesFraudCount 1 of the Information alleges that a conspiracy existed from in or about 1994 until thepresent between AYERS, EDWARDS, MORGAN, AND VALENTINE and with Owens, Smith,Harris, and others to devise a scheme to inflate artificially HealthSouth’s publicly reported

earnings and the value of its assets, and to falsify reports of HealthSouth’s financial condition. Itwas part of the conspiracy that Owens, Smith, Harris, and others would provide the ChiefExecutive Officer (CEO) with monthly and quarterly preliminary reports showing HealthSouth’strue and actual financial results. After reviewing these reports, Owens, Smith, Harris, andothers would direct that HealthSouth’s accounting staff find ways to ensure that HealthSouth’s“earnings per share” number met or exceeded Wall Street analyst expectations. After Owens,Smith, Harris, and others issued instructions as to the desired earnings per share number,HealthSouth’s accounting staff would meet to discuss ways to inflate artificially HealthSouth’searnings to meet the CEO’s desired earnings numbers.These meetings were known as “family” meetings, and attendees were known as the “family.”At the meetings, they would discuss ways by which members of the accounting staff would falsifyHealthSouth’s books to fill the “gap” or “hole” and meet the desired earnings. The fraudulentpostings used to fill the “hole” were referred to as the “dirt.” Owens, Smith, Harris, and otherswould and did direct one or more of the defendants, also members of the accounting staff, tomake false entries in HealthSouth’s books and records for the purpose of artificially inflatingHealthSouth’s revenue and earnings. Owens, Smith, Harris, and others would direct one or moreof the defendants to make corresponding false entries in HealthSouth’s books and records for thepurpose of artificially inflating the value of its assets, including, but not limited to, false entriesmade to (a) Property, Plant and Equipment (“PP&E”) accounts; (b) cash accounts; (c) inventoryaccounts; and (d) intangible asset [goodwill]. When events required that financial records andreports related to units of HealthSouth were called for by auditors, purchasers, and others,Owens, Smith, Harris, and others would direct one or more of the defendants to generate recordsand reports that would black out the false entries. Owens, Smith, and one or more of thedefendants would, for the purpose of deceiving auditors, manufacture false documents for thepurpose of supporting false record entries. One or more of the defendants would and did changecodes on accounts to deceive auditors.Reproduced from the U.S. Department of Justice’s Press Release dated April 3, 2003.Managers must be careful because group members sometimes desire tomaintain their close team relationships, or in the HealthSouth case, “thefamily relationship,” at all costs. When group members operate in agroupthink mode, they may engage in decision making. For example,consider a health care provider that has proposed a new medical procedurefor joint replacements. Some team members are initially resistant becauseof high training demands, even though the new procedure would establishbest practices. To preserve harmony in the group, other staff members goalong with the resisting members. In this case, the team has succumbed togroup thinking instead of critical thinking.Many studied the culture of the National Aeronautics and SpaceAdministration (NASA) after the Challenger disaster and found evidence ofthis type of groupthink. Engineers did not voice their concerns and criticismbecause of the strong team spirit and camaraderie at NASA. In other words,it is when groups display a high degree of cohesiveness that you have to beon guard against groupthink.

Some suggested safeguards against groupthink include: (1) solicitingoutside expert opinions during the decision-making process, (2) appointing adevil’s advocate to challenge majority views, (3) hypothesizing alternativescenarios of a rival’s intention, and (4) reconsidering decisions after awaiting period. Many researchers have questioned the effectiveness of thesesafeguards. For example, Bennis (1976) argues that a devil’s advocate willbe ignored if the group perceives the member as only role-playing.SUMMARYMany factors influence our behavior. Group dynamics is a complex subjectthat attempts to provide us with some understanding of how individualsinteract with one another and how those interactions become visible in ourresulting behavior. Burton and Dimbleby (1996) developed a model, usinginterpersonal communication as the foundation, to help us understand thecomplexity of group dynamics (see Figure 15–3).The figure is titled “The Interface of Me and Them.” Since groupdynamics is the attempt to understand how people interact with andinfluence others within groups, the title is most appropriate. Whenexamining the model, you will notice that the bottom half is concerned with“me” and the top half represents “them.” The process begins with anindividual’s needs or motivation, which triggers the “whole of self.” Thetriangle represents the various interactions we have with our groups thatare filtered through our self-concept, which, taken together, form ourpersonal roles. We then communicate our role and receive feedback fromboth ourselves (did I play the role correctly?) and from others (did theyconfirm my behavior was correct?) to restart the process of redefining whowe are as an individual (personal role). Although the model may appearsomewhat complex, it only starts to explain the complexity of humanbehavior.

Figure 15–3 The Interface of Me and ThemReproduced from Burton, G., & Dimbleby, R. (1996). Between ourselves: An introduction to interpersonal communications(2nd ed.). London: Edward Arnold.DISCUSSION QUESTIONS1. Define the study of group dynamics and discuss why it is important totoday’s managers.2. Describe the four characteristics that define a group and provideexamples of nongroups and groups.3. Explain what is meant by “group interaction.”4. Discuss how group interactions can be measured.5. Discuss why people join groups and what sustains their membership.6. Explain the importance of the various roles members assume ingroups.7. Discuss how group norms are formed and sustained within groups.

8. Explain how group cohesiveness is developed and sustained.9. Discuss why conformity can inhibit a group’s performance.10. Explain what behavior is displayed by a group operating under“groupthink.”EXERCISE 15–1Form small groups of four to five individuals and discuss the followingstatement:Often employees do not act or react as individuals but as members ofgroups.When discussing this statement, the members should share experiences ofworking in groups. Can you recall an instance in which you gave in becauseof the pressure to conform? Have you experienced a nonconformist in one ofyour groups? How did you or other members of your group react to“deviant” behavior in your group?EXERCISE 15–2Form small groups of four to five individuals. Using the worksheet “Bethe Best We Can Be Team Norms,” discuss how the answers to thequestions can assist the group with developing team norms so each memberunderstands his or her expected behaviors.Be the Best We Can Be Team Norms1. When I am upset with someone I will:2. One way I can avoid making premature assumptions is:3. One thing I think we could do to resolve differences among us as ateam could be:4. One thing important to me about how we communicate (e-mail, text,F2F, etc.) is:5. When someone comes to complain to me about so-and-so on our teamI/we will:6. One way I’d like to be recognized or appreciated is:7. One thing our group could do when we forget our TeamCommitments and want to get back on track could be:

Reprinted with permission from Nance Guilmartin: author, The Power ofPause: How to Be More Effective in a Demanding, 24/7 World.EXERCISE 15–3Analyze the level of group cohesiveness in one of the groups to which youbelong.REFERENCESAsch, S. (1952). Effects of group pressure on the modification and distortionof judgments. Reprinted in G. E. Swanson, T. M. Newcomb, & E. L.Hartley (Eds.) (1965), Readings in social psychology (2nd ed.). New York,NY: Holt, Rinehart & Winston.Asch, S. (1960). Social psychology. Englewood Cliffs, NJ: Prentice Hall.Bales, R. F. (1950). Interaction process analysis: A method for the study ofsmall groups. Chicago, IL: University of Chicago Press.Bales, R. F. (1953). The equilibrium problem in small groups. In T. Parsons,R. F. Bales, & E. A. Shils (Eds.), Working papers in the theory of action(pp. 111–167). Glencoe, IL: Free Press.Bales, R. F. (1970). Personality and interpersonal behavior. New York, NY:Holt, Rinehart & Winston.Bales, R. F. (1999). Social interaction systems: Theory and measurement.New Brunswick, NJ: Transaction.Belbin, R. M. (1981). Management teams: Why they succeed or fail. London,UK: Elsevier/Butterworth-Heinemann.Belbin, R. M. (1993). Team roles at work. London, UK:Elsevier/Butterworth-Heinemann.Belbin, R. M. (2004). Management teams: Why they succeed or fail (2nd ed.).London, UK: Elsevier/Butterworth-Heinemann.Benne, K., & Sheats, P. (1948). Functional roles of group members. Journalof Social Issues, 4, 41–49.Bennis, W. (1976). The unconscious conspiracy: Why leaders can’t lead. NewYork, NY: AMACOM.Berkowitz, L. (1954). Group standards, cohesiveness, and productivity.Human Relations, 7, 509–519.Beyerlein, M. M., Freedman, S., McGee, C., & Moran, L. (2003). Beyond

teams: Building the collaborative organization. San Francisco, CA: Jossey-Bass/Pfeiffer.Blackburn, R., & Rosen, B. (1993). Total quality and human resourcesmanagement: Lessons learned from Baldrige Award-winning companies.Academy of Management Executive, 7(3), 49–66.Burton, G., & Dimbleby, R. (1996). Between ourselves: An introduction tointerpersonal communications (2nd ed.). London, UK: Edward Arnold.Crandall, C. S. (1988). Social contagion of binge eating. Journal ofPersonality and Social Psychology, 55, 588–598.Crutchfield, R. (1955). Conformity and character. American Psychologist,10, 191–198.Feldman, D. C. (1984). The development and enforcement of group norms.Academy of Management Review, 9, 47–53.Hogg, M., & Abrams, D. (1990). Social motivation, self-esteem and socialidentity. In D. Abrams & M. Hogg (Eds.), Social identity theory:Constructive and critical advances (pp. 28–47). New York, NY: HarvesterWheatsheaf.Janis, I. L. (1982). Groupthink: Psychological studies of foreign policydecisions and fiascoes (2nd ed.). Boston, MA: Houghton-Mifflin.Janis, I. L., & Mann, L. (1977). Decision making. New York, NY: FreePress.Kameda, T., Stasson, M. F., David, J. H., Parks, C., & Zimmerman, S.(1992). Social dilemmas, subgroups, and motivational loss in task-orientedgroups: In search of an “optimal” team size. Social Psychology Quarterly,55, 47–56.Karau, S. J., & Williams, K. D. (1993). Social loafing: A meta-analyticreview and theoretical integration. Journal of Personality and SocialPsychology, 65, 681–706.Katzenbach, J. R., & Smith, D. K. (1993). The wisdom of teams: Creatingthe high performance organization. Boston, MA: Harvard Business SchoolPress.Kerr, N. L. (1983). Motivation losses in small groups: A paradigm for socialdilemma analysis. Journal of Personality and Social Psychology, 45, 819–828.Kerr, N. L., & Bruun, S. E. (1981). Ringelmann revisited: Alternativeexplanations for the social loafing effect. Social Psychology Bulletin, 7,224–231.Luft, J. (1984). Group processes: An introduction to group dynamics (3rd

ed.). Palo Alto, CA: National Press.Ringelmann, M. (1913). Recherches sur les moteurs animes: Travail deI’homme [Research on animate sources of power: The work of man].Annales de l’Institut National Agronomique, 2e serie-tome XIL 1–40.Sherif, M. (1936). The psychology of social norms. New York, NY: OctagonBooks.Shepperd, J. A. (1993). Productivity loss in performance groups: Amotivation analysis. Psychological Bulletin, 113, 67–81.Sprott, W. J. H. (1958). Human groups. Harmondsworth, England: PenguinBooks.Szymanski, K., & Harkins, S. G. (1987). Social loafing and self-evaluationwith a social standard. Journal of Personality and Social Psychology, 53,891–987.Taplin, S. H., Foster, M. K., & Shortell, S. M. (2013). Organizationalleadership for building effective health care teams. Annuals of FamilyPractice, 11(3), 279–281.Tubbs, S. L. (2001). A systems approach to small group interaction. NewYork, NY: McGraw-Hill Book Company.Tuddenham, R. (1958). The influences of a distorted norm upon individualjudgments. Journal of Psychology, 46, 227–241.Turner, J. (1987). Rediscovering the social group. New York, NY: BasilBlackwell.Turner, M. E. (2000). Groups at work: Theory and research. Mahwah, NJ:Lawrence Erlbaum Associates.U.S. Department of Justice, Northern District of Alabama. (April 3, 2003).Five HealthSouth Officers Charged with Conspiracy to Commit Wire &Securities Fraud [Press Release]. Available at: www.usdoj:gov/usao/alnYoungreen, R., & Moore, C. D. (2008). The effects of status violations onhierarchy and influence in groups. Small Group Research, 38(5), 569–587.

CHAPTER 16GroupsLEARNING OUTCOMESAfter completing this chapter, the student should be able to understand the: Importance of a group’s size. Three broad categories of groups. Difference between informal and formal groups. Different types of task groups. Five stages of group development. Seven stages of group decision making. Different methods for group decision making.OVERVIEWIn this chapter, we discuss the composition, structure, formation, anddecision-making processes of groups. The optimum size for a group is fivemembers. However, we will find groups with fewer than five members andthose with more. When groups have fewer than five members, problemsmay arise relating to an inability to make decisions and lower levels ofcreativity (Tubbs, 2001). If the group size becomes too large, subgroups mayform, distracting from the main group’s purpose, and a majority of thegroup’s time is used for functioning purposes (e.g., organizing members,assigning roles) versus the required task (Tubbs, 2001). All these situationscan cause frustration among the members and stifle the group’s ability toreach its goal.TYPES OF GROUPSGroups can be categorized into three broad groups: primary, secondary,and reference. In the workplace, groups operate under an informal or formalstructure.

Primary GroupsPrimary groups include one’s family and closest friends and/or peers.Social psychologists tend to see primary groups as those that: (1) involveregular contact between members of the group, whether through directface-to-face interaction, technology, or other means, and (2) are fairly small(i.e., 20 members or less) (Blackler & Shimmin, 1984). In addition, primarygroups: (1) involve cooperation, (2) share common goals, (3) are familiarwith all members, and (4) have an understanding of the role(s) of eachmember.Primary groups have a powerful influence on the member’s self-concept,as well as the development of the individual’s perceptions and attitudes.During an individual’s childhood and adolescent years, the family unit has astrong impact on the development of the individual’s personality and futurebehaviors, both socially and in the workplace.Secondary GroupsSecondary groups comprise the larger circle of people we associate with.During an individual’s adult years, associations with work and professionalgroups will influence his or her attitudes and perceptions through variousinteractions with these different groups. For example, Jane Kerry, RN, is amember of a family group, a member of a group of close-knit friends thatmeet for dinner once a month (friends Jane has known from high school),the president of her local bridge club, and a member of Glen HavenHospital’s neonatal intensive care unit nursing staff and qualityimprovement committee. After this, Jane’s groups become larger. She is amember of the hospital’s pediatric department, a member of the hospital’snursing staff, and a member of the hospital’s overall community. Inaddition, she is a member of the American Nurses Association. Some ofthese group memberships may be short-term and others long-term. Nomatter what the time frame, each group will influence Jane’s behavior.Reference Groups“Reference group” is a term coined by Herbert Hyman (1942, 1968) todesignate a group that an individual uses as a “point of reference” indetermining his or her judgments, preferences, and behaviors. A person usesa reference group as an anchor point for evaluating his or her own beliefsand attitudes. Even though an individual may or may not be a member andmay or may not aspire to be a member in a reference group, the group can

have great influence on the person’s values, opinions, attitudes, andbehavior patterns. A reference group’s influence on an individual may bepositive or negative. An individual may pattern his or her own beliefs andbehavior to be congruent with or opposite to those of the group. The church,labor union, and political party are examples of both positive and negativereference groups for specific individuals. The size of a reference group canrange from a single individual (i.e., a movie star, athlete, supermodel, andso on) to a large aggregate of persons, such as a political party or religiousinstitution.INFORMAL OR FORMAL GROUP STRUCTUREIn the workplace, two types of groups can be found: informal groups andformal groups.Informal GroupsThe informal group (also referred to as cliques) is organized on the basisof the members’ common interests or goals. Membership is voluntary andnot part of the official structure of the organization. Although informalgroups usually have a short life cycle, they can have a significant effect onthe organization’s current and future operations. Informal groups can andoften influence others’ attitudes, perceptions, group norms, andcommunication networks.For example, a small group of nurses, employed at a large communityhospital, were unhappy about their work environment and would meet dailyduring lunch to discuss the situation. There had been a recent change in thehospital’s senior management, which caused a high level of uncertaintyamong the clinical staff. The nurses also felt overworked as a result of thewell-recognized nursing shortage. Their wages and benefits had beenstagnant, with no salary market adjustments for the past three years.Furthermore, whenever they approached management with their concerns,they perceived that these concerns were falling on deaf ears since nochanges were ever made. This informal group of nurses decided to contact alabor union. The labor union began an organizing effort in the hospitalshortly thereafter, holding an aggressive campaign over a six-week period.There was tremendous peer pressure, as some of the well-respected nursingstaff became active leaders for unionization, although they were not part ofthe initial organizing group. The election was held and the union was votedin by two-thirds of the nursing staff. In the weeks that followed, the clinical

nursing staff remarked that they were surprised by the union’s victory; theyhad only wanted to “scare” management into making changes to their workenvironment.Many cliques in the workplace can exist harmlessly, but managers needto be aware that some informal groups can be a powerful force within theirorganization. With an understanding of their influence, managers can alsouse informal groups to initiate positive changes. For example, theadministrator of a free-standing outpatient surgical center wanted to begina cross-training program of the clinical staff to improve the organization’sperformance. She knew that staff would resist this “new” concept because ofher past failures to implement change. Learning from her past mistakes,she enlisted the support of a group of nurses that had developed into aclosely knit group. This was also the nursing group that other clinical stafflooked to for guidance on patient care issues. The administrator secured thesupport of the informal group by showing how the change would increasethe quality of care for the patients (e.g., a more knowledgeable workforce),patient satisfaction (e.g., shorter wait time for procedures to be performed),and job security (e.g., increase in the organization’s financial stability).Because of the nursing group’s support, the change was successfullyimplemented with minimum resistance from staff. Furthermore, theoutcomes that the administrator predicted would occur did happen. Theseoutcomes positively reinforced the relationship between the informalnursing group and management.Informal groups meet the needs of individuals and, therefore, have astrong influence on the members’ behaviors. If managers are aware of thesegroups, these groups can be enlisted to assist the organization in achievingits goals (see Case Studies 16–1 and 16–2).Case Study 16–1 Using Informal Groups to Promote Organizational GoalsThe clinic’s chief executive officer (CEO) was known for consistently seeking, listening to, andincorporating the views of others. While she worked effectively through the formal hierarchy, shealso regularly sought the views of both physician and employee influence leaders. These influenceleaders were part of a group that met to provide input, shape ideas, and take accurate informationforth to those who looked to them for the inside scoop. Their role in helping to sell others on newdirections was clearly recognized.For example, when it came time to consider affiliating the clinic with another health careorganization, influence leaders made site visits and came back to share their feelings with a broadcross-section of the organization. Many who listened to them would have been more skeptical if theinformation presented had come from the lips of the CEO.SOURCE: “Informal Leadership Support: An Often Overlooked Competitive Advantage,” by L. H.

Peters and E. J. O’Connor, 2001. Physician Executives, 27(3), pp. 35–39. Reprinted with permission.Case Study 16–2 Informal Leaders and Cultural ChangeAlthough informal leaders are crucial to the success of a change involving the nursing team, theyare often overlooked. In this case study, nursing leaders at Wake Forest Baptist Medical Centertapped into the valuable resource of informal leaders when implementing a new professionalpractice model, which ultimately transitioned to a theoretical basis for a new model of care. Theydescribed their story as follows:Role of the Informal LeaderBefore we could implement a change that significantly impacted nursing culture, we had tounderstand the nature of informal leadership. Teams may operate without explicitly assigned rolesor established authority and as a result are classed as “informal.” Informal leaders in nursing areoften nurses with a high level of clinical competency who are recognized as experts. This type ofleader influences the group, comes from the team, and is chosen by the team.Informal leaders don’t have the power to hire or fire other staff or influence compensation, butthey are often charismatic, with an outspoken nature or a strong will. Many informal leaders innursing can be troubleshooters, super users, and champions who volunteer for extra jobs, serve onunit or hospital-wide committees, and shared governance councils. The informal leader is oftentapped to provide feedback for new projects and may assume supportive roles such as preceptor,educator, or charge nurse.Informal leadership is often an innate characteristic found in many nurses and integral to the roleof “advocate.” Autonomy and empowerment in the work environment are key attributes supportingadvocacy. Advocacy hones communication skills in order to follow through with, or change,interventions to create more positive outcomes for patients.Informal leaders are in a unique position to influence the groups they work with. The influencecan be used in a positive or obstructive way when change is involved. The informal leader is mostinfluential when a group is first exposed to the change and the knowledge base is just beginning toform. As the group becomes more certain and experiences success, the informal leader’s influencemay diminish.Informal leaders can also be excellent followers. A follower is often thought of as weak, ineffectual,or prone to failure, but that is usually far from the truth. Followers can easily move in and out ofinformal leadership roles by supplying energy, enthusiasm, and interest. Followers often have anemotional attachment to the leader. A mentor relationship may exist, and with cultivation thefollower may become a formal leader. The relationship between the follower and leader variesdepending upon the type of change or intensity of the change that is undertaken. Through therelationship with the leader, the follower may attain a fair degree of power.Starting the ChangeWe undertook a redirection of nursing practice: developing a formal model of care, or philosophyof nursing, articulated and owned by staff. The model of care transitioned to a deeper, theoreticalformat. We enlisted the support of informal leaders within pilot units to facilitate this change.In preparation for implementing the new model, we used several techniques to strengthen ahealthy and caring environment including role playing, team-building exercises, and leveragingempowerment and autonomy. Education and discussion took place in a venue incorporating allselected representatives and was led by a formal leadership team, with delegated responsibility forthe model of care by the chief nursing officer (CNO).Two RN nurse champions were chosen by the unit staff to represent their practice areas withrecognized content experts and resources in caring practice. Relationship-based care was

implemented using a wave progression where model units completed small, incremental stepsthrough the Shared Governance structure. The Nurse Champions in Caring Practice led theeducation, discussion, and implementation of core strategies unique to each area. Strategiesaddressed care of patient/family, care of self, and care of team.Staff developed two strategies specific to their work areas. As the model units completed theirwork, the next wave of practice areas participated in the same process. As all units stabilized, thechampions assisted in planning the next transition in the model of care—operationalizing JeanWatson’s Theory of Human Caring.Value of Informal LeadersInformal leaders are important to any change process. The leader of the change needs to beavailable and provide information. Team members often address concerns and issues with informalleaders that are not shared with managers. The leader of a significant change event should be visibleto coach informal leaders by providing direction with informing, educating, observing, and givingpositive feedback. Teachable moments are critical and even small successes should be celebrated.Expectations should be clear, specific, and written. The Nurse Champions in Caring Practice weredeveloped to coach the staff in their areas. Few limitations were put on the strategies and creativitywas encouraged. Development occurred within unit-based shared governance councils so that allstaff was a part of the projects.Even when staff agrees that a change is positive, acknowledgement of loss of routine, feelings ofcompetence, the formation of a new team and new role definitions is important in the transitionperiod. Change is more successful if framed in terms of the effect on the team and should beaddressed in a direct way. Questions that arise as a result of change often represent different pointsof view. The manager/leader may be outcome focused and ask:• What is the goal?• What will it look like?The informal leader or staff may question how they are directly impacted by the change and ask:• What am I getting?• What am I losing?• What will be different?Tangible and discreet events may help smooth a change that impacts culture and allow for time toadjust emotionally within the context of a larger project. The analogy “How do you eat an elephant?One bite at a time,” may elicit buy-in and investment from the informal leaders who can then act ascoaches with other staff.The informal leaders formed a core group who acted as role models and assisted other nurses inestablishing appropriate patient goals, which helped make the change occur more smoothly. Theinformal leaders also provided follow-up and assistance if goals were missing.An early success came when the CNO held town hall meetings about the new professional practicemodel. The meetings were web-cast throughout the medical center. A nurse in the audience sharedher experience with several of the patient-centered strategies while her husband was a patient on apilot unit. His course was complicated and difficult, but she felt there was a difference in hisoutcome as a result.Resistance to ChangeWhen informal leaders do not exert a positive influence, it is important to provide information anddirectly address their role in the change. Resistance is a natural part of change and demonstratesthat staff are engaged. The leader needs to maintain a clear focus during the transition period.If the informal leader continues to resist, the leader should work to find a part of the plan that theinformal leader can live with and enlist support for that part. This endorsement often positively

affects the rest of the project. Regular meetings to provide information to all staff will narrow thegap between an informal leader and other staff, especially if the informal leader is highly resistantand blocking change. Involvement of all staff, focusing on development of the team and assessing theneed for skills training, is equally important.An example of resistance occurred when we began bedside reporting as part of patient care.Bedside reporting was supported as a tool to increase patients’ participation in their plan of care byproviding direct information and improving communication between the staff at shift change as wellas supportive of the development of the nurse–patient relationship.Report shifted from the conference room to the bedside and included nursing assistants. All stafffelt uncomfortable with this change at first and hesitated to share sensitive information. Theybelieved the histories were too complex to deliver in the presence of the patient. Their feedbackreflected the challenge with communication skills in this type of report.Several informal leaders were especially vocal, and unless the manager invited them to move tothe bedside, they resisted. Individual discussion and coaching occurred on several levels and actionswere taken to avoid making this change a compliance issue.The resistance was defused in several ways. Nurse managers met with charge nurses, the nursechampions. As informal leaders, the nurse champions addressed the issue through the sharedgovernance process and developed a flow sheet for report that provided more structure forinexperienced nurses. The process was changed so that histories and sensitive information werediscussed outside the room and report at the bedside was shorter in preparation for a fuller versionin the future when the comfort and skill level of the nurses improved. The patient was asked if he orshe preferred report given in front of visitors, or a private report. Additional in-services using low-fidelity simulations were scheduled to discuss scripting, family or visitor appropriateness, privacyissues, and other barriers defined by the staff.A Valuable ResourceThe following strategies may be used to best integrate informal leaders into the change process:• Obtain staff buy-in and feedback in the selection of informal leaders to lead change.• Provide information and make it safe for informal leaders to ask questions, take risks, andchallenge the change by providing different perspectives.• Ask for suggestions and find common ground following feedback.• Incorporate the feedback provided by the informal leader into the change or the process leadingto the change.• Break the change down into parts with the informal leaders sponsoring the differentcomponents to avoid the perception of one person “owning” the change.• Give the informal leader frequent feedback and share outcomes.Effective change requires a nursing team of members who feel that the environment is supportive,the change has value, and they are acting together. The informal leader is a critical part of thisprocess.Copyright ©2015, HealthCom Media. All rights reserved. American Nurse Today: Informal leadersand cultural change, August 2013. http://www.americannursetoday.com/informal-leaders-and-cultural-change/.Formal GroupsFormal groups are created by an organization; therefore, they are part ofthe organization’s formal structure. These groups can be a long-term team

(e.g., functional or command) or short-term team (e.g., ad hoc committees).A functional or command group is specified and outlined in an entity’sorganizational chart. For functional groups, members are grouped bysimilar tasks, such as financial and administrative services, ancillaryservices, human resources and organizational development, and nursingservices (see Figure 16–1).For command groups, members are formed into subgroups under theleader’s legitimate power position within the organization. For example, alllaboratory technicians report to the manager of laboratory services. Themanager forms a group of laboratory technicians to discuss theimplementation issues of providing clinical support for the hospital’s newoutpatient clinic.

Figure 16–1 Organizational Chart for ABC Hospital and Health SystemTask groups include two (a dyad) or more people who are focused on anidentified target, a project, or a specific issue or goal. Task groups may beeither short- or long-term and may be evaluated on the basis of theiridentified objectives. Unlike in the functional or command groups, memberscan be from various functional areas and levels of organizational authority,depending on the specialized knowledge, experience, or authority that maybe required by the group. For example, the CEO of a local hospital forms amultidisciplinary task force to address the organization’s disasterpreparedness procedures. Members of this group would include allfunctional areas of the hospital, including administration, patient care,information technology, and physical plant. Task groups can be permanentgroups, which may be used for policy making or coordination of activities.Permanent groups can exist from one year or indefinitely. Ad hoc groups aregenerally established to deal with a specific issue or problem. These lattergroups may exist for a very short period, such as from one month up to oneyear, depending upon resolution of problems, tasks, and issues.

GROUP DEVELOPMENTGroups go through five sequential stages of development. Some groups,on the basis of their leadership or members’ prior experiences, can movethrough these stages more quickly than others. Because of the same factors,some groups may never experience all five stages. The five stages ofdevelopment are:1. Forming: During the forming stage, members try to determine whatthe appropriate behaviors and core values of the group are. Theyfocus on exchanging functional information, task definition, andboundary development. They begin to establish tasks and determinehow they might meet objectives. During this initial stage, membersmust gain an understanding about the reason or purpose for joiningand find a social niche in the group.2. Storming: The second stage of group development, storming, ischaracterized by high levels of emotion, because members are tryingto find their group identity and exert their individuality. At thisstage, members are claiming their social power within the group, anda hierarchy is established as people question authority, react to whatis supposed to be accomplished, and jockey for power within thegroup. Intermember criticism, scapegoating, and judgments mayaccompany this struggle for control.3. Norming: Within the third stage, the development of cohesion andstructure occurs when the group’s standards, key values, and rolesare accepted. The gradual development of cohesion occurs after theconflict in stage two. In this third stage, the rules for behavior areexplicitly and implicitly defined. There is a greater degree of orderand a strong sense of group membership.4. Performing: In the fourth stage, performing, we find that membershave found their role(s) within the group and that their energy isfocused on the task. The group works through the problemsconfronting it and, when the task is almost near completion, thegroup moves to the final phase.5. Adjourning: Adjourning is the final stage of group development,which represents the dissolution or termination of the groupmembership.GROUP DECISION MAKING

Group decision making is the process of arriving at a judgment based onthe feedback of multiple individuals. Such decision making is a keycomponent to the functioning of an organization because organizationalperformance involves more than just individual action. Therefore, managersneed to understand the ways in which the group process affects groupdecision making.Group decision making usually takes longer than an individual decision(Nour & Yen, 1992); however, research confirms that groups produce moreand better solutions to problems than do average individuals working alone,and the choices groups make will be more accurate and creative (Robbins,2003). This is due to the higher levels of communication, coordination, andcollaboration that occur within groups during the decision-making process(Nour & Yen, 1992).There are four factors that play an important part regarding the qualityof a group’s decision. First, the group should be diverse (i.e., membersshould have differences in experiences, individual knowledge, talents, skills,culture, and age) (Butterfield & Bailey, 1996). Second, the members need tofeel that they are in a safe environment so their ideas can be expressedfreely (i.e., this will lead to avoidance of conformity and groupthink). Third,the degree of task interdependence must be high (i.e., if the task is simple,members can solve the problem individually with no assistance from othermembers). Fourth, the group must have the potency for success (i.e., themembers believe that the group can be effective) (Shea & Guzzo, 1987).Peterson (1997) and Burn (2004) provide a model that illustrates theprocess by which groups make decisions (see Figure 16–2).• Stage 1—Problem Definition: The better informed members are, thebetter they are at formulating the problem or issue at hand. Clarityabout the problem is necessary for a quality decision.• Stage 2—Identify Alternatives: Groups sometimes limit and restrictoptions on the basis of the ideas and perceptions of only a few members.Inclusivity and careful review of all available options expandproblemsolving alternatives. Members sometimes believe that they haveto choose the first alternative for the sake of time or that they do nothave access to all of the relevant information.• Stage 3—Gather Information: Information needs to be gathered aboutall possible consequences on the basis of the identified alternatives.Groups often neglect to take the time to gather all of the relevantinformation and do not develop a process by which all members can

contribute to gathering information.Figure 16–2 Group Decision Process Model• Stage 4—Evaluate Alternatives: The group must objectively analyze allof the available alternatives and potential consequences. The challenges

that emerge during this stage range from developing processes thatensure that all information is reviewed, that higher status members donot dominate, and that decisions are not made for any member’spersonal gain. Group members could choose the first availablealternative that meets minimal standards and convince themselves andothers that it is the most appropriate. Therefore, rational and objectivecriteria are needed to prevent flawed decisions.• Stage 5—Make the Decision: The method by which the group chooses tomake the decision is extremely important. Some members may try tocontrol and bolster their own ideas without supportive evidence. Lower-status members might vote with higher-status members when the voteis by a show of hands; the vote might totally change if there is a secretballot.• Stage 6—Implementation: The challenges at this stage involve theresolution of all of the tasks necessary to fully implement the decision,including the identification of all of the needed resources.• Stage 7—Evaluate the Outcome: After implementation, a step that isoften disregarded is to evaluate the outcome. Are processes developed sothat the decision group can actually measure the success or relevance ofthe outcome? Did the decision meet the goals and objectives? Thiscritical inquiry is essential to learning from the experience.The collective information processing of a group takes time to develop.This may be due to members not being aware of the information resourcesof the group or members being hesitant to provide information to the group.Some groups provide structured techniques so that every memberparticipates equally and positive interaction is encouraged. These strategiesinclude brainstorming, the nominal group, and Delphi techniques.BrainstormingBrainstorming requires a designated amount of time (usually five to sevenminutes) to generate as many ideas as possible without discussion aboutfeasibility or practicality. The originator of this technique (Osborn, 1957)believed that members’ tendencies to judge and criticize others’ offeringswould deter members from freely expressing creative ideas. Osbornhypothesized that the more ideas a group developed, the greater the chancethe ideas would be of higher quality. However, research does not supportOsborn’s hypothesis. Brainstorming groups do not produce more or higher-quality ideas than those that are generated individually (Mullen, Johnson,

& Salas, 1991). Some factors that may reduce the performance ofbrainstorming groups include social loafing, apprehension about beingjudged by others, or the tendency for introverted people to withdraw whenin the company of extroverted members who may compete and try todominate the brainstorming process. People also have a difficult timethinking and listening to others at the same time. Dennis (1996) contendsthat computer-based brainstorming, a technique in which group membersinteract electronically, often anonymously, and at the same time, eradicatesthe interpersonal pressure. The advantages are that they are less likely toforget what they are sharing as they type; the written record of allcontributions can be made available for all and at any time; and because ofthe anonymity, lower-status members do not feel the pressure of theevaluation of their contribution by other members. In addition,computerized group support systems may also reduce the potential forgroupthink.Nominal Group TechniqueThe nominal group technique is a brainstorming technique that isimplemented on an individual and nonverbal basis. The informationobtained is then pooled. This technique is efficient because it does notrequire a great deal of leadership training, and the group can communicatewithout the risks involved in verbal communication. A typical five-stepprocess begins with a period of silence during which group members writedown their ideas independently. This is followed by a round-robin recordingof ideas. Third, the leader calls on each member to share one idea at a timeand writes each idea down in view of the total group. Fourth, there is groupdiscussion of each idea on the list, and all ideas are clarified and evaluated.Fifth, the participants identify and privately rank their ideas in order ofpreference, and then they vote, the vote is recorded, the voting pattern isdiscussed, and the highest ranked idea is discussed. The nominal grouptechnique has been used extensively in business and government because ofits efficiency and its capacity to limit emotional arguments.The Delphi TechniqueThe Delphi technique is intended to help with the challenge faced bygroup members who may lack the experience to understand that theinformation they hold is needed to generate and evaluate options oralternatives. This technique uses a series of written communications tocollect and synthesize the opinions of a group of experts into a decision. A

carefully devised letter is sent to several experts that defines the problemand asks the experts for advice toward a solution. The leader collects andcollates the responses for each of the experts and sends them back to theexperts for commentary and additional solutions. The leader collects theletters and analyzes them for consensus. If clear consensus emerges, adecision can be made. If not, the process is repeated until consensus isachieved. This process can be time consuming, and the same result may beachieved through a face-to-face meeting of experts.“GARBAGE CAN” DECISION-MAKING PROCESSUnlike the rational decision-making model described earlier, wheregroups follow a step-by-step process to arrive at the best solution to aproblem, the “garbage can” model of decision making is a process that doesnot begin with a problem and end with a solution. In the garbage canprocess, many types of independently generated problems and solutions areplaced in a “garbage can” (see Figure 16–3). Managers and otherparticipants then search through the “garbage can” looking for interesting,suitable, or important “problems” and “solutions” (Cohen, March, & Olsen,1972; Lovata, 1987; Schmid, Dodd, & Tropman, 1987). Although thegarbage can decision-making approach is not very efficient, the process isappropriate for group decision making in organizations where thetechnologies are not clear, the involvement of participants fluctuates in theamount of time and effort given, and choices are inconsistent and not welldefined (Cohen, March, & Olsen, 1972; Lovata, 1987; Schmid, Dodd, &Tropman, 1987).The “garbage can” model is often referred to as political or anti-rationalbecause it disconnects problems, solutions, and decision makers from oneanother. As such, Cohen, March, and Olsen (1972) relate that specificdecisions (i.e., choices) do not follow an orderly process from problem tosolution, but are outcomes of several relatively independent streams ofevents within the organization:1. Problems identified in organizations usually require attention due toperformance gaps.2. Solutions are ideas that have been identified to solve one or moreproblems, which are independent and distinct from the problems thatthey might be used to solve (e.g., in some cases, solutions are answerslooking for a problem).3. Participants come and go, and levels of participation vary for each

problem and each solution based on the time demands of participantsor on other situational factors.4. Choices are made only when the combination of problems, solutions,and participants allows the decision to happen (i.e., when they are inalignment).

Figure 16–3 Illustration of Independent Streams of Events in the “Garbage Can” Model of DecisionMakingReproduced from Organization Theory and Design (8th ed.), by R. L. Daft, 2004, Mason, OH: Thomson South-Western.Consequently, the alignment of the problems, solutions, and individualsoften occurs after the opportunity to make a decision regarding a problemhas passed, or it occurs even before the problem has been discovered (Cohen,March, & Olsen, 1972). The garbage can model provides a real-worldrepresentation of the nonrational manner in which decisions are often madewithin an organization. In a broad sense, the model provides some clue tounderstanding “how organizations survive when they do not know what

they are doing” (Cohen, March, & Olsen, 1972).SUMMARYGroups remain the context for most of our social and work activities. Thepowerful impact that groups have on people and the powerful influence thatpeople have on groups merit our ongoing attention.DISCUSSION QUESTIONS1. Discuss why the size of a group is important to performance.2. Explain the different broad categories of groups.3. Describe the difference between informal and formal groups.4. Discuss the various task groups within an organization and theirpurposes.5. Explain the five stages of group development.6. Discuss the factors that may hinder the effectiveness of a groupdecision-making process.7. Explain the seven stages of group decision making.8. Describe the various methods for group decision making.EXERCISE 16–1Analyze the last poor decision made by a group of which you were amember. What do you think contributed to the group’s poor decision? Didthe group think of alternative possibilities? Did the group move too quicklythrough any of the development stages? If yes, did this cause lack ofcooperation or poor communication?EXERCISE 16–2Form small groups of four or five individuals and, within 10 minutes,brainstorm as many solutions as possible that address the followingsituation:A small nonprofit organization for which you serve as a member ofthe board of directors needs to raise $500,000 in order to support its

programming needs.After the exercise is completed, personally reflect on the groupinteractions. Did you notice any factors that may have reduced theperformance of the group (i.e., social loafing, apprehension of beingcriticized by others, dominant behavior by one or more members)?REFERENCESBlackler, F., & Shimmin, S. (1984). Applying psychology in organizations.London, UK: Methuen.Burn, S. B. (2004). Groups: Theory and practice. Belmont, CA: Thompsonand Wadsworth.Butterfield, J., & Bailey, J. J. (1996). Socially engineered groups in businesscurricula: An investigation of the effects of team composition on groupoutput. Journal of Business Education, 72(2), 103–106.Cohen, M. D., March, J. G., & Olsen, J. P. (1972). A garbage can model oforganizational choice. Administrative Science Quarterly, 17, 1–25.Daft, R. L. (2004). Organization Theory and Design (8th ed.). Mason, OH:Thomson South-Western.Dennis, A. R. (1996). Information exchange and use in small group decisionmaking. Small Group Research, 27, 532–551.Hyman, H. H. (1942). The psychology of status. Archives of Psychology, 269,5–91.Hyman, H. H. (1968). Reference groups. In D. Sills (Ed.), InternationalEncyclopedia of the Social Sciences (Vol. 13, pp. 353–359). New York, NY:Macmillan Company and Free Press.Lahti, R. K. (1996). Group decision making within the organization: Canmodels help? Center for Collaborative Organizations, University of NorthTexas, Denton. Available at:http://www.workteams.unt.edu/literature/paper-rlahti.htmlLovata, L. M. (1987). Behavioral theories relating to the design ofinformation systems. MIS Quarterly, 11(2), 147–149.Mullen, B., Johnson, C., & Salas, E. (1991). Productivity loss inbrainstorming groups: A meta-analytic integration. Basic and AppliedSocial Psychology, 12, 3–23.Nour, M. A., & Yen, D. C. (1992). Group decision support systems, toward aconceptual foundation. Information and Management, 23(1), 55–64.

Osborn, A. F. (1957). Applied imagination. New York, NY: Scribner.Peterson, R. S. (1997). A directive leadership style in group decision makingcan be both virtue and vice: Evidence from elite and experimental groups.Journal of Personality and Social Psychology, 72(5), 1107–1121.Robbins, S. P. (2003). Organizational behavior (10th ed.). Upper SaddleRiver, NJ: Prentice Hall.Schmid, H., Dodd, P., & Tropman, J. E. (1987). Board decision making inhuman service organizations. Human Systems Management, 7(2), 155–161.Shea, G. P., & Guzzo, R. A. (1987). Group effectiveness: What reallymatters? Sloane Management Review, 8(3), 25–31.Tubbs, S. L. (2001). A systems approach to small group interaction. NewYork, NY: McGraw Hill Book Company.

CHAPTER 17Work Teams and Team BuildingLEARNING OUTCOMESAfter completing this chapter, the student should be able to understand the: Various types of teams. Differences of a virtual team as compared with conventional types ofteams. Various approaches for building team performance. Various organizational barriers to effective team building. Common characteristics of successful teams.OVERVIEWCase Study 17–1 Dr. R’s OfficeDr. R works in a private practice that includes herself and one other general internist. She beginsher 20-minute visit with Mr. H by thumbing through the chart to find the dates and results from hismost recent hemoglobin (HbA1c), low-density lipoprotein cholesterol, eye examination, and prostate-specific antigen tests. The office has a medical records clerk who is not trained to perform thesetasks. Dr. R then spends five minutes comparing the medication bottles brought by Mr. H with herchronic medication list. After reviewing the health maintenance form, she leaves the room to ask amedical assistant to draw up pneumonia and influenza immunizations and finds the medicalassistant sitting at her desk waiting for instructions about what to do next. Returning to theexamination room, Dr. R learns that Mr. H has been unable to obtain an appointment with theurologist for a prostate biopsy; she promises to arrange the appointment herself. As Mr. H leaves,Dr. R realizes that she did not need a medical degree to accomplish any of the tasks performedduring the medical visit.Copyright © 2004 American Medical Association. All rights reserved. Can health care teamsimprove primary care practice?” by K. Grumbach and T. Bodenheimer, 2004. JAMA, 291(10), p. 1246.What is the difference between groups and teams? Does a group of peoplewho happen to be thrown together in a surgical suite or primary care officeconstitute a team? The answer is obviously “no”—not all groups are teams

(see Case Study 17–1).In general, groups are much broader than teams. Teams are specialgroups that have highly defined tasks and roles and demonstrate high groupcommitment (Katzenbach & Smith, 1993). We begin this chapter with adiscussion of teams. We then examine the various types of teams, theircharacteristics, and the factors that either assist or hinder the effectivenessof teams in the workplace.TEAMSA team can be defined as a small group of people who are committed to acommon purpose, who possess complementary skills, and who have agreedon specific performance goals for which the team members hold themselvesmutually accountable (Katzenbach & Smith, 1993; also, see Case Study17–2 and Case Study 17–3). On the basis of this definition, a team (1)should be composed of a small number of members (preferably an oddnumber, e.g., five or seven) to ensure consensus without discord; (2) musthave specific goals; and (3) must contain members with mutualaccountability, requiring interdependence and collaboration of efforts(Gordon, 2002).Case Study 17–2 Dr. Charles BurgerA Well-Functioning Primary Care Team in a Small Private OfficeCharles Burger is a private practitioner in Bangor, Maine. From a distance, his remarkableprimary care practice resembles thousands of physician offices throughout the country. Uponentering the office door, it is clear that—within a traditional practice setting—Dr. Burger hascreated a smoothly functioning primary care team. The entire office functions as one team—twophysicians and two nurse practitioners are the clinicians, complemented by medical assistants,greeters, receptionists, and schedulers. The practice is financially stable and is busy, with eachclinician seeing 23 to 30 patients per day. The following case typifies how the team model works.Ms. P called Dr. Burger’s office complaining of recurrent abdominal discomfort after eating. Thereceptionist consulted her computerized triage protocol and provided Ms. P with a same-dayappointment. When she arrived, the greeter, already aware of the patient’s problem, gave her amedical history questionnaire specifically related to abdominal pain, which Ms. P filled out in thewaiting room. Ms. P met with the medical assistant, who checked her vital signs and quickly enteredher questionnaire responses into the computer. Ms. P then saw the physician, who reviewed thehistory, performed a relevant physical examination, and consulted a diagnostic software program.Discussing the options with Ms. P, the physician and patient decided on a diagnostic and treatmentplan. Ms. P then met with the scheduler, who arranged laboratory and ultrasound studies.Dr. Burger’s staff members were all trained at a 15-week course in quality management at anearby college. Greeters, receptionists, and schedulers (who are cross-trained) also received sixweeks of in-office training.All clinical processes in Dr. Burger’s office are guided by a system. The practice has adoptedadvanced-access scheduling, offering patients same-day appointments. For years, the office has

tracked demand and can predict how each day will unfold. On Mondays, heavy with telephone calls,more staff act as receptionists and few scheduled appointments are made.Whereas in most offices, receptionists are not trained to properly triage patients into emergency,urgent, and routine categories, Dr. Burger designed a triage system that receptionists consult onevery telephone call. When Ms. P called with abdominal complaints, the receptionist pulled up thegastrointestinal screen on the triage protocol, which prompted a series of questions including painseverity and presence of vomiting, diarrhea, black and/or bloody stools, or fever. In the case ofpositive answers, the protocol tells the receptionist to send Ms. P to the emergency department. Formilder symptoms, an appointment is made, perhaps with previsit laboratory studies. The interactionis routed to Ms. P’s medical record and a clinician’s email inbox.Most communication is routinized by the office’s clinical systems. Team members do not attendendless meetings. Incoming calls are routed to the email inbox of the appropriate team member.Urgent messages are delivered in person. Diagnostic studies go to the appropriate email inbox andthe medical record. The well-trained medical assistants order clinical preventive studies on thebasis of the patient’s age and sex. Clinic goals and performance measures are communicated to allstaff by posters prominently displayed in the office.Copyright © 2004 American Medical Association. All rights reserved. Can health care teamsimprove primary care practice?” by K. Grumbach and T. Bodenheimer, 2004. JAMA, 291(10), p. 1246.Case Study 17–3 Kaiser Permanente in GeorgiaA Well-Functioning Primary Care Team in a Large Group PracticeIn 1997, Kaiser Permanente’s Georgia region (KP/Georgia) developed primary care teams withseveral goals: increased patient satisfaction, improved Health Employer Data and Information Setscores, and lowered costs.This group practice model currently consists of nine primary care offices with 25 teams. Each teamhas three to five clinicians (physicians, nurse practitioners, or physician assistants), two registerednurses, one to two receptionists or clerks, and six to seven licensed practical nurses or medicalassistants providing care to a panel of 8,000 to 15,000 patients. Prior to the rollout of the teamstructure, clinicians and staff received training in team-oriented care.Patients view their clinician, not the team, as their primary caregiver, but are aware that anonphysician clinician may provide care for acute problems or if the physician is not available.Eighty-five percent of visits are handled by a clinician on the patient’s team.The KP/Georgia team has well-defined systems and protocols for all clinical processes, includingtriaging telephone calls, reviewing and informing patients of laboratory and X-ray results, makingreferrals, and renewing prescriptions. One registered nurse is the advice nurse, answering patientquestions and triaging patients who telephone or drop in. The other registered nurse is the team co-leader, working with the physician co-leader to solve day-to-day problems, ensure that clinicalsystems are functioning well, and supervise team members.Each team receives a budget based on the number of patients on the team’s panel with riskadjustment according to age and disease severity. Initially given limited decision-making autonomy,teams demonstrating effective self-management are allowed flexibility in staffing mix and division oflabor. Teams can decide whether they want more physicians, more nonphysician clinicians, or moresupport staff in their personnel mix. Some teams delegate chronic-care management functions tolicensed practical nurses and medical assistants; others are less successful in this redesign. Eachteam decides how chronic disease registries are used to improve its panel’s outcome measures. Someuse the registries extensively, others minimally.Each team receives a quarterly report on team functioning, patient satisfaction, staff satisfaction,and clinical quality measures, enabling KP/Georgia’s central leadership to assess each team’s

functioning and allowing each team to compare itself with other teams.Copyright © 2004 American Medical Association. All rights reserved. Can health care teamsimprove primary care practice?” by K. Grumbach and T. Bodenheimer, 2004. JAMA, 291(10), p. 1246.Teams are very popular in the workplace. According to Lawler (1999),almost every organization uses some form of problem-solving team, themost common being the self-managing work teams that are used in a highmajority of Fortune 1000 companies. As teams become more of the norm inthe workplace, managers need to understand the complexity of teams,whether in their work design, the composition of the members, or thefactors that enable them to achieve high levels of performance andeffectiveness.TYPES OF TEAMSCohen and Bailey (1997), following an extensive literature review,determined that teams can be organized into the following four categories:(1) work teams, (2) parallel teams, (3) project teams, and (4) managementteams.• Work teams are continuing work units responsible for producing goodsor providing services. Traditional work teams are directed by managerswho make most of the decisions about what is done, how it is done, andwho does it. However, an alternative form of work team with a varietyof labels—self-managing, autonomous, semiautonomous, self-directing,empowered—is gaining favor. Self-managing work teams involveemployees, not managers, deciding how to carry out tasks, allocatingthe work within the team, and making decisions. Examples includeprimary care teams, surgical teams, and emergency department teams(Taplin, Foster, & Shortell, 2013).• Parallel teams draw members from different work units or jobs toperform functions that the regular organization is not equipped toperform well. They exist in parallel with the formal organizationalstructure. They generally have limited authority and can makerecommendations only to individuals higher up in the organizationalhierarchy. Parallel teams are used for problem-solving andimprovement-oriented activities. Examples include quality improvementteams, employee involvement groups, quality circles, and patientsatisfaction task forces.

• Project teams are time limited. They produce one-time outputs, such asa new electronic health record implementation team, or a new facilitydesign and construction team. Typically, project team tasks arenonrepetitive in nature and involve considerable application ofknowledge, judgment, and expertise. The work that a project teamperforms may represent either an incremental improvement over anexisting concept or a radically different new idea. Frequently, projectteams draw their members from different disciplines and functionalunits so that specialized expertise can be applied to the project at hand.For example, a new drug-development team of a pharmaceuticalcompany would draw its members from research and development,marketing, finance, and manufacturing. When a project is completed,the members either return to their functional units or move on to thenext project. Cross-functional project teams enhance project success as aresult of their capacity to handle multiple activities simultaneously,rather than sequentially. This saves time and is important toorganizations concerned with rapid development of new services and/orproducts due to competition.• Management teams coordinate and provide direction to the subunitsunder their responsibility, laterally integrating interdependent subunitsacross key business processes. The management team is responsible forthe overall performance of a business unit. Its authority stems from thehierarchical rank of its members. It is composed of the managersresponsible for each subunit, such as vice presidents of nursing,compliance and security, finance, and medical affairs. At the top of theorganization, the executive management team establishes and managesthe organization’s strategic direction and performance. The use of topmanagement teams is expanding in response to the turbulence andcomplexity of the health care environment. Management teams can helporganizations achieve competitive advantage by applying collectiveexpertise, integrating disparate efforts, and sharing responsibility forthe success of the organization.VIRTUAL TEAMSThe virtual team has emerged along with technology advances. Unlikeconventional teams, a virtual team works across space, time, andorganizational boundaries through various communication technologies(Lipnack & Stamps, 1997). Roebuck and Britt (2002) note that the primary

difference between a conventional team and a virtual team is the dimensionof physical space or distance between team members. Virtual teams allowemployees to be located anywhere in the world. Virtual teams rarely meetface to face and are supported by technology to collaborate (Lurey, 1998).Often, these teams are set up as temporary structures existing toaccomplish a particular task, or they may be more permanent teams thataddress ongoing organizational issues (Roebuck & Britt, 2002).Organizations benefit from virtual teams through access to previouslyunavailable expertise enhanced through cross-functional interaction and theuse of systems that improve the quality of the virtual team’s work (Lipnack& Stamps, 1997). By using virtual teams, organizations can assign the rightperson to the job, regardless of where he or she lives. However, thedimension of physical distance between members does affect the way teammembers interact. Roebuck and Britts (2002) advise that for a virtual teamto be successful, members must be firmly committed to the team’s purposeand to each team member. They must want their collaborative work to besuccessful and be willing to go the extra mile. For example, Rush UniversityMedical Center in Chicago implemented a pilot program known as VirtualIntegrated Practice, in which primary care physician practices recruit andorganize their own offsite interdisciplinary teams consisting of socialworkers, dietitians, pharmacists, and other health care providers to manageand coordinate care for geriatric patients with chronic disease. These teamscollaborate virtually using email, phone, and fax to plan and delivercoordinated patient care. A comparison of four practices using the virtualintegrated practice model to four similar practices providing usual carefound that the virtual integrated practice program reduced emergencydepartment visits, enhanced patient satisfaction and understanding of theirmedical condition(s) and medications, increased physician knowledge, andboosted referrals to interdisciplinary team members (Rothschild & Lapidos,2009).Teamwork doesn’t always come naturally to health care professionals;health care cultures too often emphasize autonomy and working withinprofessional boundaries (Bartunek, 2011). Yet a lack of effective teamworkand communication among and between teams of caregivers can haveserious patient safety consequences. To deliver safe and effective care, staffin high-risk areas such as emergency departments, intensive care units,labor and delivery units, and operating rooms must work as cohesive, high-functioning teams. A highly cohesive team will be more cooperative andeffective in achieving the goals they set for themselves (Oxford Centre,

2011). Daft and Marcic (2009) relate that members of a highly cohesiveteam focus on the process, not the person; are respectful of one another; arefully committed to team decisions; and hold each member accountable to theteam.BUILDING TEAM PERFORMANCEKatzenbach and Smith (1993) developed the team performance curve toillustrate how small groups may develop into high-performing teams (seeFigure 17–1). Katzenbach and Smith (p. 85) found that, “unlike teams,working groups rely on the sum of ‘individual bests’ for their performance.They pursue no collective work products requiring joint efforts. By choosingthe team path instead of the working group, people commit to take the risksof conflict, joint work-products, and collective action necessary to build acommon purpose, set goals, approach, and mutual accountability. Peoplewho call themselves teams but take no such risks are at best pseudoteams.”Although there is no guaranteed “how-to” recipe, Katzenbach and Smith(1993, pp. 119–127) list eight approaches to building team performance:1. Establish Urgency and Direction: All team members need to believethe team has urgent and worthwhile purposes, and they want toknow what the expectations are. The best team charters are clearenough to indicate performance expectations, but flexible enough toallow teams to shape their own purpose, goals, and approach.2. Select Members on the Basis of Skills and Skill Potential, NotPersonality: Teams must have the complementary skills needed to dotheir job. Three categories of skills are relevant: (1) technical andfunctional, (2) problem-solving, and (3) interpersonal. The key issuefor potential teams is striking the right balance between memberswho already possess the needed skill levels versus developing the skilllevels after the team gets started. Margerison and McCann (1989)have performed extensive research on the “people” side of successfulteam-building. On the basis of studies incorporating over 5,000managers, they developed the Team Management Wheel, whichassists managers in selecting the right “balance” for their teamsregarding roles (advisers, explorers, organizers, and controllers) and“linking” skills (e.g., main role of the team leader) (see Exhibit 17–1and Figure 17–2).

Figure 17–1 The Team Performance CurveSource: The Wisdom of Teams: Creating the High-Performance Organization, by J. R. Katzenbach and D. K. Smith, 1993.Boston, MA: Harvard Business School Press, p. 84. McKinsey & Company. Used with permission.3. Pay Attention to First Meetings and Actions: Initial impressionsalways mean a great deal. When potential teams first gather,everyone alertly monitors the signals given by others to confirm,suspend, or dispel going-in assumptions and concerns. They payattention to those in authority: the team leader and any executivewho set up, oversee, or otherwise influence the team. What leaders dois more important than what they say!Exhibit 17–1 The Team Management Wheel

The Margerison–McCann Team Management Wheel defines members’ roles and is based on thefollowing eight characteristics:1. Reporter–Advisors: Those who prefer work involving gathering and sharing of information.Supporters, helpers, collectors of information, knowledgeable, flexible.2. Creator–Inventors: Those who prefer work that generates and experiments with new ideas.Imaginative, creative, enjoy complexity, future-oriented.3. Explorer–Promoters: Those who prefer work that involves investigation and presentationof new opportunities. Persuaders, influential and outgoing, easily bored.4. Assessor–Developers: Those who prefer work that involves planning to ensure that ideasand opportunities are feasible in practice. Analytical and objective, idea developers,experimenters.5. Thruster–Organizers: Those who prefer work that allows them to arrange and organize theway work is done. Results-oriented, analytical, organizers, and implementers.6. Concluder–Producers: Those who prefer work that can be implemented systematically toproduce regular outputs. Practical, production-oriented, like schedules and plans, valueeffective efficiency.7. Controller–Inspectors: Those who prefer work involving controlling and auditingprocedures and systems. Controller, detail-oriented, inspectors of standards andprocedures, low need for personal interaction.8. Upholder–Maintainers: Those who prefer work that involves upholding and conservingprocesses and procedures. Conservative, loyal, supportive, strong sense of right andwrong, motivation based on purpose.The hub of the Team Management Wheel is the “Linker,” and that is often the main role of theteam leader, although all team members need to contribute to this activity. The Linker circle canbe expanded into a full-range team leadership model that describes three levels of Linking thatshould be practiced, to varying degrees, by everyone in an organization.At the first level of Linking are the skills arranged around the outside of the model. Theseskills are the People Linking Skills. They create the atmosphere in which the team works, bypromoting harmony and trust. As such, everyone in a team has a responsibility to implement thislevel of leadership.• Active Listening• Communication• Team Relationships• Problem Solving and Counseling• Participative Decision Making• Interface ManagementInside the People Linking Skills are the Task Linking Skills. These skills create a solid core orfoundation on which the work of the team relies. They promote confidence and stability.• Work Allocation• Team Development• Delegation• Objectives Setting• Quality StandardsThese skills tend to apply more to people on the second rung of the leadership ladder—thosein more senior positions within a team, responsible for guiding others. This guiding may be donein either a supportive or directive way, but should not violate the first level of People LinkingSkills. The challenge is to find the balance where the six People Linking Skills and five TaskLinking skills can coexist.

At the core of the Linking Skills Wheel are the two Leadership Linking Skills of Motivationand Strategy. Leadership Linking is the third step on the leadership ladder and applies toleaders who have organizational responsibility for strategy. They need to implement these twoskills along with those of the People and Task Linking Skills to achieve the status of the LinkerLeader, a term used to describe someone who is effective at implementing all three levelsdescribed in the Linking Skills Wheel.4. Set Some Clear Rules of Behavior: All real teams develop rules ofconduct to help them achieve their purpose and performance goals.The most critical early rules pertain to attendance (“no interruptionsto take phone calls”), discussion (“no sacred cows”), confidentiality(“the only things to leave this room are what we agree will leave thisroom”), analytic approach (“facts are friendly”), end-productorientation (“everyone gets assignments and does them”), constructiveconfrontation (“no finger pointing”), and often the most important,contributions (“everyone does real work”).

Figure 17–2 The Linking Skills WheelSource: Team Management Systems (TMS) by Charles Margerison and Dick McCann. Reprinted with permission.5. Set and Seize upon a Few Immediate Performance-Oriented Tasksand Goals: Most teams trace their advancement to key performance-oriented events that forge them together. Potential teams can setsuch events in motion by immediately establishing a few challengingyet achievable goals that can be reached early on.

6. Challenge the Group Regularly with Fresh Facts and Information:New information causes a potential team to redefine and enrich itsunderstanding of the performance challenge, thereby helping theteam shape a common purpose, set clearer goals, and improve on itscommon approach.7. Spend Lots of Time Together: Common sense tells us that teams mustspend a lot of time together, especially at the beginning. The timespent together must be both scheduled and unscheduled. Creativeinsights as well as personal bonding require impromptu and casualinteractions just as much as analyzing spreadsheets, interviewingcustomers, and so on. These meetings or interactions need not bealways face to face. Use of technology is encouraged!8. Exploit the Power of Positive Feedback, Recognition, and Reward:Positive reinforcement works well in a team context. There are manyways to recognize and reward team performance, of which directcompensation is only one. Ultimately, the satisfaction in the team’sperformance becomes the most cherished reward. Until then,however, potential teams must find other ways to recognize andreinforce their individual and team contributions and commitment.BARRIERS TO EFFECTIVE TEAMWORKThe barriers to effective teamwork fall within four categories: (1) lack ofmanagement support, (2) lack of resources, (3) lack of leadership, and (4)lack of training (see Table 17–1). If these barriers exist within anorganization, the likelihood that groups would be provided the opportunityto develop into high-performing teams is limited. Teams need managementsupport, proper leadership, adequate resources, and training to reach theirfull potential.Dunphy’s (1996) research supports the fact that teams contributesignificantly to the productivity and efficiency of organizations. In today’senvironment, hospitals and other health care providers are seekinginnovative ways to reduce medical errors and costs while increasing qualityof care and customer/employee satisfaction. Effective and high-performingteams can help accomplish these goals. However, team building is a processthat takes time and resources. Management needs to invest today to reachtomorrow’s goals.

Table 17–1 Barriers to Effective TeamworkCategoryDescriptionManagementLack of sufficient support and commitment from senior managementManagementPressure for short-term resultsManagement andLeadershipPolitical meddling and power politicsManagement andLeadershipLack of trust among team members and with leadership (i.e., communication is closed and risktaking is not encouraged or rewarded)LeadershipLack of clear vision, goals, and objectivesLeadershipUnwillingness to allow teams the necessary autonomy and decision-making powersLeadershipPoor communication and interpersonal skillsLeadership andResourcesFailure to recognize and reward group effortsResourcesInsufficient release time from other duties for team membersTrainingInadequate training and skills developmentTrainingLack of project management skillsSource: “Transformation Through Teamwork: The Path to the New Organization?” by S. Drew and C.Coulson-Thomas, 1996. Management Decision, 34(1), p. 7. Reprinted with permission.COMMON CHARACTERISTICS OF SUCCESSFUL TEAMSHackman (2011) has studied teams for many years, and he has identifiedsix enabling conditions for effectiveness. The team must (1) be real, (2) havea compelling purpose, (3) consist of the right members, (4) establish andfollow clear norms of conduct, (5) work under a highly supportive context,and (6) receive well-timed team coaching. Elaine Biech, as cited in Gordon(2002, p. 184), outlines 10 most commonly mentioned characteristics forsuccessful teams:• Clear Goals: Clear goals allow everyone to understand the function andpurpose of the team.• Defined Roles: Defined roles allow team members to understand whythey are on the team and enable clear individual- and team-based goalsetting.• Open and Clear Communication: Effective communication is consideredthe most important aspect of team building. It hinges on effectivelistening.• Effective Decision Making: Effective decision making is critical, and fora decision to be effective, the team must be in agreement with thedecision and must have reached agreement through a consensus-findingprocess.• Balanced Participation: Balanced participation ensures that allmembers are fully engaged in the efforts of the team. Participation is

also directly linked to leader behaviors. Effective team leaders shouldnot see their role as authoritarian and should strive to be seen as theteam’s mentor or coach.• Valued Diversity: The team must recognize each member’s expertiseand value variety of knowledge, skills, and abilities. In the world ofteams, diversity is larger than just race or gender.• Managed Conflict: Managed conflict requires that all team membersfeel safe to freely state their points of view without fear of reprisal. Forteams, managed conflict is almost akin to brainstorming, in that conflictallows the team to openly discuss ideas and decide on common goals.• Positive Atmosphere: Positive atmosphere requires that a climate oftrust be developed. One way of developing trust is to allow teammembers to come together in a positive atmosphere. Allowing teammembers to become comfortable with one another will generate apositive atmosphere, leading to enhanced creativity and problemsolving.• Cooperative Relationships: Cooperative relationships are a must, andteam members should recognize that they need one another’s knowledgeand skill to complete the given task(s).• Participative Leadership: Participative leadership includes having goodleadership role models, as well as leaders who are willing to shareresponsibility and recognition with the team.I would also add reflection and appreciation inquiry to Biech’s list ofsuccessful team characteristics. Teams should be encouraged to allocatetime for reflection and debriefing on the results of their actions anddecisions. Appreciative inquiry can help with this process by encouraginghonest communication and analysis by the group (Drew & Coulson-Thomas,1996). Appreciative inquiry encourages members to identify and reflect onperiods of excellence and achievement. By looking at the past, members candevelop a vision of what they want to accomplish in the future. They buildon what worked best to reach their goal.SUMMARYIn conclusion, Messmer (2004, pp. 13–14) provides an excellent guide toassist managers in the coordination of activities for building an effectiveteam (see Exhibit 17–2).

Exhibit 17–2 Building Effective Teams: A Checklist for Managers1. Begin by creating an action plan that specifies the group’s mission, the types of expertiserequired to achieve this objective, and how team members will work together. Criticalquestions to answer include:• How long will the group need to be active?• What are the different components of the project and the deadlines for completing them?• Is the team responsible for generating and implementing its suggestions?• Will the group operate independently, or will any of its activities overlap with thosemanaged by full-time employees currently not on the team?2. Be sure you have researched how the project impacts the department or company so youcan convey its importance at the first team meeting. Also, create a handout (e.g., atimeline) and gather supporting materials that can be used for reference.3. When selecting the team members, be sure to evaluate their interpersonal andcommunication skills as well as their individual professional abilities and expertise. Ahospital’s accountant with solid analytical skills may have the knowledge you need toassess the organization’s operations, but if he or she lacks the ability to explain his or heranalysis effectively to colleagues outside accounting or finance, you’ll need to either helphim or her develop those skills or appoint someone with a persuasive communication styleto co-present.4. Ask others in your company for recommendations of people who would be appropriate forthe project. Always check with each individual’s manager before making a final selection toensure that a potential team member can commit the necessary time and effort to theinitiative.5. In addition to identifying employees who meet specific project needs, you may also want toselect a coordinator. This person would periodically collect, organize, and distribute statusreports to everyone in the group.6. After team members have been identified, plan an initial meeting to review the action planyou drafted. Encourage feedback from participants so they feel more connected to theproject and upcoming assignments. You may also want to establish protocols for certainpractices such as conflict resolution and expenditure approvals to help preventmisunderstandings and encourage more effective collaboration. Once final guidelines andexpectations have been agreed upon, distribute a revised action plan to everyone involved.7. As team leader, you must walk a fine line between coaching and micromanaging. Whenparticipants come to you with problems or challenges, encourage them to develop theirown solutions, and reward those who take reasonable risks to make improvements.Sometimes the difficulties encountered during a project can spur innovative ideas that aretransferable to other groups or the company as a whole.8. Evaluate the team’s progress periodically to make sure everyone is contributing. If anindividual’s regular work demands are affecting his or her ability to complete projectrequirements, you may need to select a substitute participant who has the necessary time.Also pay attention to the level of interaction during group meetings. Sometimes a fewpeople will speak up more than others. While you want to avoid discouraging their input,make sure that quieter team members don’t feel intimidated. An administrativeprofessional should be just as comfortable as a financial executive when sharing ideas thatmight help the team. You may need to solicit comments from certain employees to prompttheir participation.9. Providing motivation should be an ongoing priority. Even when things aren’t goingsmoothly, do your best to keep the mood upbeat and positive. Try to begin each meetingwith a summary of accomplishments before you address problems. Also take time to

acknowledge and celebrate project milestones. You will help to maintain productivity andgenerate ongoing enthusiasm for the initiative.10. In your role as leader, you play a pivotal role in helping the team get results. Your strategyshould include careful consideration of potential participants and sufficient direction andmotivation once the team is formed. The right approach will encourage more effectivecollaboration among participants while maximizing the team’s contribution to theorganization.SOURCE: “Project Teams That Get Results,” by M. Messmer, 2004. Strategic Finance, 85(8), pp.13–14. Reprinted with permission.DISCUSSION QUESTIONS1. Explain why teams and groups are not the same.2. Describe the various types of teams used in today’s organizations.3. Explain the difference between a traditional work team and a self-managing work team.4. Discuss the positive and negative issues of using a virtual teamversus a conventional-type team.5. Explain the difference between a working group and a high-performing team.6. Explain the various approaches managers can use to build teamperformance.7. Discuss the various organizational barriers to team effectiveness.8. Are there other characteristics of a successful team that can be addedto Biech’s list?EXERCISE 17–1List and describe the types of teams most commonly used in yourorganization. What are the purposes of the teams?EXERCISE 17–2List the teams of which you are a member. Select one of these teams toanalyze. Is this a high-performing team? If yes, why is it? If no, why isn’t it?What changes need to be made to increase the probability that it could bechanged into a high-performing team?

REFERENCESBartunek, J. M. (2011). Intergroup relationships and quality improvementin healthcare. BMJ Quality and Safety, 20(Suppl. 1), i62–i66.Cohen, S. G., & Bailey, D. E. (1997). What makes team work: Groupeffectiveness research from the shop floor to the executive suite. Journalof Management, 23(3), 239–390.Daft, R., & Marcic, D. (2009). Understanding management (6th ed.). Mason,OH: Southwestern Cengage Learning.Drew, S., & Coulson-Thomas, C. (1996). Transformation through teamwork:The path to the new organization? Management Decision, 34(1), 7.Dunphy, D. (1996). Organizational change in corporate settings. HumanRelations, 49(5), 541–552.Gordon, J. (2002). A perspective on team building. Journal of AmericanAcademy of Business, Cambridge, 2(1), 185–188.Hackman, J. R. (2011). Collaborative intelligence: Using teams to solve hardproblems. San Francisco, CA: Berrett-Koehler Publishers.Katzenbach, J. R., & Smith, D. K. (1993). The wisdom of teams: Creatingthe high-performance organization. Boston, MA: Harvard Business SchoolPress/McKinsey & Co.Lawler III, E. E. (1999). Employee involvement makes a difference. Journalof Quality and Participation, 22(5), 18–20.Lipnack, J., & Stamps, J. (1997). Virtual teams reaching across space, timeand organizations with technology. New York, NY: John Wiley & Sons.Lurey, J. (1998). A study of best practices in designing and supportingeffective virtual teams. Los Angeles, CA: California School of ProfessionalPsychology.Margerison, C., & McCann, D. (1989). Managing high-performance teams.Training & Development Journal, 43(11), 52–60.Messmer, M. (2004). Project teams that get results. Strategic Finance,85(8), 13–14.Oxford Centre for Staff and Learning Development. (2011). Characteristicsof a group-cohesiveness. Available at:https://www.brookes.ac.uk/services/ocsld/resources/small-group/sgt107.htmlRoebuck, D. B., & Britt, A. C. (2002). Virtual teaming has come to stay—Guidelines and strategies for success. Southern Business Review, 28(1),29–39.

Rothschild, S. K., & Lapidos, S. (2009). Virtual teams that coordinate carefor chronically ill geriatric patients reduce emergency department visitsand improve medication compliance, referral patterns, and patientoutcomes. AHRQ Health Care Innovations Exchange, Available at:http://www.innovations.ahrq.gov/content.aspx?id=2459Taplin, S. H., Foster, M. K., & Shortell, S. M. (2013). Organizationalleadership for building effective health care teams. Annals of FamilyMedicine, 11(3), 279–281.OTHER SUGGESTED READINGBeich, E. (Ed.) (2001). The Pfeiffer book of successful team building: Best ofthe annuals. San Francisco, CA: Jossey-Bass/Pfeiffer.Wise, H., Beckhard, R., Rubin, I., & Kyte, A. L. (1974). Making healthteams work. Cambridge, MA: Ballinger Publishing Co.

PART VIManaging Organizational ChangeIn Part VI, we discuss planned organizational change and how to manageit. To manage organizational change, a leader needs to apply all the theoriesand concepts discussed throughout this textbook. The leader, or changeagent, must use his or her knowledge of motivation, leadership, groupdynamics, team building, and conflict management, in addition tocommunication and negotiation skills, to be successful. In Chapter 18, weexplain the role of organization development in planned changemanagement. In Chapter 19, we describe the strategies used for successfulimplementation of change within organizations.

CHAPTER 18Organization DevelopmentLEARNING OUTCOMESAfter completing this chapter, the student should be able to: Understand the role organization development (OD) plays in anorganization’s planned changes. Appreciate the function and responsibilities of the OD professional. Understand the components of the Action Research Model. Identify and understand the OD process. Understand the interventions used in the OD process.OVERVIEWHealth care has been a dynamic industry in recent history. Newreimbursement models, escalating costs, and changing regulations haveresulted in an environment fraught with survival struggles. In addition tothe financial and structural struggles, real and projected staffing shortageshave also resulted in retention issues as well as the infiltration of laborunions into the health care industry. These issues have caused healthsystems to be in a flux of constant change. Health service organizations(HSOs) need the necessary strategies to successfully implement therequired changes for future sustainability. As such, many organizationshave turned to experts in the field of organization development (OD) toassist with change initiatives and to help ensure the long-term viability ofthe HSO.OD has extensive roots dating back to the early 1900s. Frederick Taylorand his theory of scientific management were extremely influential becausethe theory advocates exploring ways to increase the productivity of workers.The Hawthorne Studies conducted between 1924 and 1933 also played apredominant role in paving the way for understanding organizationalbehavior-oriented change processes (Ott, 1996). As the nation progressedthrough the Industrial Age and through the Depression and two world wars,

the emphasis on the way employees were viewed changed as the nationdeveloped a better understanding of employee motivation. In addition, thepopularity of labor unions contributed to the organization’s motivation fordesigning a better working environment. The end result of a century ofhistory has been organizations that understand the need to change in orderto remain competitive, yet that also recognize that an emphasis onemployee satisfaction is critical in meeting organizational goals. Therelationship of needing change and striving to understand how employeeswill react to change is the focus of the field of OD. Meaningful change is acentral deliverable of the OD profession (Hanson, Moir, & Wolf, 2011).ORGANIZATION DEVELOPMENTOD is a field that incorporates a number of characteristics. Most agreethat OD is a planned process of change (Beckhard, 1969; Burke, 1982) usingbehavioral science (Beckhard, 1969; Beer, 1980; Burke, 1982; French & Bell,1990) in an organization-wide process (Beckhard, 1969) utilizing asystematic approach (Beer, 1980; McLagan, 1989) to problem solving withthe goal of improving the effectiveness of the organization. On the basis ofthese characteristics, OD is not a one-time training program, a quick-fixchange, or a “flavor of the month” initiative. Rather, OD is designed to be aplanned initiative, which may be based on a needs analysis, and utilizes astrategic approach to implement the change.Many things that occur in an organization deal with some type of change;however, not all are necessarily OD initiatives. For example, expanding aservice, such as an emergency department (ED), requires long-termplanning, a needs assessment determined by increasing volumes orchanging market conditions, a thorough cost–benefit analysis, and astrategic plan. However, this type of change may be successfullyimplemented without an OD intervention. Why? Although the expansion ofthe service directly impacts the functioning of the ED staff as well asvarious other functional units within the hospital, the organization’s culturewill most probably not be affected by this change initiative. Most employeeswill likely understand and probably welcome the expansion; therefore,behavioral science intervention is not needed. One of the components of ODthat is fundamental to the definition of the field is the behavioral scienceapplication. If the ED expansion requires a culture change for the hospital,then the interrelationship between the expansion and the culture shift mayrequire the expertise of an OD professional.Cummings and Worley (2009) describe three features of OD that

differentiate it from other change initiatives: (1) it applies to an entiresystem; (2) it involves the impact of behavioral science on the changeprocess; and (3) it includes planned change based on diagnosis, intervention,and redirecting, if necessary.First, OD applies to an entire system that may include the entireorganization or a division, but OD does not involve change directed at asingle person or a single unit. For example, the introduction of a newmagnetic resonance imaging (MRI) scanner into the newly expanded EDmay require training for the radiologic technologists utilizing this newmachine, but this training is targeted to new technology and to thosespecific individuals who will be working with the new equipment.The second feature of OD, outlined by Cummings and Worley (2009), isthe impact of behavioral science on the change process. Practitioners in thefield of OD recognize the interrelationship of group dynamics, groupprocesses, and culture on the change initiative, and great strides are takento ensure that this relationship is cultivated throughout the change processto ensure the success of the initiative. In addition, OD practitionersunderstand the psychological and sociological components of change andwork to assist the organization to develop a greater understanding of thesedynamics. The importance of the behavioral science approach cannot beunderstated. Since OD involves change within an organization, themembers of that organization will be directly affected by any changes. If achange initiative is implemented without an understanding of how thepeople within the organization will react and respond to this change, thechange is likely to be difficult at best, and completely unsuccessful at worst.The behavioral science component will help the leadership of theorganization understand the psychology of change, key phases in asuccessful change, and the importance of critical mass, as well as barriers tobe prepared to overcome any anticipated time frames.The third feature of OD is that planned change is based on diagnosis,intervention, and redirecting if the change efforts are not progressing asplanned. Cummings and Worley (2009) state that OD is focused onimproving organizational effectiveness and utilizes a variety of processchange techniques. Five components of OD work toward achieving the goalsof improving organizational effectiveness through process changetechniques: (1) OD is supported by multidisciplinary theories; (2) OD viewsorganizations as open systems; (3) OD recognizes that if one part of theorganization is impacted by change, an effect will be felt in another part ofthe organization; (4) OD is based on action research, which is a continuous

examination of the progress of the interventions; and (5) OD is based ondata (see Case Study 18–1: Doctor’s Hospital’s Organizational Change).Case Study 18–1 Doctor’s Hospital’s Organizational ChangeDoctor’s Hospital was facing a serious financial hardship as health care costs continued to spiralout of control and reimbursement plummeted. A new chief executive officer (CEO) was hired to turnthings around in an effort to save the hospital. The CEO was determined to change theorganization’s culture, which he identified as apathetic and accustomed to mediocrity. He noted thatthe financial performance was suffering, and he attributed much of this to a variety of process issuesas well as a lack of focus on the core business of patient care.The CEO immediately took action to look at financial issues and cut costs. A drastic cost and laborreduction strategy was implemented with an aggressive timeline to turn the financial bottom linearound. Within a few months, the hospital started to show less of a financial loss and things seemedto stabilize financially. However, the morale of the staff had taken a significant hit. Turnoverincreased as a sense of job security decreased, and the impact on the patients began to be seen in anincrease in patient complaints and lowered patient satisfaction scores. An employee trainingprogram was introduced to reemphasize the need for customer service, but it had no impact onresults. Finally, the CEO hired a consultant who performed an assessment. A multilevel programwas implemented that incorporated all levels and all aspects of the hospital. This assisted seniormanagement with understanding the linkages between finances, employee morale, and patientsatisfaction. After two years, a mindset of accountability started to emerge that began a culture shiftto one of service. Finally, all the organizational metrics started moving in the right (and same)direction.Questions1. What were the key components of changing the organizational culture?2. Why wasn’t the training effective?3. Why do you think a culture change was necessary?4. What steps do you think the consultant recommended in order to effect this change?THE ORGANIZATION DEVELOPMENT PROFESSIONALThe behavioral science nature of the field requires that OD practitionershave a particular skill set in order to ensure success. The role of the ODpractitioner consists of a variety of activities, depending on the relationshipbetween the practitioner and the organization. Gottlieb (2001) suggests thatthe primary role of the practitioner is assisting clients with achieving clarityand understanding, whereas other roles consist of assisting with diagnosis,assisting with process, providing information, or providing trainingactivities. Ultimately, the OD practitioner primarily facilitates a changeinitiative in an organization. The OD practitioner is similar to a therapistwho guides someone through a difficult time, recommending strategies andenabling the change process. However, just as a good therapist recognizesthat ultimately the client must pave his or her own way to success, so does

the OD practitioner. The OD practitioner provides the foundation forchange, but management must pave the organization’s way. Consequently,the relationship between the organization and the OD practitioner requiresa delicate balance. The leaders and members of the organization mustultimately work through the process and are responsible for ensuring thesuccess or failure of the initiative. It is critical that OD practitionersestablish a psychological distance and set boundaries to clearly define rolesin order to ensure a successful relationship (Browne, Cotton, &Golembiewski, 1977) (see Case Study 18–2: What Went Wrong?).Case Study 18–2 What Went Wrong?Joan was asked to consult with a hospital that was attempting to enhance organizationaleffectiveness. She was able to meet briefly with the CEO before she embarked on a series ofmeetings with front-line managers. The managers were quite informative about the issues theyobserved in their departments and provided Joan with what she thought was an honest assessmentof the issues. After two weeks of meetings, she met again with the CEO to review the data andrecommend a course of action. The CEO seemed genuinely interested in what she had to say, butdisagreed with many of her conclusions and plan of action. He determined the problem to be poorteam dynamics, whereas Joan had suggested that the team issues were a “symptom” of problemprocesses resulting in role ambiguity and apathy. The CEO decided that the easier course of actionwas to work on the team dynamics and directed Joan to pursue that course of action.Against Joan’s better judgment, she embarked on a team-building initiative involving manymonths and over 500 employees. As a result of the initiative, there seemed to be some bettercamaraderie, yet the role ambiguity and other problems persisted. Six months after the completionof the team-building project, the CEO commented at the senior management monthly meeting that itwas a waste of time with no significant outcomes and vowed to never hire an OD consultant again.Questions1. What went wrong?2. What should have been done differently?3. How effective was Joan in her role?There are many skills that make an OD practitioner successful, includinga combination of technical, interpersonal, and consulting skills (Block,1981). Technical skills include specific education or training in some area.An example might be specific training in statistical process control wherebya particular process improvement was initiated or a Total QualityManagement or Six Sigma program implemented. Specific expertise in thepsychology of change management would be another example of anappropriate expertise.Another skill set of OD practitioners is interpersonal skills. Listeningskills are as critical as the ability to maintain a psychological distance.

Marginality has also been identified as a key characteristic of an effectiveOD practitioner (Browne, Cotton, & Golembiewski, 1977; Burke, 1982;Gottlieb, 2001), which involves the ability to be involved in an organizationwithout being unduly influenced (Church, Hurley, & Burke, 1992). Theability to be collaborative is another key characteristic (Argyris, 1970) andinvolves the ability to facilitate rather than direct activities. In a qualitativeanalysis conducted by Gottlieb (2001, p. 45), clusters of roles were identifiedfor an OD professional. These roles include:1. Assisting in clarification, such as by asking questions, challenging,and confronting.2. Diagnosing, which includes data gathering and the analyzing andinterpreting of data.3. Designing or assisting with the design and implementation ofinterventions.4. Providing expert information on organization theory, change, orbusiness issues.5. Process identification, which includes assisting clients withunderstanding process options.6. Facilitating interventions by guiding and directing groups throughprocess changes or strategies to ensure effective communicationduring the implementation and intervention.7. Training activities, which may run the gamut from the training needsassessment through the training design and delivery of trainingprograms.Overall, depending on the type of initiative, the skill level and role of theOD practitioner will vary. However, one key characteristic is the ability toapply theory to practical application.OD practitioners are professionals who are employed by the organization,thus serving as an ongoing internal consultant, or organizations maycontract for the services of an external consultant. There are pros and consof each, and the leaders of an organization must be able to identify whichtype of consultant would be best suited for their organization for the issueat hand. The internal consultant has an advantage over the externalconsultant because the individual has a working knowledge of theorganization, knows the key players, understands what interventions havebeen attempted previously, and may have access to data without the need tostart from scratch. The downside of utilizing an internal consultant is thatin some cases the consultant is too close to the individuals working in the

organization and may not be able, in the eyes of the leadership of theorganization, to separate the relationships. Additionally, the internalconsultant, if it is someone who has been employed by the organization for alength of time, may be blind to the issues that are creating theorganizational symptoms, and thus may suffer a loss of objectivity.In contrast, an external consultant does not have an establishedpsychological connection with the organization, so he or she may bring theobjectivity that might be lacking with the internal consultant. In addition,an external consultant is often skilled at a particular intervention or set ofinterventions that have been used in other organizations, so the consultantbrings experiences in the implementation of the intervention. Anotheradvantage of an external consultant is that a particular skill set may existwith the external consultant that the internal consultant may not possess.For example, if an organization wants to implement Six Sigma, the internalconsultant may not have the training or skill set to assist withimplementation of this complex process. One disadvantage of an externalconsultant is that there is not a prior relationship with the organization inmany cases, so the external OD practitioner must begin with rapport andtrust-building steps. This lack of a relationship may, in some cases, hamperthe data-collection steps, especially if employees are mistrusting of anoutside person. It is interesting, however, that this may also be anadvantage to the data-collection initiatives, as often the employees aremistrustful of providing information to an internal person for fear ofretaliation.ACTION RESEARCHAs mentioned earlier, OD is a systematic process. Most OD practitionersuse a model of planned change known as the Action Research Model(Cummings & Worley, 2009). According to Rothwell, Sullivan, and McLean(1995), action research can be used as a model to represent the complexactivities that occur in a change process. As illustrated in Figure 18–1, theAction Research Model contains eight main steps. This model may, in fact,serve as a road map for change agents to follow as they implement changein an organization (Rothwell et al., 1995). Ultimately, the goal of actionresearch is to base the intervention on initial research, followed by feedbackthrough further data analysis to determine the effectiveness or impact,make adjustments as necessary, and ultimately use the results to supportadditional research (Rothwell et al., 1995).

STEPS IN THE ORGANIZATION DEVELOPMENTPROCESSAs illustrated in Figure 18–1, traditional OD theorists have identifiedeight steps to the Action Research Model (Burke, 1982; McLean & Sullivanas cited in Rothwell, Sullivan, & McLean, 1995), which has served as thetemplate for OD practitioners to follow. However, other practitioners haverecommended that the model be consolidated into a smaller number ofidentified steps. The two models are compared in Table 18–1. A fewadditional points about each of the major steps are worth noting.

Figure 18–1 Action Research ModelReproduced from Cummings, T. G., & Worley, C. G. (1997). Organization development and change (6th ed.). Cincinnati, OH:South-Western College Publishing, pp. 29–30.

Table 18–1 Comparison of the Two Models for Action ResearchBurke, 1982; McLean andSullivan, 1989Cummings and Worley, 1997Description1. Entry1. Entry and contractingKey leaders identify a need and work to begin the ODprocess. An OD practitioner is identified and the keycomponents of the working relationship between theorganization and practitioner are established. Groundrules, mutual expectations, and deliverables areidentified.2. Startup3. Assessment andfeedback2. DiagnosingData-collection techniques are employed to determine theextent of issues identified by the organization. Adiagnosis of relevant organizational processes,interpersonal relationships, or group analysis may beemployed.4. Action planningSteps are taken to work with the organization to ensurelong-term success of any intervention. Key relationshipsare established and mutual plans are developed. Theimpact of change on any change initiative is reviewed,and steps put into place to assist the organizationthrough the change process.5. Intervention3. Planning andimplementing changeThe planning phase is similar to the action planning phasejust listed. The plan is implemented and carried out.The process of managing change is implemented, andsteps taken to ensure the success of the intervention.6. Evaluation7. Adoption4. Evaluating andinstitutionalizing changeThe change process is evaluated through data analysisand comparison to previous data. The change becomespart of the organization, and the members of theorganization begin to adopt these strategies and takeownership for their success.8. SeparationThe OD practitioner begins the disengagement processfrom the organization if it is an external consultant or thedisengagement of the project if it is an internalconsultant.Entering and ContractingThe entering and contracting phase is the first critical step in the plannedchange process. During this stage a contract is developed between theorganization and OD practitioner, during which mutual expectations areidentified. These expectations should include outcomes expected, such asgreater employee satisfaction, increased revenues, lower turnover; length ofthe engagement; and communication and reporting expectations—forexample, who is the primary contact at the organization for the ODpractitioner, frequencies of reports and updates, and so on. In addition,ground rules need to be established that outline how to handle sensitiveissues such as feedback of difficult information, maintaining employeeconfidentiality (whether that is an expectation), and how to terminate theengagement if there are concerns or issues from either party (Cummings &Worley, 1997; Rothwell, Sullivan, & McLean, 1995).

DiagnosisThe diagnosing phase is the second major phase in the general model ofplanned change. It involves a strategic plan for understanding theorganization and gathering, analyzing, and feeding back of information tomanagers and organization members about the problems or opportunitiesthat exist. When well done, diagnosis clearly points the organization and theOD practitioner toward a set of appropriate intervention activities that willimprove organization effectiveness (Cummings & Worley, 2009).There are various methods of collecting data within the organization.Cummings and Worley (1997) outline the most typically utilized methods.Usually, a variety of methods may be used, with the choice being largelydetermined by efficiency, sample size, and type of information that isneeded. The most commonly used methods include questionnaires,interviews, observations, and unobtrusive methods.Questionnaires are often the first method used for collecting informationfrom an organization (Cummings & Worley, 1997). Questionnaires are oftenutilized because of their relative ease of administration and ability to collectinformation from large groups of people and to provide some responseanonymity. Additionally, questionnaires, if developed correctly, enable anefficient means to quantify and analyze information. An experienced ODpractitioner understands how to construct an effective tool for capturing theinformation that would be relevant for performing an organizationalanalysis. Such expertise is needed because it is important to understand thestatistical properties of sample size, the power of results, and scaleconstruction, as well as how to create a nonbiased instrument. Additionally,in the current litigious world, one must work to ensure that there is somevalidity to any questionnaire that is used in an organization and that it doesnot seemingly target any particular group of individuals with a biasedresult.The construction of a questionnaire with an appropriate scoring scale iscritical to the ability to effectively analyze the data. All too often, new ODpractitioners create an open-ended questionnaire and send it out to 300employees in the hopes of collecting a variety of responses, only to discoverthat there is no easy way to analyze the results since every employee haswritten something different. Another difficulty in using a questionnairemethod is that it is rare that everyone who receives a questionnaire is goingto complete it. It is likely that you have received many satisfaction surveysat home, only to throw them in the trash or forget to complete them. Thereality is that there is typically a relatively low response rate for

questionnaires, and the missing data mean that a piece of the puzzle ismissing. This nonresponse bias is impossible to interpret but exists andmakes an impact on analysis. Therefore, OD practitioners commonlyattempt to send questionnaires to as many employees as possible to ensure asample with enough respondents to reduce statistical error of the results.A second type of data-collection tool is the use of interviews (Cummings &Worley, 1997). Occasionally, interviews are used as a follow-up to resultsobtained from a questionnaire, but this method is also used to capture datathat cannot be readily obtained in the questionnaire. Through a two-waycommunication approach, an effective interviewer can delve into issuesidentified by the employee and attempt to get to the heart of any issueidentified. However, coding of responses is a hurdle for analyzing the resultsof the interview. Additionally, the interviewer may hear the responses thatthe interviewee wants to be heard. This response bias may make it difficultto obtain valid results, but this can be overcome to some degree througheffective rapport building and reassurance of confidentiality from theinterviewer. The final disadvantage of this approach is that it is verydifficult to conduct a large number of interviews, so the sample size tends tobe small.Another method for data collection is that of observation (Cummings &Worley, 1997). An observation is designed to allow the OD practitioner tosee firsthand what is occurring with either a particular group of people or aprocess. For example, one organization might be concerned with the lack ofteamwork among a group of employees, and questionnaire data collectionrevealed a variety of potential reasons for these issues. Because the resultswere somewhat ambiguous, the OD practitioner might decide to go in andactually observe the interpersonal dynamics occurring among the teammembers. This might reveal communication patterns, leadership issues, orineffective conflict resolution strategies within the team that might not bediscovered through traditional data-collection strategies. In anotherexample, a process might be observed in order to determine whether thereare inherent inefficiencies that might not be recognized by the employeesperforming the various tasks within the process because they are soaccustomed to performing those tasks regularly. Therefore, it is obviousthat there are some distinct advantages to the observation method of datacollection. However, as with all data-collection techniques, there are alsosome pitfalls. The most apparent is that employees behave differentlysimply because they are being observed (known as the “Hawthorne Effect,”based on the Hawthorne Studies; see Roethlisberger & Dickson, 1939;

Homans, 1950). Many employees become concerned that they will face someoutcome if, during the observation, some negative data are collectedregarding their work performance. Since ultimately the goal for manyemployees is job security, it is probable that in some cases the employeesmay in fact alter their behavior simply to “look good.” Additionally,observers face considerable difficulty in coding observed behavior into sometype of aggregate result. Observers must also guard against theirpreconceived ideas of what should occur, so that they are in fact recordingactual behavior rather than either an ideal or a judged version of whatactually occurred.Finally, one additional type of data collection frequently utilized by ODpractitioners is that of the unobtrusive method (Cummings & Worley,1997). The interesting component in this type of data collection is that thedata are obtained directly from preexisting information. These types of dataexist in various formats throughout every organization. Examples of thisinclude financial reports; human resources information such as turnover,vacancy rates, performance appraisals, and exit interviews; safety reports;and customer satisfaction information, to name a few. The advantage of thistype of data is that they are relatively easy to utilize once they are obtained,although in some organizations the information systems or mechanisms bywhich organizations collect information are either cumbersome or in somecases nonexistent. A second advantage of these data is that they aretypically free of biases that may be introduced as a result of other data-collection strategies.Planning and Implementing ChangeAn enormous variety of interventions are utilized by OD practitioners.According to Cummings and Worley (1997, p. 141), three major criteria areneeded for an effective intervention: “(1) the extent to which it fits theorganization, (2) the degree to which it is based on casual knowledge ofintended outcomes, and (3) the extent to which it transfers competence tomanage change to organization members.” Essentially, the types of ODinterventions that are typically utilized fall into several broad categories(Cummings & Worley, 1997).A brief overview of these interventions is outlined here, although someare discussed in greater detail later in the chapter. These interventionsinclude:1. Strategic Interventions: Strategic interventions deal with large-scale

organizational strategic issues, such as ensuring the organizationmaintains a competitive advantage, and marketing strategies, as wellas other organizational performance issues. Assessing theorganizational environment and external factors impactingperformance may identify an intervention whereby a diversification inproducts or change in geographic location may be identified as the keyto long-term organizational success.2. Technostructural Interventions: Technostructural interventions dealwith structural issues within an organization, such as organizationaldesign issues or work design issues. An example of this might be therecognition through data collection that an organization with afunctional structure is no longer efficient in its business strategy. Thestructure is providing some limitations that are ultimately impactingon coordination between products and services and resulting incustomer service or quality issues.3. Human Process Interventions: Human process interventions dealprimarily with issues between people within an organization. Oftenthere are distinct communication barriers, a history betweenemployees, or perhaps ineffective leadership. In these interventionsthe data might point to a problem involving fundamentalcommunication processes, and, therefore, the recommendedintervention might be a strategy to assist the group with improvinginterpersonal relationships. An intervention such as communicationtraining involving the Johari Window (a model used to improvecommunication between individuals; see Luft, 1984) or a team-building strategy might be appropriate in these cases.4. Human Resource Management Interventions: Human resourcemanagement interventions deal with larger-scale typical humanresource issues. Interventions in this arena might be based on datasuggesting that there is an exodus of good employees from theorganization. Exit interviews might reveal that employees aredisenchanted with reward programs or with organizational successionplanning. Interventions such as a career planning system might be away to address such concerns.Evaluating and Institutionalizing ChangeThe true test of the effectiveness of an OD intervention is the outcome. Inorder to truly know whether there is an effective outcome, there has to besome sort of follow-up evaluation and measurement. The follow-up

evaluation should be predetermined at the outset and agreed upon by bothparties as part of the original contract. Feedback to managers about theintervention’s results provides information about whether the changesshould be continued, modified, or suspended (Cummings & Worley, 2009).Institutionalizing successful changes involves reinforcing them throughfeedback, rewards, and training.It is critical that the OD practitioner be viewed solely as the facilitator ofthe new process rather than as the owner. It is therefore extremelyimportant that the impact of the intervention be transferred back to theorganization. In other words, the organization must transfer responsibilityand accountability from the OD practitioner to the organization and withthat ensure that the proper steps have been taken to implant the newstrategy into the fabric of the organization.ORGANIZATION DEVELOPMENT INTERVENTIONSListed below are some typical OD interventions suggested by Rothwell,Sullivan, and McLean (1995) that might be utilized by OD practitioners:1. Team Building: Team building can be done in a variety of ways, fromproviding assessments to team members, team-building workshops, orin-depth group analysis. Regardless of the strategy utilized, the goalis to increase the effectiveness and cohesiveness of either an intactwork group or a project team.2. Process Improvement: The process improvement intervention isdesigned to look at work processes and the way an individual maywork within the process. The goal is to improve efficiency.3. Total Quality Management: The total quality managementintervention is designed to enable groups of people to work togetheron a single problem and, through a regimented process utilizingspecific problem-solving tools, work to solve the issue at hand. Someof the tools that the team is trained to use are Pareto diagrams,cause-and-effect diagrams, brainstorming, and flowcharts, as well asa host of other tools. Team members are trained on these techniques.Teams typically meet regularly over a long period of time in an effortto solve the problem or mission that they have been given. Thisintervention not only is an effective intervention for problem solvingor process improvement, but also impacts on team dynamics andprovides opportunities for employee involvement.4. Work Redesign: The work of Hackman and Oldman (1980) suggests

that there is a significant relationship between core job dimensions(skill variety, task identity, task significance, autonomy, andfeedback) and critical psychological states (experiencedmeaningfulness of work, experienced responsibility for outcomes ofwork, and knowledge of actual results of work activities). Therelationships between these produce personal and work outcomes(internal motivation, high-quality work performance, highsatisfaction, and low absenteeism and turnover). On the basis of thismodel, OD practitioners may opt to look at the design of the job todetermine what core job dimensions are inherent in the work.Depending on the outcome of the analysis, a redesign of the job maybe recommended so that specific psychological states are addressed inthe core job.5. Structural Change: As mentioned earlier, it is possible to change theorganizational structure if it is determined that the current structureis ineffective. Changing the structure essentially changes reportingrelationships, which is designed to streamline and improve qualityoutcomes.6. Training: Training is often seen as the only intervention needed.Often organizations fall into the trap that a training program will bethe panacea that addresses and solves all of its organizational issues.This is clearly not the case; however, training is considered to be avery effective intervention when conducted with the right goal inmind or as an adjunct to an additional initiative. The goal of trainingshould be to improve a skill base.7. Performance-Management Systems: Performance-managementsystems intervention is one of the Human Resource ManagementInterventions. A performance-management system is composed ofgoal setting, appraisal, and reward systems. Some organizations havenone of the components in place; some have one or two components,or all. This intervention may involve designing a performance-management system within an organization where none exists or theredesign of one in an organization with an ineffective system in place.The goal of this strategy is to identify the appropriate mechanisms,specific to an individual, for measuring employee performance.APPRECIATIVE INQUIRYA relatively new approach or process for planned change is appreciative

inquiry (AI). Where the action research process is primarily deficit based—focusing on the organization’s problems and how they can be solved so itfunctions better—AI focuses on what the organization is doing right(Cummings & Worley, 2009; Fitzgerald, Murrell & Newman, 2002). AIsuggests that for organizational change to take place, the organizationneeds to begin with the recognition of its positive attributes and then askthe questions that will take it along the path toward the organization itvisualizes itself becoming (Cooperrider & Srivastva, 1987). Similar to anathlete using visualization to prepare for an upcoming competition, wherebythe athlete mentally reviews every step of the competition and visualizessuccess, so does AI challenge the organization to capitalize on its strengths.AI is a guided change process by an OD practitioner adept at maneuveringthrough the maze of possibilities that might be exposed through the positiveissues identified (see Case Study 18–3: Creating Positive Conversationsaround Exceptional Healthcare Dining Services). The OD practitioneressentially helps the organization see the future and then sets theorganization on a path to make that visualization a reality (Cummings &Worley, 2001).AI is often explained using the five Ds: Define, Discover, Dream, Design,and Deliver. This approach is described in the five steps below (Fitzgerald,Murrell, & Newman, 2002, pp. 209–211).Phase 1: Define—The most critical phase of the process is defining thetopic(s) for an appreciative inquiry.Phase 2: Discover—This step typically begins with paired appreciativeinterviews exploring participants’ peak experiences of each topic and whatmade those experiences possible. Participants look for the best of whathappened in the past, and what is currently working well. In this phase,questions are designed to get people talking and telling stories about whatthey find is most valuable/appreciated, and what works particularly well.Phase 3: Dream—During this phase, the best of the past is amplified intocollectively envisioned and desired futures. In other words, the participantsdream of “what might be.”Phase 4: Design—In this phase, participants identify key facets oforganizational systems and structures that will be needed to support therealization of their collectively generated dreams. During this step,members determine the types of systems, processes, and strategies that willenable the dream to be realized.Phase 5: Deliver—During the fifth or implementation phase, participantsself-select projects or tasks that they would like to work on or otherwise

support. Actions are implemented over time in an iterative, appreciativelearning journey. The overall results are changes that occur simultaneouslythroughout the organization—all serving to support and sustain the dream.Case Study 18–3 Creating Positive Conversations around Exceptional Healthcare Dining ServicesFocus of the Appreciative Inquiry: To have a group of 20 Foodservice Directors discuss andidentify their experience with exceptional dining services and transfer that learning to theirhealthcare facilities.Client Organization: UHF Purchasing is a group purchasing organization that provides primevendor contracts, product supply contracts and services to healthcare facilities through a nationalpurchasing agreement. The majority of the participants worked in long term care facilities or smallcommunity hospitals throughout the state of Wisconsin. The Food Service Directors meet quarterlyto discuss trends and issues affecting the foodservice departments. The AIC consultant was invitedin to create positive conversations around the dining experience and to teach the FoodserviceDirectors to train their staff in an appreciative approach.Client Objectives/Specific Goals:• Build energy around training regarding excellent customer satisfaction• Educate the Foodservice Directors on an appreciative approach to learning versus gap analysis• Create a dialogue in which Foodservice Directors can share and learn from others in thePurchasing GroupWhat Was Done: UHF Purchasing created a learning seminar “Breakfast for Champions” in whichFoodservice Directors could get together for four hours. An interview guide was developed toexplore in detail the elements that make up an excellent dining experience. The participants pairedup for interviews and then shared with the group the stories and their key learning from theinterviews. The participants identified themes and elements that contributed to their exceptionaldining experience. The participants shared with each other how they could use a similar process fortraining their staff.Outcomes:• Collectively the Foodservices Directors created a list of elements for an exceptional diningexperience• Foodservice Directors were exposed to an appreciative process for trainingReprinted with permission from Peirick, R. (2003). Creating Positive Conversations aroundExceptional Healthcare Dining Services.SUMMARYIn general, organizational development (OD) is one of the most popularand widely used approaches for implementing organizational change(Waclawski & Church, 2002). Many types of interventions are available andat the disposal of a well-trained OD practitioner. A successful OD initiative

will be based on a thorough analysis of any symptoms of problems, with thisanalysis based on a thorough analysis of data. The partnership with theorganization is critical, and the OD practitioner must work to ensure thatultimately the organization understands and accepts that the responsibilityfor the success of any intervention lies with management.DISCUSSION QUESTIONS1. Identify and discuss the various characteristics of OD.2. Describe the unique features of OD that differentiate it from otherchange initiatives.3. How would you describe the role of the OD professional? What skillsare necessary for an OD practitioner?4. Explain the various components of the Action Research Model.5. Identify and explain the steps necessary in the OD process.6. Why is data collection so important to the OD process?7. Identify and explain the various interventions used in the OD process.8. What is appreciative inquiry, and how is it used in the OD process?Case Study 18–4 Gateway HospitalGateway Hospital is a 500-bed tertiary-care hospital located in a busy metropolitan area. A recentemployee satisfaction survey scored well below the national norms on most scales. The hospital hasbeen facing higher than average turnover and vacancy rates. Recruitment for professional positionsis very difficult because the hospital has gained a reputation as a bad place to work, especially if oneis new; the term “eat their young” seems to be a prevalent description. Salaries are below the localmarket, as are annual pay increases. Many departments seem to have a critical shortage of staff, andclosing services has been a recent topic of discussion.Additionally, the financial picture of the organization is bleak. The payor mix has changed;Medicare cutbacks are impacting the bottom line, as are changes in private insurance funding. Keyphysicians are beginning to take their services elsewhere, as they sense the inefficiency of thehospital processes.The various stresses appear to be having a significant impact on the overall morale of employees.Poor teamwork is rampant, and communication breakdowns seem to be a normal occurrence. Severalleaders have been let go in an effort to address issues.The leadership of Gateway Hospital is extremely concerned about the organizational prognosisand has decided to begin to address the issues by enlisting the assistance of a consulting team. Onemember of the team is a financial expert who has been hired to address the significant financialissues affecting the hospital. The time frame on fixing the financial issues is one of a critical need;since the environment is rapidly changing, the consultant must get a handle on how to help thehospital operate successfully, given the current financial downslide.A second member of the team is hired to address the morale and employee issues. A review of theemployee opinion survey is conducted, and trends are identified in exit interviews. Employeeinterviews and focus groups are held in an attempt to determine the root cause of the morale issues,as well as the breakdown in teamwork and communication.

The data collection is discussed with leadership; after a series of discussions, leadership admitsthat many of the financial pressures have created a “knee-jerk” reaction to staffing issues, oftencutting back dramatically on employee hours. This would create a crisis mode and the need to askemployees to work harder. This cycle has created a significant lack of trust from the employees’perspective, coupled with the fact that employees have not felt that they have been apprised of thereasons for the rollercoaster changes and have not been offered any words of appreciation when theyhave either reduced their hours or worked in a crisis.The consultant and the leadership agree that in order to fix the “people” issues of theorganization, there will need to be a culture shift of leadership and employee interactions so thattrust can be rebuilt.Discussion Questions1. On the basis of these issues, what OD interventions do you think should be utilized to addressthe problems this hospital is facing?2. How would you proceed if you were the consultant in this case?3. What skill set do you think the practitioner will need in order to be effective in thisorganization?4. What type of a timeline would you establish if you were this consultant?Case Study 18–5 City HospitalCity Hospital is a growing hospital in a large metropolitan city. The hospital is currentlyexperiencing an issue that many other organizations are also facing, that of the multigenerationalworkforce. The senior leadership of this hospital is the typical “baby boom” generation, but thepopulation of employees is slowly growing into one of a younger workforce. The leadership isstruggling to deal with issues such as iPods at work, cell phone use, Internet use, tattoos, bodypiercing, and so on. Equally troublesome is a different perceived commitment to the job andbreakdowns in communication. Leadership has decided to hire an outside consultant to help theorganization understand the impact of the multigenerational workforce and to try to become a morecohesive organization.Discussion Questions1. Which type of OD intervention is the leadership using in this situation?2. What obstacles do you see in this situation that may make this intervention more difficult thanother types?3. What recommendations do you have for this situation?4. What other interpersonal issues exist in organizations besides generational that may create aneed for an OD intervention?REFERENCESArgyris, C. (1970). Intervention theory and method. Reading, MA: Addison-Wesley.Beckhard, R. (1969). Organization development: Strategies and models.Reading, MA: Addison-Wesley.

Beer, M. (1980). Organization change and development: A systems view.Santa Monica, CA: Goodyear Publishing.Block, P. (1981). Flawless consulting. San Diego, CA: University Associates.Browne, P. J., Cotton, C. C., & Golembiewski, R. T. (1977). Marginality andthe OD practitioner. Journal of Applied Behavioral Science, 13(4), 493–506.Burke, W. W. (1982). Organization development principles and practices.Glenview, IL: Scott, Foresman.Church, A. H., Hurley, R. F., & Burke, W. W. (1992). Evolution orrevolution in the values of organization development: Commentary on thestate of the field. Journal of Organization Change Management, 5(4), 6–23.Cooperrider, D., & Srivastva, S. (1987). Appreciative inquiry inorganizational life. In W. A. Pasmore & R. W. Woodman (Eds.), Researchin organizational change and development (pp. 129–169). Greenwich, CT:JAI Press.Cummings, T. G., & Worley, C. G. (1997). Organization development andchange (6th ed.). Cincinnati, OH: South-Western College Publishing.Cummings, T. G., & Worley, C. G. (2001). Organization development andchange (7th ed.). Cincinnati, OH: South-Western College Publishing.Cummings, T. G., & Worley, C. G. (2009). Organization development andchange (9th ed.). Cincinnati, OH: South-Western College Publishing.Fitzgerald, S. P., Murrell, K. L., & Newman, H. L. (2002). Appreciativeinquiry: The new frontier. In J. Waclawski & A. H. Church (Eds.),Organization development: A data-driven approach to organizationalchange (pp. 203–221). San Francisco, CA: Jossey-Bass.French, W., & Bell, C., Jr. (1990). Organization development (4th ed.).Englewood Cliffs, NJ: Prentice Hall.Gottlieb, J. Z. (2001). An exploration of organization developmentpractitioners’ role concept. Consulting Psychology Journal: Practice andResearch, 53(1), 35–51.Hackman, J., & Oldman, G. (1980). Work redesign. Reading, MA: Addison-Wesley.Hanson, H., Moir, M. J., & Wolf, J. A. (2011). Organization development inhealth care: The dialogue continues. In J. A. Wolf, H. Hanson, & M. J.Moir (Eds.), Organization development in health care: High impactpractices for a complex and changing environment (pp. 273–279).Charlotte, NC: Information Age Publishing.

Homans, G. C. (1950). The human group. New York, NY: Harcourt, Braceand Company.Luft, J. (1984). Group processes: An introduction to group dynamics (3rded.). Palo Alto, CA: Mayfield.McLagan, P. (1989). Models for HRD practice. Alexandria, VA: AmericanSociety for Training and Development.Ott, J. S. (1996). Classic readings in organizational behavior (2nd ed.).Belmont, CA: Wadsworth Publishing Company.Roethlisberger, F. J., & Dickson, W. J. (1939). Management and the worker.Cambridge, MA: Harvard University Press.Rothwell, W. J., Sullivan, R., & McLean, G. N. (1995). Practicingorganization development, a guide for consultants. San Diego, CA: Pfeifferand Company.Waclawski, J., & Church, A. H. (2002). Organization development: A data-driven approach to organizational change. San Francisco, CA: Jossey-Bass.* We wish to acknowledge and thank Dr. Lorrie Jones, who was the contributing author of anearlier version of this chapter, which appeared in Organizational Behavior in Health Care (2011),Jones and Bartlett Publishers.

CHAPTER 19Managing Resistance to ChangeJeffrey Ritter, DBALEARNING OUTCOMESAfter completing this chapter, the student should be able to: Identify the drivers of change. Understand the various change models. Identify the various barriers to change. Understand the step-by-step change process.OVERVIEWPlanned change arises from a single change or series of changes inorganizational goals and objectives (e.g., increased patient satisfaction).These changes may originate from an organization revising its mission,creating a new vision, or responding to other internal or external forces.Unplanned change arises from the unexpected, which impinges on thewell-being of the organization. Unplanned changes occur because of, forexample, sudden shifts in the marketplace accompanied by reducedproduct/service demand, emergence of more competitive products/services,changes in technology, depressive economic conditions, natural disasters, orthe death or impairment of a senior manager.Whether planned or unplanned, many changes within an organization willmeet with resistance because, as Lippitt (1973, p. 3) noted, “change is a verycomplex phenomenon involving the multiplicity of man’s motivations in bothmicro and macro systems and that a man gets satisfied with his equilibriumand is resistant to changing his status quo.” Resistance to change is notlimited to clinical or entry-level administration staff. Resistance may also beexpressed by middle managers and senior executives. As such, it is a toppriority for managers to understand the factors involved with changemanagement. By understanding these factors, employees’ readiness for

change can be increased, causing a reduction in their resistance toorganizational change.DRIVERS OF CHANGEOrganizations function within three identifiable environments:external/social, industry/task, and internal (see Figure 19–1).The primary forces creating the need for change originate in anorganization’s external and industry environments. Change becomes theorganization’s attempt to respond and adapt to new operating requirementsgenerated by demands from these environments.

Figure 19–1 EnvironmentsSource: Strategic Managementand Business Policy (6th ed., p. 10), by T. L. Wheelan and J. D. Hunger, 1997, Upper SaddleRiver, NJ: Addison-Wesley. Used with permission.Today’s organizations are facing many challenges. For example, war andterrorism are viewed as powerful political/legal forces impactingorganizations worldwide. Economic forces include other countries’ economicthreats of inflation, deflation, and recession and the resulting general

weakening of the U.S. dollar. Advances in technology and “big data”availability are major forces affecting today’s businesses. The Internet hasdramatically empowered consumers and enabled buyers and sellers to cometogether with drastically reduced transaction and intermediary costs,creating much more robust marketplaces for the purchase and sale of goodsand services. Although these external forces affect all organizations, theyhave had a direct impact on changes within the health care industry. Forexample, patients have become informed consumers of health care services’value and costs; stem cell research and cloning capabilities have challengedan organization’s ethical practices; special interest groups, such asinsurance companies and employer-sponsored health consortiums, havedirectly impacted the way health services organizations do business; and theincrease in union representation of not only nonlicensed employees but alsoprofessional groups, such as nurses and physicians, has had a direct impacton the health care industry. The government, with its changing healthpolicies, has had a direct and major impact on the industry, with theimplementation of the Prospective Payment System in the 1980s; theBalanced Budget Act and the Health Insurance Portability andAccountability Act (HIPAA) in the 1990s; the Medicare Prescription Drug,Improvement, and Modernization Act of 2003; and most recently, thePatient Protection and Affordable Care Act (PPACA) of 2010. The PPACArepresents the most significant regulatory overhaul of the U.S. health caresystem since the passage of Medicare and Medicaid in 1965.In addition to external forces, internal forces are influencing changewithin health services organizations. Internal forces are related to anorganization’s structure, processes, and resources. Because of the manyexternal factors cited, health services organizations (HSOs) areexperiencing decreasing reimbursements and increasing costs, resulting insmaller profit margins. In addition, they are being challenged to deliverpatient-centered care with value-based outcomes. As a result, HSOs areconsidering and engaging in redesign to include more alignment andinclusion across systems (Fischer, Berwick, & Davis, 2009). Whatever thereasons that create a need for change, a planned response must bedeveloped and implemented by management to ensure future organizationaleffectiveness.RESISTANCE TO CHANGEAlthough resistance to change is a deeply embedded concept in changemanagement, there are situations in which individuals will embrace it.

Kirkpatrick (2001) identified change outcomes that would cause individualsto react positively to change:Security—The change may increase demand for an individual’s skill set.Money—The change may involve salary increases.Authority—The change may involve promotion.Status/prestige—There may be changes in titles, work assignments, andadditional decision-making responsibilities.Better working conditions—The physicial environment may change,including new equipment and updated technology.Self-satisfaction—Individuals may feel a greater sense of achievementand challenge.However, managers need to be aware that most organizational changeefforts will be met with resistance. Resistance to change may arise from twosources: organizational barriers and individual barriers. Organizationalbarriers may include: (1) lack of change agent, (2) inadequate financesand/or capacity, (3) poor leadership and resistance to change by seniormanagement, (4) lack of the necessary technology, (5) time restraints, or (6)poor market conditions. Overcoming organizational barriers to change maybe beyond the control of the manager and is usually a topic within astrategic management course. Because our concern is to understand thebehavior-oriented change process, our focus will center on understandingthe individual’s barriers or resistance to change.Individuals’ Barriers to ChangeFor individuals, resistance to change may involve affective, behavioral,and cognitive components (Palmer, Dunford, & Akin, 2009). The affectivecomponent relates to how an employee may feel about the change, thecognitive component is how the employee thinks about the change, and thebehavioral component is what the employee does when confronted with theneed to change (Palmer, Dunford, & Akin, 2009). For a majority ofindividuals, it is contextual factors that determine how they will react(Bareil, Savoie, & Meunier, 2007).The famous Hawthorne Studies that discovered that employees behavedifferently simply because they are being observed. Roethlisberger (1941)proposed that an individual’s attitudes affect his or her response to change.In other words, how a person feels about a change determines his or herresponse. Feelings are not random. Feelings and/or attitudes toward anobject are based on the collective experience of one’s life; thus, each

employee may well be affected in a different fashion when changes areintroduced in the workplace.As illustrated in Figure 19–2, Roethlisberger’s X model suggests, on thebasis of his work at the Hawthorne plant, that two primary forces areinfluencing an individual’s perception, attitude, and response towardchange. The first force consists of the worker’s cumulative life experiences.The second, which functions within the formal organizational setting, is theinfluence of the social forces or informal groups. The identification of thesesocial forces subsequently led to considerable research efforts in the area ofgroup dynamics. These studies revealed the great potential for social forcesto directly influence an individual’s behavior and beliefs, which in turn serveas the foundations for establishing or changing an attitude.Employees may resist change as a result of many issues. Palmer,Dunford, and Akin (2009, pp. 163–168) provide us with some of thecommonly cited barriers:• Discomfort with uncertainty• Perceived negative effects on interests• Perceived breach of psychological contract• Lack of clarity as to what is expected• Excessive changeFigure 19–2 Roethlisberger’s X Chart (Model for Change)Reproduced from Management and morale (p. 21), by F. J. Roethlisberger, 1941. Cambridge, MA: Harvard University Press.

Discomfort with UncertaintyEmployees require a stable psychological condition in the workplace. Ininstances where changes occur, issues of professional and personalinsecurity are kindled primarily by a lack of knowledge and understandingof what changes are taking place and the official causes for internaladjustments. Management’s failure to furnish realistic information in atimely fashion further adds to an employee’s uncertainty. This uncertaintyoften results in lower morale, increased absenteeism, and reductions in bothquality and quantity of output.Perceived Negative Effects on InterestsEmployees may lack an understanding of the likely effect of the change ontheir “interests,” which can relate to numerous factors, such as their level ofauthority, status, salary, autonomy, and job security. Employees find iteasier to be supportive of changes that they perceive as nonthreatening totheir interests and will resist those that are seen as damaging to theseinterests.Perceived Negative Effects on InterestsEmployees form beliefs as to the nature of the reciprocal relationshipsbetween them and their employers—that is, a “psychological contract.”Change often leads to a disruption of employee expectations. The employee–employer psychological contract becomes unbalanced; historical feelings oftrust and perceptions of honest relationships become questionable.Lack of Clarity as to What Is ExpectedResistance to change may be due to management’s lack of providing aclear message of the behavior expected of employees at the organizationallevel. As Gadiesh and Gilbert (2001, p. 74) noted, “A brilliant businessstrategy … is of little use unless people understand it well enough to applyit.”Excessive ChangeResistance to change can be characterized as having two forms. The firstis when an organization is pursing several change initiatives simutaneouslyand employees perceive them as unrelated or in conflict. The second formoccurs when the organization is introducing numerous change projectsbefore others are completed and employees feel that their resources

(including their time) are being “spread too thin,” not allowing for theinitiatives to be effectively implemented. Such “waves of change” may causeemployee initiative fatigue and burnout.Creating and influencing readiness for change within an organization is away that managers may act to prevent or minimize the likelihood ofresistance to change (Armenakis, Harris, & Mossholder, 1993). Readinessfor change refers to organizational members’ shared determination toimplement a change (change commitment) and shared belief in theircollective capability to do so (change efficacy) (Weiner, 2009). Armenakis,Harris, and Mossholder (1993) identified five elements for developingorganizational readiness for change: (1) create a clear and compellingmessage for the need for change (discrepancy), (2) demonstrate that it is theright change (appropriateness), (3) ensure that employees demonstrate self-efficacy (i.e., confidence in skills and ability) supported by the requiredorganizational infrasctructure (i.e., technology, policies, procedures,managerial talent) for successful change implementation and continuedsustainability (efficacy), (4) ensure that key leaders, both formal andinformal, visibly support the change (principal support), and (5) helpemployees understand how the change benefits them (personal valence).LEWIN’S CHANGE MODELTo fully understand the influence of group dynamics on an individual’sattitude toward change, consider the work of Kurt Lewin (1947) and hismodel of Force Field Analysis. Lewin’s model permits us to view change as aseries of forces working in different directions. In effect, some forces andinterests within an organization desiring change may well be offset byforces and interests striving to maintain the status quo (see Figure 19–3).For implementation of change, there must be an increase in the strengthof the force for change (i.e., driving forces); the strength and position ofopposing forces (i.e., restraining forces) must be reduced or removed.Employing this model requires an improved managerial understanding ofthe external and internal environments. By identifying each force, itbecomes possible to distinguish between forces and issues that may bechanged and those that cannot

Figure 19–3 Lewin’s Force Field AnalysisAccording to Lewin (1947), change can be enacted in one or two ways: byincreasing the force for change in the desired direction or by reducing thestrength of any opposing forces. Borkowski and Allen’s (2002) researchregarding physicians’ nonacceptance of clinical practice guidelines (CPGs)

into their medical practice illustrates the application of Lewin’s Force FieldAnalysis in the change process. CPGs are viewed as important tools toreduce variances of medical services received by patients and to improvequality of care by establishing “best practices.” As such, there is greatconcern as to why CPGs have been remarkably unsuccessful in influencingphysician practice patterns. Borkowski and Allen suggested that the drivingforces for acceptance and implementation of CPGs represented knowledgeand attitudinal change and were viewed positively by physicians, whereasthe restraining forces represented changes being imposed by some externalforce that were viewed by physicians with resentment and negativity (seeTable 19–1).By understanding these forces or variances, a realistic approach toplanning change can be undertaken. As reflected in Figure 19–4, Lewinprovides us with a three-step process for implementing planned change:1. Unfreeze: Workers involved in perpetuating resistance acquire anunderstanding of variances that exist between current practices andbehavior and desired activities and behavior. Using the CPG example,unfreezing may occur when managers effectively communicate theneed for change (driving forces), such as mortality and/or morbidityrates, hospital readmission data, and best practices benchmarks.2. Change: On the basis of new objectives, a series of revised policies,procedures, and operating practices is implemented. It is importantthat members of the affected workforce understand the reasons forchange and participate in the design of new approaches. Participatingin the change design, followed by appropriate training andreorientation, presents each worker with the opportunity to buy intothe new approaches. Again, using the CPG example, Borkowski andAllen (2002) found that physician participation (whether directly orindirectly) in the development of a CPG does increase the acceptanceof a CPG, as measured by hospitals’ reduced length of stays andinpatient costs.3. Refreezing: Changes are implemented and monitored, and they areadjusted where necessary. New organizational goals are reinforced bysubsequent changes in daily activities. Continuous monitoring ensuressuccessful operating practices. Regarding the implementation ofCPGs, Borkowski and Allen (2002) found that audit of and feedbackon physicians’ practice patterns were the most commonreinforcements used by managers.

Table 19–1 Suggested Driving and Restraining Forces Regarding Physicians’ Acceptance of ClinicalPractice GuidelinesDriving ForcesRestraining ForcesQuality patient care (e.g., professional competence)Administrative edicts (e.g., cost control)Best practices (e.g., evidence-based findings)Legislative mandates (e.g., laws and regulations)Effective use of limited resourcesFinancial penalties/incentivesGood educational toolsLicensing and accreditation mechanismsConvenient sources of adviceUtilization review

Figure 19–4 Lewin’s Three Step Change ProcessKotter (1995, 1996), building on Lewin’s change model, identified eightsteps for managers to follow for successful organizational change. The firstfour steps change the status quo (i.e., unfreezing), steps 5 through 7introduce new policies (i.e., change), and step 8 institutionalizes the changes(i.e., refreezing). The eight steps, as described by Kotter and Cohen (2002),are as follows:1. Establish a Sense of Urgency: The first step must be to “unfreeze” theorganization’s current state and establish a sense of urgency aboutthe need for change (i.e., new desired state). Managers need to raisethe feeling of urgency (i.e., discussing crises, potential crises, or majoropportunities) so that employees start telling each other thatsomething must be done about the problems and opportunities.2. Create a Powerful Guiding Coalition: Management needs to create a

powerful guiding coalition, a group that spans both the functions andlevels of the organization (i.e., includes members who are not part ofsenior management). This requires pulling together the right peoplewith the right characteristics and sufficient power to drive the changeeffort.3. Develop a Vision: Management must create a vision to direct thechange effort and develop strategies for achieving that vision. Inother words, they must create the right compelling vision to direct theeffort and assist the guiding team to develop bold strategies formaking the vision reality.4. Communicate the Vision: Management must use every vehiclepossible to communicate the new vision and strategies, includingteaching new behaviors by the example of the guiding team.Managers need to send clear and credible messages about thedirection of the change, using words, actions, and technology to opencommunication channels and overcome confusion and distrust.5. Empower Others to Act on the Vision: Management must eliminatebarriers to change, and they must encourage risk taking and creativeproblem solving. They must change systems, structures, processes,and procedures that create barriers for employees to achieve thevision.6. Plan for and Create Short-Term Wins: Management must plan forvisible short-term performance improvements to diffuse cynicism,pessimism, and skepticism. In addition, employees who are involvedin the improvements must be recognized and rewarded. Thesestrategies build momentum by “speaking” to what employees deeplycare about.7. Consolidate Improvements and Produce More Change: Managementshould use the credibility achieved by short-term wins to create morechange. This may include hiring, promoting, and developingemployees who can reinvigorate the change process with new projectsand themes, and assume change agent roles.8. Institutionalize New Approaches: Management must reinforcechanges by highlighting connections between new behaviors andorganizational success. Managers should use the employee orientationand promotions processes, as well as the power of emotion to enhancenew group norms and shared values.TRANSFORMATION OF HEALTH CARE ORGANIZATIONS

Many health care entities are implementing change management totransform their organizations for delivering high-quality patient care. Forexample, VanDeusen Lukas and colleagues (2007) examined twelve healthcare systems that either were participants in the Robert Wood JohnsonFoundation’s Pursuing Perfection program, or have existing reputations forlong-standing commitments to improvement and high-quality care. Theresearchers identified five interactive elements as being critical for thesuccessful transformation of a health care organization (see Figure 19–5):1. Strong impetus to change: Impetus to change can be external orinternal to the organization. In most cases, external pressure forchange is the strongest (i.e., regulatory, changes in reimbursementschemes, and so on).2. Leadership commitment to quality: Leadership is a critical elementfor organizational transformation. Leaders must demonstrateauthentic passion for and commitment to quality and steer the changethrough the organization’s structures and processes to maintainurgency, set a consistent direction, reinforce expectations, and provideresources and accountability to support the change.3. Improvement initiatives that actively engage staff in meaningfulproblem solving: Improvement initiatives must actively engage staffacross disciplines and hierarchical levels in problem solving aroundobjective, meaningful, urgent problems (i.e., eliminating never eventsand reducing 30-day readmissions). These initiatives, such as clinicalredesign and improved operations, must be built into routine newwork practices that are visible as well as easier to perform, morereliable, and more efficient than old practices.4. Alignment to achieve consistency of organization goals with resourceallocation and actions at all levels of the organization: Changes mustbe aligned with the organizational mission and strategic direction. Assuch, changes need to be consistent with plans, processes, informationtechnology, resource decisions, actions, results, and analysis tosupport key organization-wide goals.5. Integration to bridge traditional intraorganizational boundariesamong individual components: For an organization to succeed, changeinitiatives must be integrated across intraorganizational boundariesto improve coordination and continuity of care (i.e., patient flow, casemanagement, electronic medical records). Extensive integration isneeded to break down barriers between departmental silos so that the

system operates as a fully interconnected unit to supportorganization-wide goals.

Figure 19–5 Key Elements of Organizational Transformation to Deliver High-Quality Patient CareReproduced with permission of the Turning Point Program, which was funded by the Robert Wood Johnson Foundation,Princeton, N.J.SUMMARY

The primary objective of change is to ensure the future competitivesustainability of an organization. The rationale and need for change risefrom both external and internal forces. For successful implementation,managers need to recognize and appreciate employees’ attitudes, taking intoconsideration the various organizational and individual barriers that willcreate resistance to the required change. In addition, management shoulduse a documented, step-by-step process that includes specific opportunitiesfor feedback, evaluation, and adjustments. As Peter Senge (1990) advocates,organizations must develop the capacity to adapt and change continuously.Senge (1990) relates that organizations must learn to create attributes andimplement practices that: (1) dismiss old ways of thinking, (2) share ideasfreely, (3) create an organizational vision, and (4) establish a collectiveeffort to design a plan to achieve the vision. To become a continuouslylearning organization requires management to establish a commitment tochange and develop an open organizational culture.DISCUSSION QUESTIONS1. Identify and describe the drivers of change.2. Explain the components of Roethlisberger’s X model.3. Explain the concept of Lewin’s change model.4. Identify and explain the various barriers to change.5. Describe the steps used by managers in the change process.CASE STUDIES AND EXERCISESCase Study 19–1 Organizational and Cultural Change for Providing Safe Patient CareThe chairperson of the Department of Medicine (DoM) in an urban academic medical center wasconcerned. During the past two years, events had occurred in which patients had needlessly sufferedserious harm. Although the events were few and far between, the chairperson’s view of patient caresafety meant that there was no place for such incidents. After all, the medical center had a qualityimprovement department, a process improvement oversight committee, and a risk managementdepartment. Nevertheless, despite the considerable efforts of all of these well-intentioned groups,medical errors were still occurring. This could be attributable to the constant competitive pressureto do more with less, but everyone still understood that improvements in efficiency had to be madewithin the boundaries of safe patient care delivery. Didn’t they?Because the physicians in the DoM were at the center of decision making in the patient careprocess, the chairperson felt the responsibility not only to continue his support of the medicalcenter’s efforts to improve patient safety, but also to address the issue more directly. His perceptionwas that the medical center’s current mechanisms for dealing with patient safety matters focused

more on broad policy issues, as in the institutional patient safety committee (PSC). Theorganization’s culture did not allow for an open exchange of ideas, which was needed to improvepatient care in such a complex environment. Actual and potential patient safety problems werereported to risk managers, who determined the root causes and assigned blame. In addition, themedical center was in a high medical malpractice award area, which also promoted a closed,defensive attitude toward patient safety issues.Although the DoM already had its own quality-assurance committee, the chairperson wanted toemphasize safe patient care, so he created a PSC. The PSC was going to have to deal with a numberof barriers before reaching its goals. First, physicians resist changing their practice patterns unlessthey are supplied with hard evidence that the change will be beneficial to their patients; second,many of the solutions to patient safety problems would cross departmental boundaries; and third,many of the solutions to patient safety problems would involve the medical center’s patient careinformation systems.Recognizing that resident practice patterns might have to change to solve patient safety problems,the DoM chairperson appointed the associate director of the medical resident education program asa co-chairperson of the PSC. Furthermore, he appointed the associate chief of the section of medicalinformatics, an outgoing medical researcher and educator with a positive attitude, the second co-chairperson of the PSC.The DoM chairperson and the PSC co-chairpersons felt strongly that safer patient care would notbe readily achieved within a culture of blame. They wanted to promote a culture of collaboration,group learning, and prevention. The PSC co-chairpersons decided that the PSC meetings would berelatively informal and open to all interested parties. This would provide an atmosphere conduciveto discussion and a forum for anyone who wanted to talk about patient care safety issues. PSCcommittee members were recruited from the chief residents, medical informatics, nursing,pharmacy, and utilization management to ensure that all aspects of patient care safety issues couldbe addressed in the PSC discussions.In examining the balance of the forces that would facilitate or hinder these changes, the DoMchairperson concluded that the driving forces were adequate. Caregivers want to be effective and dowell by the patient, take pride in their work, avoid the waste of scarce medical resources byproviding efficient care, compete successfully in the local health care marketplace on the basis ofeffective and efficient care, and avoid malpractice (i.e., another waste of scarce medical resources).However, the DoM chairperson also knew that there were restraining forces that had to be dealtwith, such as the desire to remain in one’s comfort zone and avoid change, the tendency to seekscapegoats and assign blame, and the defensive attitude developed in response to the legalenvironment.The change agents were skillful and up to the task. The DoM’s chairperson had decades ofmanagement experience and was politically and culturally savvy. He would provide the necessaryorganizational support of the PSC’s work. The PSC co-chairpersons were respected medicaleducators. In addition, one of the co-chairpersons possessed extensive research experience andunderstood the value and necessity of evidence in the improvement of patient care processes.These change agents knew that they would need resources to bring about patient care safetychanges. Original cost estimates included the salaries of the PSC members and programmingchanges to the medical center’s clinical and management information systems. Fortunately, themedical center was among the most wired in the nation, so the infrastructure to support e-mail, datastorage, and so on in the patient care (i.e., clinical) information systems already existed.Nevertheless, the PSC would need approximately $300,000 annually to develop and implementpatient safety initiatives.The very announcement of the formation of the PSC served to unfreeze the previously existingenvironment. The DoM chairperson communicated his support of the PSC’s efforts by way ofdiscussions with colleagues, as well as his support of discussions with management and staff withinand without the DoM. He also remarked on the dangerous lapses in patient care safety andexpressed his dissatisfaction with the current state of affairs. These communications served to

strengthen the driving forces. Critics of the efforts viewed the PSC as duplicating the efforts ofexisting departments and committees (Figure 19–6). However, the critics of the PSC were soonconvinced that it was performing a worthwhile activity when the committee undertook the project ofcreating protocols to avoid potassium overdosing; when administered incorrectly, potassium mayresult in a patient’s death.The PSC’s initial charge was to examine lapses and problems in the delivery of safe patient careand identify trends and clusters that merited action. The responsibility of the PSC was subsequentlybroadened to include the development of protocols for improving patient care. The participatorystyle of the PSC’s leadership allowed all members and their respective departments to participate inthe development and implementation of the agreed-upon new practices and procedures. The effortsof the PSC were communicated through educational events and status reports at its frequentmeetings.For example, the activities of the PSC involved providing objective data regarding the currentlevel of patient care before beginning a project and then providing periodic follow-up measurements.The original data and project results were presented by PSC committee members at medicalconferences, patient safety seminars, quality fairs, and research forums. These communicationsreinforced the positive effects of the changes and served to reinforce acceptance as successfuloperating practices, thus promoting the refreezing of the operating environment with the newpractices in place.

Figure 19–6 Adverse Event Work FlowReproduced with permission of the Turning Point Program, which was funded by the Robert Wood Johnson Foundation,Princeton, N.J.

Figure 19–7 Intervention ModelReproduced with permission of the Turning Point Program, which was funded by the Robert Wood Johnson Foundation,Princeton, N.J.

The PSC was intended as a means to the goal of safer patient care delivery. It provided anenvironment that welcomed problem reporting and patient safety initiatives. The PSC was thecatalyst for developing and implementing projects to promote safer patient care. The number ofprojects and the quality of their results served as judge of the PSC’s success. Projects successfullycompleted by the PSC include:• Development and implementation of an online adverse-event reporting system.• Development of a model for designing three-stage interventions to address patient safetyproblems (Figure 19–7).• Reduction of the use of potassium and magnesium supplements.• Development of an online narcotic conversion calculator and its deployment in clinical systems.• Elimination of sliding-scale orders for insulin therapy.• Reduction of use of serum amylase orders for diagnosis of pancreatitis.Senior management support of a culture of learning and prevention and an organizationalstructure that promotes collaboration have provided an environment in which patient safetyinitiatives can flourish.Identify and discuss Kotter’s eight-step approach for successful organizational change in this casestudy.Case developed by Richard Odwazny, Assistant Professor, and Robert McNutt, MD, FACP,Professor, Department of Health Systems Management, Rush University, Chicago, IL. Reprintedwith permission.Exercise 19–1 Individual Readiness AssessmentINTRODUCTIONThe Individual Readiness Assessment is an analysis of readiness for the change and potentialsources of resistance and one component of the overall approach.INDIVIDUAL READINESS ASSESSMENTResistance to change is natural and inevitable. A thorough analysis of the specific reasons whyand how you will resist the change project is critical to increasing the probability ofimplementation success. Strategies and tactics can be developed to anticipate likely barriers andsuccessfully manage the implementation project toward the accomplishment of importantbusiness objectives. Valuable information can be obtained by having this resistance assessmenttool completed by Sponsors, Change Agents, and/or Targets and comparing the different results.In this manner, different Frames of Reference about the change can be surfaced and effectivelymanaged.INSTRUCTIONSEach of the items on the following pages is to be rated on a scale from 1 to 5, with “1” meaningthat you “strongly disagree” with the statement. A “5” indicates that you “strongly agree” withthe statement. To the left of each item, place the number that represents your assessment of howyou will react to your specific change. Your answers will be more accurate to the extent theyreflect your perspective about the change.

_____1. I am very clear about WHY the change is being implemented._____2. I believe that there is a strong need for the change._____3. I can easily see how this change can directly solve a problem for me._____4. I do NOT believe this change implies I have performed poorly in the past._____5. I see this change as having a LOW personal cost to myself._____6. This change has HIGH compatibility with the values and “unwritten rules” of the organization._____7. I see this change as having HIGH compatibility with my personal values._____8. I think there is a HIGH reward for successfully accomplishing this change._____9. I believe there will be no disruption of stable personal relationships after this change isimplemented._____10. This change will have a positive impact on my job characteristics, such as status and/or salary._____11. Important habits and routine procedures are NOT disrupted by this change._____12. I feel the confidence necessary to accomplish this change._____13. I do NOT tend to focus on the old way of doing things._____14. I believe this change will have a positive impact on my power or the power of people importantto me in the organization._____15. I see the change as reversible if it does not prove effective once it is implemented._____16. I do NOT believe this change will lead to less control over key aspects of my job._____17. I am very clear about what is specifically expected from me as a result of the change._____18. Generally this change will NOT cause a great deal of disruption in my work life._____19. I feel very involved in this change._____20. I believe that adequate organizational support and resources are provided to accomplish thischange._____21. I think that adequate time is provided to accomplish this change._____22. I believe that the organization has been consistently successful in past implementations._____23. I am NOT experiencing a significant amount of work pressure and stress._____24. I believe that this change project will be implemented successfully._____25. Important Sponsors and Change Agents have a HIGH level of credibility with me.INDIVIDUAL READINESS SCORE

RESULTSYour Individual Readiness Score represents the probability of implementation success for yourcurrent change project on the basis of your assessment of the level of Individual Readiness.Scores in the high range indicate a strong likelihood that you will be successful in this change aslong as you continue to manage important sources of resistance. Scores in other ranges mean thatyou must develop strategies to eliminate or minimize significant sources of Target resistance toavoid the real costs of implementation failure and achieve strategic business objectives.INDIVIDUAL READINESS PROFILE

SOURCE: © Implementation Management Associates, Golden, Colorado, 2001. Reprinted withpermission.Case Study 19–2 Healthy Lives: A Cost-Effective, User-Friendly Way to Improve Health andProductivity in Targeted Chronically Ill WorkersSt. Mary’s Health System, headquartered in Evansville, Indiana, is part of the Ascension HealthNational System. The system is composed of multiple entities, including a 450-bed medical centerwith more than 3,000 employees. The average age of employees is 44, the workforce is predominantlyfemale, and the average tenure is 11 years.St. Mary’s Medical Center has a wellness center called Health Matters, which has performedhealth screenings on employees and spouses since 1993. The system also has a preferred providernetwork, SelectHealth, which has more than 1,800 providers in a three-state area. The network hasbeen accredited in Health Network and Health Utilization Management since 1999 by the UtilizationReview Accreditation Commission (URAC).St. Mary’s Health System was experiencing annual, double-digit increases of more than 18–20percent in medical claims costs for its health plan. Through analysis of this expenditure, modifiable

lifestyle-related conditions such as diabetes, hypertension, obesity, and hyperlipidemia weretargeted as an opportunity for improvement. This presentation shows how St. Mary’s successfullytriaged and educated about 75 percent of its employees and offered health promotion and diseaseprevention/management programs to 5 percent of its benefit-eligible population. This 5 percent ofemployees committed to modifying lifestyles to optimize health and to minimize costs for individualswith hypertension, obesity, diabetes, and hyperlipidemia. These conditions were selected because:(1) efforts can be concentrated on selected, measurable conditions, (2) these conditions occurfrequently in high-dollar medical cases, and (3) individuals can minimize the effects of chronic illnesson productivity and quality of life by making a commitment to learn and better care for themselves.Results after 18 months showed significant improvements in financial, productivity, and clinicalindices, which had been measured over the course of the program.Historical Perspective/Cultural AssessmentBefore the inception of Healthy Lives, St. Mary’s had a wellness screening program from 1993 to2001 named HealthStyle Plus! This program included basic laboratory tests and physicalassessments. Participating employees and spouses received counseling on their results.To encourage good health, the hospital used the clinical results to categorize participants as low,mid, or high risk for purposes of health insurance premiums paid for benefits. Employeesparticipating in HealthStyle Plus! received “credits” to offset insurance premiums in accord withtheir risk level. For example, if an employee smoked, was obese (defined as having a body massindex of 30 or more), or had high lipids or high blood pressure, he or she would be classified as highrisk and get the minimal reward. If married, the spouse had to participate, or the employee wouldautomatically be placed in the high-risk category.This old system had several problems. One, it rewarded individuals with good health anddiscouraged those with poor health from participating. Two, the program made the medical centervulnerable by motivating results rather than participation, once the Health Insurance Portabilityand Accountability Act (HIPAA) was passed in 1996. Three, employees worried about how poorhealth would affect their careers. Four, the wellness program and the externally managed healthplan worked in silos, limiting the possibilities of optimizing the health and medical resources usedby the St. Mary’s population. Five, healthy employees, rather than the individuals driving healthplan costs and productivity, were targeted by HealthStyles Plus!Communicating the Message for the Paradigm ChangeThe Plan1. Data mine the wellness screening, medical claims, pharmacy claims, and productivity statisticsto find the 20 percent driving health costs (Pareto principle applies).2. Identify the chronic health conditions that can be modified by lifestyle changes, and targetthose individuals who are ready to change.3. Hold individuals accountable, not for health status but for behaviors within their control thatinfluence health, performance, and medical costs.4. Convince senior management and then the employees that this is a sound approach that willreward them with lower health plan costs and better productivity in their peers.5. Use a systematic approach in triaging the health plan population, intervening and providingresources, measuring outcomes, and rewarding commitment to personal health.6. Use the quality improvement process to identify systematic issues in benefit design, claimsmanagement, use of insurance, medical treatment, and educational or communication needs,and prioritize and implement changes to address issues.7. Provide feedback to the employer, physicians, and employees.8. Market the program to other employers.The Message

1. Employees who are chronically ill don’t do their share of work, causing more overtime, poormorale, lower customer satisfaction, disability, turnover, and lost dollars through absenteeismand presenteeism. That is why health costs are only about 25 percent of what the chronically illcost us.2. Health is more than the absence of disease. It is about being the best that you can be. Healthypeople have energy, endurance, strength, confidence, optimism, and a sense of well-being.Everyone deserves to feel this good.3. Chronically ill people have problems because of bad genes or bad luck. The bad luck is in theform of inherited conditions, preventable illness, and complications, as well as lack of self-care,emotional problems, or accidents.4. Chronic illness is insidious and silent. Many people don’t know they have a health problem,don’t take needed medications, and don’t take care of the problem because they think they feelfine, they are in denial, or they believe they cannot afford treatment and medication. Onlywhen they start getting healthy do they realize how badly they once felt and the risk that theywere taking.5. Chronically ill people are often stressed, uninformed, and caught up in a vicious cycle, wherethey never budget time or money to care for themselves. They require a personalized approachto understanding their health needs, obstacles, and resources and help in creating andimplementing their own health plan.6. Good health is its own reward. Let’s put our money to use where we will get the most benefit;that is, in helping the chronically ill health plan members learn about their health and takeresponsibility for improving it.7. Make the reward within reach of all benefit-eligible employees and spouses on the health planwho commit to taking personal responsibility for their health.8. Keep results confidential. Release only aggregate results to management or to other publics.Include a confidentiality statement that binds the wellness and health plan to these standards.The CultureThe system was recently redesigned to integrate the purchase of another hospital in the city andto compete with large national health plans in attracting employers to the SelectHealth network inthe tri-state area of Southern Indiana, Southeastern Illinois, and Western Kentucky. The hospitalmerger with all its issues of integration was a great factor. At the same time, insurance premiumsincreased dramatically in 2003, and health plan management was contracted to SelectHealth toimprove the system’s experience and reduce medical costs.The incidence of obesity, hypertension, hyperlipidemia, and diabetes was increasing annually inthe employees who were screened. In summary, medical costs were soaring and the system was inmajor flux, making the timing ripe for introducing a change that could correct the problem. (Majorhistorical works on change process indicate that change is most readily accepted when a system is influx)Assessment of ForcesIn most situations, there are conflicting forces that drive and restrain the change process. A majorproblem for this program was that an integrated wellness/health promotion and diseasemanagement program needed to be developed, marketed, and implemented within three calendarmonths. The plan for the program is outlined in Table 19–2.Table 19–2 Driving and Restraining Forces to Healthy LivesFactorDriving ForcesRestraining ForcesModel1. Develop a simple model, targetinglifestyle illnesses that will reduce healthcosts for everyone.1. Communicate a paradigm flip to employees.2. Well people want to be rewarded.3. Employees wonder why people with poor

2. Make the participant accountable.3. Reward commitment to personal health.4. Leadership wants change that willimprove health and pro-ductivity.lifestyles get rewarded.4. What if program can’t be measured?5. What if program doesn’t work?6. What if no one voluntarily participates?Resources1. Chronically ill will be able to affordmedical care.2. Money already budgeted.3. Wellness and managed care staffs areexperienced in program development,screening, and disease management.4. Staff committed to work with availableresources.1. Fear that employees will say, “I counted on themoney to reduce my health insurancepremiums.”2. “Program isn’t fair.”3. Must work with accounting to reallocate funds.4. Need to create new program and integratestaffs from two different departments todevelop and implement plan in three months.5. Actual budget for new program unknown.Infrastructure1. Program leaders are well organized.2. Employees accustomed to annual healthscreenings.3. System needs to measure absenteeismand presenteeism that was complicatedby the introduction of a Paid Time Off(PTO) system.1. Need to develop database.2. Establish baseline.3. Create participant report cards.4. Set up new program and reporting mechanism.5. Need to find a reliable and valid tool formeasuring absenteeism and presenteeism.Leadership1. System is in flux from merger.2. System needs to stop the annual 18 to20 percent increases in medical claimscosts.3. Leadership wants to make positivechanges now.4. This program could reduce health plancosts.5. Some cheerleaders have been identifiedin different work areas.1. Need to educate and get top- down support.2. Must educate/convince leaders to participateand be resources for their employees.3. Need employees to volunteer.4. Need to report de-identified success stories.5. What if physicians don’t support the program orrefuse to change practices?Physicians1. Physicians will do what is best for thepatient if included in the plan andeducated.2. Medical Director and Physician AdvisoryGroup for health plan are supportive.3. Physicians will have more resources toachieve their goals with patients.4. Medical Director is well respected by themedical staff and has strongcommunication with them.1. Physicians need education to be part of theteam.2. Safety and follow-up issues with current,serious health issues.3. Physicians must give permission for employeesto participate in disease management program.ProjectDesign/OutcomesMeasurement1. Commercial health risk analysis toolidentified that minimizes scoring timeand gives participants real time results.2. Willing, salaried staff that have goodrelationship.3. Staff is knowledgeable and experienced.4. Consultant hired to expedite project.1. No time or money for new information systems.2. Three months to identify key measures, set upsystem to track improvements.3. Need to accurately select baselinemeasurements and benchmarks.4. Actual staff needs unknown.Savings Potential1. Improved health will translate into higherproductivity, reduced absenteeism andpresenteeism.2. Medical costs will be reduced.3. Healthy Lives participants will haveimproved health.1. Database needs to be developed to captureclinical data.2. Systematic method needed to track relevantmedical costs through claims data.3. Most health plans complain about inability totrack actual costs.4. What if baseline cannot be measured properlyprior to intervention?Communication1. Consultant MD is experienced in writinga complex program in simple terms.2. Consultant has charisma andexperience.3. Leaders in medical management and1. Logistics of reaching physicians, leaders, andemployees and convincing them to participatein three months.2. Challenge of using multimedia.3. Need to send a message that encourages

wellness have credibility withemployees.4. Program staff is entrepreneurial; able tohandle change.participation.4. Challenge of reaching all parties.5. Way to keep track of responses.Personal Response1. Participants will learn and be pleasedwith the experience.2. Participants have time with healthprofessional tailored to their needs.3. Participants will be able to see actualresults from their efforts.1. There will be no volunteers.2. Employees will not trust the program.3. The proposed program might not work.4. The new program might be disorganized.5. All factors may not have been considered indevelopment.Health SystemFuture1. This program is innovative, and willdistinguish our system for its excellenceand leadership in addressing lifestyleproblems that have become a nationalhealth crisis.2. System needs to model wellness anddisease management program before itis sold to other employers.3. Employers want to see results and getrelief from high medical costs.4. Successful health systems attractcommercial business.1. System needs to be implemented successfully.2. Results may not be positive; program may notwork.3. Difficult to measure “soft results”; i.e., howdoes a lower blood pressure save money thatfalls to the bottom line this year?4. Employers want to see bottom line savings.5. Employers want to understand what they arereceiving for their investment and how thehealth plan is improving the lives of theiremployees; few systems know how to showresults in dollars.Reproduced with permission of the Turning Point Program, which was funded by the Robert WoodJohnson Foundation, Princeton, N.J.Implementation PlanThe leaders at the system level recognized the need for innovative changes in how employeehealth issues were identified and managed. They also wanted to stop the annual 18 to 20 percentincreases in paid medical claims costs. The system hired a consultant who worked with the HealthyLives team to develop the program. The sequence for major objectives was as follows:1. Develop program and PowerPoint explaining program, including rationale.2. August—Show senior management, accept input, and make changes.3. August—Present program to leadership team of all managers at monthly meeting.4. September—Revise employee handbook to include Healthy Lives program.5. September—Develop forms and program methodology. Present design to senior management,including goals.6. October—Present jointly with human resources at open enrollment meetings so thatemployees learn about the changes in health screening, the new disease managementprogram, and the incentives. Have a sign-up booth at open enrollment meetings to answerquestions and enroll volunteers into disease management programs. Provide participants withhandouts. Enroll participants in November wellness screening sessions.7. November—Perform health screening, and coach all disease management participants.Explain what participants must do for their particular health conditions.8. December—Present baseline statistics to system management team.9. January—Provide incentives to those who participated in screening, coaching, and education.10. February—Receive first quarterly reports, submitted by disease management participants.11. February—Reward participants who completed online education programs.12. March—Send incentives to first-quarter participants. Present first-quarter results tomanagement team in relation to goals for hypertension and diabetes.13. May—Analyze second-quarter reports.14. June—Send second-quarter incentives. Present two quarters of results to senior managementteam.

15. August—Receive third-quarter reports.16. September—Reward third-quarter participants. Report results to senior management.17. October—Announce 2004 program of hypertension, diabetes, lipids, and obesity, and enrollparticipants.18. November—Year-end screening for 2003 participants and 2004 screening for year twoprograms. Turn in fourth-quarter disease management reports.19. December—Receive fourth-quarter incentive.20. January—Start the cycle again. Report full-year results.21. July—Report financial results of plan for 2003, and productivity and progress for currentparticipants.Healthy Lives Program—Making the ChangesHealthy Lives is a corporate-wide health promotion and disease prevention program thatemphasizes hands-on assessment, education, personalized commitment, goal setting, and coachingfor all employees and their spouses. The initial health assessment process allows populationscreening and early identification, as well as intervention opportunities. Additionally, individualswith diabetes, obesity, hypertension, and hyperlipidemia are invited to participate in an intensive,personalized program to live a healthy lifestyle. The program is an on-site health initiative thatblends health promotion with disease and case management to achieve remarkable results forparticipants.This “case study” presentation reviews the steps and interventions that resolved problems.The ActivHealth health assessment tool and online educational Personal Health Developmentprograms that were developed by Duke University were licensed for use in Healthy Lives. Results ofhealth screenings were available in an access database from which queries could be generated by thevendor and by St. Mary’s. Claims and pharmacy data were available to the health plan. An accessdatabase was developed to store clinical information, according to the critical measurementsidentified. The Work Limitations Questionnaire (WLQ) from Tufts–New England Medical Centerwas the tool selected to monitor absenteeism and presenteeism.Management and human resources had feedback in the form of aggregate data compared withnational benchmarks. The year two 2004 program included hands-on quarterly coaching, whereparticipants were being evaluated and coached on current progress in relation to pre-set goals. Moreexercise and nutrition classes were added at Health Matters, and pharmacists attended exerciseclasses to educate participants on disease-specific medications. Fitness and nutritional analysis wasadded in 2004, at the request of participants.This program has been very successful in improving the clinical and financial performance ofHealthy Lives participants. The program was presented at the Ninth Annual Disease ManagementCongress in Boston in September 2004 and has been successfully sold to other area employers.Healthy Lives ResultsDiabetes Program Results: Clinical results from year one were impressive. For example, at the endof the first year, 69 percent of diabetics achieved glycolated hemoglobin (HbA1c) levels of less than7.0, compared with 43 percent at the beginning of the year. Statistically significant improvements inblood pressure, weight reduction, and compliance with national guidelines for monitoring the urine,eyes, and feet were also noted.Hypertensive Results: At the beginning of the project, 57 percent of the hypertensive participantshad blood pressure readings of less than 140/90. (Results are available in more detail and in graphicsdisplays.) Seventy-five percent or more of participants in the hypertensive program achieved bloodpressures of less than 140/90 for 9 of 12 months. They also had significantly improved results inother clinical measures.In year two, beginning in November 2003, participants began to be measured using the WLQ, aTufts-New England Medical Center productivity tool, to better assess the total costs of having achronic health condition (see Table 19–3).

Table 19–3 Managing the Change ProcessProcessIssuesResolutionOutlining theProgram andDevelopingForms,Processes, andBaselineMeasures(August)1. Process took more hoursthan anticipated.2. Everyone had differentideas.3. Search of literatureshowed congruence onmajor lifestyle healthconditions; paucity ofactual measures.4. Medical claims databasemassive and time-consuming to analyze.5. Outcome measuresneeded to be simple,focused.1. Consultant served as facilitator in driving work. Both thedirector of health promotion, the medical manager, and themedical director had experience in change process. The teamworked well together, split tasks, and spent extensiveovertime to meet deadlines.2. Use physician consultant and medical director to get supportof senior management.Selecting the HealthConditions1. Conditions needed to bemodifiable by lifestylechanges and quantifiable.1. The MD consultant and medical director helped with theliterature review. The Physician Advisory Council reviewedinformation and advised Healthy Lives staff.Open EnrollmentPresentation andEmployeeHandbookChanges1. Educate seniormanagement, leadershipteam, and humanresources prior to openenrollment.2. Response to programswas overwhelming andmuch greater thananticipated.3. This totally new approachwas hard to understand.1. Accommodate those who meet criteria, assuming that somewill not follow through with program requirements. HealthyLives leaders had to prioritize time and arrange additionalmeetings to meet with participants to explain how the programworks.Health Screening1. Participants were at allsocioeconomic levels;some were barely literate,and others were educatedbut in denial.2. It took longer to take thecomputerized assessmentthan planned.3. Many had limitedcomputer skills.1. Healthy Lives staff had to make adjustments as needed.Structure1. Some participants statedthey could not progresswithout structure.2. Many wanted to change,but did not know how.3. Physician’s releasesneeded.1. Need for structure and hands-on help led to special exerciseclass for diabetics and hypertensives that followed AmericanCollege of Sports Medicine guidelines.2. Staff had to assist participants in getting releases and had tobudget time/be available in classes as resources.3. Additional needs for structure will have to be addressed inyear two program.Reporting1. Database needed to bebuilt for clinicalinformation.2. Data entry for health planmedical managementneeded to be streamlined,accurate, and complete.3. Medical and pharmacyclaims needed to bemined to determine healthplan costs.1. The medical director and medical manager wrote a letterexplaining the program to physicians and presented theprogram initially and when results were available at a medicalstaff luncheon. Case managers worked with physicians toresolve individual participant problems.

Incentives1. Changes in the budgetcaused the accountantsto have problems inpaying incentives.2. Incentives were taxed.1. The team was expanded to include other health planprofessionals with experience in database design, projects,and claims analysis.Physicians1. Patients had to beeducated about theirhealth and screeningresults, so that they coulddiscuss them with theirphysicians.2. Written materials andformal education wereneeded.1. This took member education and multiple meetings withfinance. Rules had to be set to encourage compliance withrules, while not discouraging the newly motivated.Telling the Story1. The program wasmultifaceted andcomplex.2. Pressure to get resultsthat can be marketed toother employers.3. Measurement needs to berelevant and simple.1. Access database allowed multiple sorts to identify outliersneeding special attention. It also enabled rapid analysis ofresults.2. Financial results were delayed for seven months to incorporatedata on 2003 claims.MeasuringProductivity1. The PTO system does nottrack the reasons for daysoff.2. The system does nottrack presenteeism.1. The health promotions director and the medical managerattended the 2003 Annual Institute of Productivity Managementconference and were able to identify a tool, connect with theauthor, and secure permission to use this reliable and validtool.Reproduced with permission of the Turning Point Program, which was funded by the Robert WoodJohnson Foundation, Princeton, N.J.In year two, second-year participants had consistently higher results than the new programparticipants. For example, results in the hypertension program were as follows:• Hypertensive patients in Healthy Lives cost the plan one-half as much as nonparticipants.• Diabetics in Healthy Lives cost the health plan one-third less than nonparticipants.Summary and Application of Healthy Lives Programs to Other Work SettingsThe Healthy Lives Program has been very successful. This case study has focused on introducing amajor change into a large health system. Results were successfully measured, but a presentation ofthese outcomes is beyond the scope of this case study.General principles learned from this project are as follows:A. Disease management is a continuation of the employer’s commitment to workplace wellnesspromotion.B. Disease prevention/management involves the following steps:1. Analyze the claims experience to identify the chronic health conditions that are mostprevalent in the work population.2. Determine which conditions can be most effectively modified by lifestyle changes ormodifications in work patterns.3. Further narrow the list by identifying the cost/benefit of implementing each program.4. Design a high-touch program that is result-oriented, simple, and based on self-responsibilityand continuous learning in collaboration with the physician’s plan of care for participants.5. Invite participants, and think of creative, tangible programs and incentives to keep theminterested.6. Emphasize education and coaching, supported by helpful ideas and resources to make

essential life changes.7. Capture the spirit of the culture and strive to recruit company leaders to set the example.8. Infuse a measure of fun and provide special one-to-one attention for individuals who are notprogressing.9. Measure the outcomes quarterly, using these results as a springboard for fine-tuning theapproach to individual participants.10. Add a productivity measure so that the full impact of illness can be calculated on absenteeismand presenteeism.11. Evaluate self-concept and changes in health status, along with financial, clinical, andproductivity measures to assess impact.12. Identify and discuss the 12 steps for implementing and monitoring a change managementprogram.Principal Project ManagersKishor R. Bhatt, MD, Medical Director, St. Mary’s Managed Care ServicesDr. Bhatt completed medical school in India at M.P. Shah Medical College, where he also did arotating internship. He then went to Metropolitan Medical Center in Minneapolis for a secondrotating internship. From there he moved to the Bronx, where he became chief resident in pediatricsat Misericordia-Fordham in New York. After working in private practice in the Bronx, he moved toSouthern Indiana, where he was director of the Pediatric Clinic and later chairman of pediatrics atSt. Mary’s Medical Center. He also served as chief of staff at St. Mary’s Warrick Hospital. Dr. Bhattis board certified in pediatrics, serves as chief of pediatrics at St. Mary’s Medical Center, hasexpertise in quality and utilization management, is currently in private practice, and works as themedical director for SelectHealth Network. He also has several systemwide appointments, where heserves as an advocate for health care quality, a peer educator in managed care, and a member of thehospital patient care evaluation committee and the managed care executive team.Barbara E. Rutkowski, EdD, MN, Medical Manager, St. Mary’s Managed Care ServicesMs. Rutkowski earned her bachelor’s and master’s degrees in nursing from the University ofFlorida and received her doctoral degree in higher education and administration from IndianaUniversity. She has authored four books (two were named American Journal of Nursing Book of theYear) and multiple professional articles and book chapters, and she has published two nationalemployment and labor law newsletters with her attorney husband for the past 19 years. Over thepast 10 years, she has created and currently manages credentialing, quality, site visits, utilization,clinical risk, and case/disease management programs for St. Mary’s Managed Care Services. Thenetwork spans the Illinois, Kentucky, and Indiana tri-state area and has full URAC Health Networkand Utilization Management Accreditation. Dr. Rutkowski has been active in community affairs andhas spoken at conferences conducted by the Centers for Disease Control and Prevention and theCenters for Medicare and Medicaid Services. She has recently served on a Joint Commissionadvisory group in managed care and is on the advisory board for the Journal of Nursing RiskManagement. She has also presented hundreds of management workshops across the country.Cynthia Williams, RN, BSN, Director of Health Promotion, St. Mary’s Medical CenterMs. Williams graduated from the University of Evansville with a bachelor’s degree in nursing. Forthe past 20 years she has been in health promotion. In 1992, she was promoted to director of healthpromotion for St. Mary’s Medical Center. In addition to overseeing the wellness program foremployees, she has developed and implemented numerous creative wellness programs in businessand industry throughout the tri-state area. Ms. Williams regularly does formal presentations atseminars, at company retreats, and at other businesses. Together with Ms. Rutkowski, she hascreated and beta-tested the Healthy Lives program.

SOURCE Barbara E. Rutkowski, EdD, MN. Reprinted with permission.REFERENCESArmenakis, A. A., Harris, S. G., & Mossholder, K. W. (1993). Creatingreadiness for organizational change. Human Relations, 46(6), 681–704.Bareil, C., Savoie, A., & Meunier, C. (2007). Patterns of discomfort withorganizational change. Journal of Change Management, 7(1), 13–20.Borkowski, N., & Allen, W. (2002). Using organizational behavior theoriesto manage clinical practice guideline implementation. Journal ofAmerican Academy of Business, 1(2), 365–370.Carroll, L. (1865). Alice’s adventures in wonderland. New York, NY:Penguin Putnam.Fischer, E., Berwick, D., & Davis, K. (2009). Achieving health care reform:How physicians can help. New England Journal of Medicine, 360(24),2495–2497.Gadiesh, O., & Gilbert, J. L. (2001). Transforming corner-office strategyinto frontline action. Harvard Business Review, 79 (5), 73–79.Kirkpatrick, D.L. (2001). Managing change effectively: approaches, methodsand case examples. New York, NY: RoutledgeKotter, J. P. (1995). Leading change: Why transformation efforts fail.Harvard Business Review, 73(2), 59–67.Kotter, J. P. (1996). Leading change. Boston, MA: Harvard Business SchoolPress.Kotter, J. P., & Cohen, D. S. (2002). The heart of change. Boston, MA:Harvard Business Review Press.Lewin, K. (1947). Frontiers in group dynamics. Human Relations, 1(1), 5–41.Lippitt, G. L. (1973). Visualizing change: Model building and the changeprocess. La Jolla, CA: University Associates.Palmer, I., Dunford, R., & Akin, G. (2009). Managing organizationalchange: A multiple perspective approach. New York, NY: McGraw-HillIrwin.Roethlisberger, F. J. (1941). Management and morale. Cambridge, MA:Harvard University Press.Senge, P. M. (1990). The fifth discipline. New York, NY: Doubleday.VanDeusen Lukas, C., Holmes, S. K., Cohen, A. B., Restuccia, J., Cramer, I.E., Shwartz, M., & Charns, M. P. (2007). Transformational change in

health care systems: An organizational model. Health Care ManagementReview, 32(4), 309–320.Weiner, B. J. (2009). A theory of organizational readiness for change.Implementation Science, 4, 67. doi:10.1186/1748-5908-4-67Wheelen, T. L., & Hunger, J. D. (1998). Strategic management and businesspolicy (6th ed.). Upper Saddle River, NJ: Addison Wesley.OTHER SUGGESTED READINGBardwick, J. M. (1991). Danger in the comfort zone. New York, NY:AMACOM.Burke, W. W. (1987). Organization development: A normative view. UpperSaddle River, NJ: Addison-Wesley.Lewin, K. (1951). Field theory in social science. New York, NY: Harper &Row.Mone, M. A., McKinley, W., & Barker, V. L. (1998). Organizational declineand innovation: A contingency framework. Academy of ManagementReview, 23, 115–132.Riggio, R. E. (2003). Industrial/organizational psychology (4th ed.). UpperSaddle River, NJ: Prentice Hall.Sheehy, G. (1991). New passages: Mapping your life across time. New York,NY: Random House.Tomasko, R. M. (1987). Downsizing. New York, NY: AMACOM.Zand, D. E. (1995). Force field analysis. In N. Nicholson (Ed.), Blackwellencyclopedic dictionary of organizational behavior. Oxford, U.K.:Blackwell.

IndexThe index that appeared in the print version of this title was intentionally removed from the eBook.Please use the search function on your eReading device to search for terms of interest. For yourreference, the terms that appear in the print index are listed below.Aabsenteeismabuse of workersACA. See Affordable Care Act of 2010access to careaccommodation, conflict andaccountability, CLASaccountable care organizations (ACOs)ACHE. See American College of Healthcare Executivesachievementachievement-oriented leadersACOs. See accountable care organizationsacquisitions, industryaction. See behaviorAction Research Modelacute stressAdam’s Equity Theory of MotivationAdams, J. Stacyadjourning stage of group developmentadjustment bias techniqueAdler, Alfredadoption, action researchadrenalineadverse event work flowaffective conflictsaffiliationAffordable Care Act (ACA) of 2010age, patientage, populationageismaggressionaging population

agreeablenessagreement and employee behaviorAI. See appreciative inquiryalarm response to stressAlderfer’s ERG TheoryAllen, Robertallies as political toolsAllport, Gordonambiguity, tolerance forambitiousAmerican College of Healthcare Executives (ACHE)American Heritage Dictionary of the English Language (4th ed.)American Hospital AssociationAmerican Recovery and Reinvestment Act of 2009American workers’ perceptionanalytic decision makinganchoring bias techniqueanchoring errorsanti-rational decision makinganticipatory coping strategiesappreciative inquiry (AI)5 Ds ofapproach/approach conflictapproach/avoidance conflictAsian population in United Statesassertivenessassessment, action researchassessor-developer (team member role)assimilation, stress andassistance. See support for employeesassociation (affiliation)attacks as political toolsattention, management ofattitudesformation oftri-component model of attitudesattraction and influenceattribution styleself-assessmentattribution theorymanaging employees’ attributionsmotivation andattribution–emotion–behavior processauthoritarian leadership styleauthorityconflictsautocratic decision makingautonomy, job

availability bias techniqueavailability erroraverage group satisfactionavoidanceawareness of self. See self-awarenessBbalanced participationBales’ Interaction Process AnalysisBaptist Health South Floridabarriers to changebarriers to communicationbarriers to effective teamworkbarriers to successbases of power. See power and influence behaviorcontent theories of motivationcase studycomparisons of theoriesERG Theory (Alderfer)Hierarchy of Needs (Maslow)job design3-Needs Theory (McClelland)Two-Factor Theory (Herzberg)group dynamics, norms ofHierarchy of Needs (Maslow)organizational. See organizational behavior (OB)process theories of motivationcase studyequity theory of motivationExpectancy Theory (Vroom)Goal-Setting TheoryReinforcement TheorySatisfaction–Performance Theorystress, consequences ofteam rules forbehavioral competenciesbehavioral decision makingbehavioral theories of leadershipbehavioral competenciesBig Five personality frameworkemotional intelligence (EI)Belbin’s Team Role TheorybeliefsBenchmarking Survey by the Institute of DiversityBenne and Sheets (Function Role Theory)Benson, Herbertbiases approach to decision making

Big Five personality frameworkBlake and Mouton’s Managerial Gridblame as political toolsBlanchard and Hersey’s Situational Leadership Modelbody languageboundary spanningbounded rationality model of decision makingbrainstormingburnoutBurton and Dimbleby Interface of Me and ThembystandersCCampbell Interest and Skills Inventorycandidates, jobcareer development, stress andcausal attributionscentralized networks of communicationCEO. See chief executive officerchain pattern of communicationchallengesimproving team performance withchangecase studydrivers ofForce Field Analysis (Lewin)force forimpetus tomanagement oforganization development (OD)organizational readiness forprocessresistance tovisionary leadershipchange stage (implementing change)changing attitudeschanging demographics of patientschannels of communicationcharismatic leadershipCHD. See coronary heart diseasechief executive officer (CEO)chief operating officer (COO)Chief Safety and Compliance Officer, case studychronic stresscircle network of communicationCLAS. See Culturally and Linguistically Appropriate Servicesclinical outcomes

closed-mindedness of groupscoalition formationcoalitions as sources of powercoercive powercognitive conflictscognitive dissonancecognitive errors in clinical decision makingcognitive theories of motivationcognitive-transactional theory (Lazarus)cohesiveness of groupscollaboration and conflictscollaborative leadershipcommitment and stressCommonwealth Fundcommunicationbarrierschannels ofcross-cultural situationsdiscipline of OBemailenvironmental barriers toexternal communication linksfeedbackflowsgroup decision makingindex of communication effectiveness (ICE)informalknowledge managementnetworksnonverbal communicationovercoming barriersoverviewsociogramsstakeholders, externalstrategicstressvaluing in teamsverbalcommunication, CLAScommunication processcommunication, visioncommunities, responsibilities tocomparisons of theoriesERG Theory (Alderfer)Hierarchy of Needs (Maslow)job design3-Needs Theory (McClelland)Two-Factor Theory (Herzberg)

competencies, behavioralcompetition and conflictscompliance, motivating to improvecompromise and conflictcomputer-aided communicationconceptual decision makingconcluder-producer (team member role)conflict-handling styles, case studyconflict managementcase studydecision making modelsdefinitions oflevels ofnegotiation modelsresolution oftypes ofconformityConfronting Racial and Ethnic Disparities in Health Careconscientiousnessconsensus and employee behaviorconsequences, employeeconsideration of people as dimension of leadershipconsistency and employee behaviorconsolidation, industryconstructive conflictconsultants, organization development (OD)consultative decision makingconsulting skillscontemporary leadership approaches. See also leadershipcontent theories of motivation. See also behavior; comparisons of theories; motivationcontentment. See satisfaction, jobcontext, strategic communication plancontingency theories of leadershipcase studyFiedler’s TheoryHersey and Blanchard’s Situational Leadership ModelHouse’s Path–Goal theoryLeader-Member Exchange Theory (LMX)Tannenbaum and Schmidt’s Continuum of Leadership Behaviorcontingent rewardscontinuous improvement, CLAScontinuous reinforcement scheduleContinuum of Leadership Behavior (Tannenbaum and Schmidt)contracting phase of organization developmentcontrast effectscontrast, principlecontrollocus of

controllabilitycontroller-inspector (team member role)COO. See chief operating officerscooperationcoronary heart disease (CHD)cost/benefit analysis of relationshipscounseling employeescreator-inventor (team member role)cross-cultural communicationcultural competency. See also diversityaging populationdiversity issues within clinical settingdiversity managementDiversity and Cultural Proficiency Assessment Tool for Leadershealth care leadershipHofstede’s Cultural Dimensionsimplications for health care industrytraining of workforceUnited States populationcultural competency in health care, diversity and. See health care, diversity and cultural competencyincultural groups, challenges forCulturally and Linguistically Appropriate Services (CLAS)Ddabsdata collection for organization developmentday-to-day performance coachingdecentralized networks of communicationdecision makingescalation of commitment and framing heuristicgroupsgarbage can processgroups and groupthinkjob demands–decision latitude model (Karasek)models ofstress andstylesVroom-Yetton modeldecodeddegree of centralizationdelegation of powerdelivery networks, integratedDelphi brainstorming techniquedemand appraisalsdemocratic leadership styledemographics of patients.See patient diversity

demotivation, immunization todependency as source of powerdepersonalizationdescriptive feedbackdesk ragedevelopment, organizational (OD)action researchinterventionsOD professional, theoverviewprocessdiagnosis phase of organization developmentdiagonal flow of communicationDimbleby and Burton Interface of Me and Themdiminished, by stressdiminished personal accomplishmentdirection, establishing for teamdirective decision makingdirective leadersdisabled patientsdisciplinediscriminationracial and ethnicdissatisfaction, jobdistinctiveness and employee behaviordistressDistress-Eustress modeldistributive model of negotiationsdiversity. See also cultural competencycross-cultural communicationDiversity and Cultural Proficiency Assessment Tool for Leadersemployeein health care, and cultural competency. See health care, diversity and cultural competency inissues within clinical settingpatientprejudicesstereotypingvaluing in teamsDiversity and Cultural Proficiency Assessment Tool for Leadersdiversity-based conflictsdiversity managementDiversity and Cultural Proficiency Assessment Tool for Leadersdivision of labordownward flow of communicationEeconomic analysis approach

economic changes and effect on health careeconomic rationality modelED. See emergency departmenteffective communication, for knowledge managementeffective decision makingeffectiveness of managementEI. See emotional intelligenceemailemergency department (ED)emotional exhaustion and stressemotional intelligence (EI)emotional stabilityempathylack ofempirical researchemployeesindustry statisticsmaturity ofemployeesmotivatedpower gains byrecruitment ofsurveys oftermination ofempowermentenabling successesengagement, CLASentering phase of organization developmentenvironmental barriers to communicationenvironments, industryEquity Theories of Motivation (Adams)equity theoryERG Theory (Alderfer)errors by managementescalation of commitmentethnicity/raceconflicts and stress based onemployeepatient. See also diversitypopulationstereotypingeustressevaluating performanceevaluating source of informationevaluation, action researchevaluation of changeevaluative feedbackexception, management by

exchange of help as political toolexecutive positions, charisma in. See also leadershipexhaustion response to stressexistence needs of employeesexit interviewsexpectancyExpectancy Theory, Vroom’s (VIE)expectations from managersGalatea effectPygmalion effectexpert powerexplain, management responsibility toexplorer-promoter (team member role)external attributionexternal barriers to successexternal communication linksexternal consultantexternal stakeholders, communications withexternal stressorsextinction reinforcementsextroversioneye and facial behaviorFfacial behavior and eyefailures by managementfalse advertisingfear as communication barrierFederal Employers’ Liability Act judgmentsfeedbackaction researchimproving team performance withstrategic communication planFiedler’s Contingency Theoryfight-or-flight responsefilter theory (Broadbent)Five-factor Model of Personality. See Big Five personality frameworkfixed-interval reinforcement schedulefixed-ratio reinforcement schedulefollow-up evaluationFord, Henryformal groupsforming stage of group developmentframing heuristicFrench, JohnFreud, AnnaFreud, Sigmund

frustration–regression principleFunction Role Theory (Benne and Sheats)GGalatea effectgarbage can decision-making processGAS. See General Adaptation Syndromegender, employeesexual harassmentstereotypingstress andgender, populationGeneral Adaptation Syndrome (GAS)geriatric medicineglobality, individual’s explanatory styleglobalization in healthcare industrygoalgoal conflictsgoal settingGoal-Setting Theorygoals of organizational behaviorgoals of teams. See also motivation; teamsGolembiewski’s phases of burnoutgovernance, CLASgrapevine communicationnetworksgrievancesgroup cohesivenessgroup decision makingconformitygarbage can processgroupthinkquality ofgroup decision process modelgroup dynamics. See also teamsaffiliationattitudes towards change, influencecohesivenessdefinitions ofeffect on productivityinter- and intragroup conflictsnormsroles of membersgroup feedbackgroup interactiongroups, types ofinformal and formal

groupthinkgrowth, professional. See also risk-takingHhalo effectharassment, sexualhardiness trainingharm from stressful situationsHawthorne StudiesHCA. See Hospital Corporation of Americahealth care, diversity and cultural competency inindustry, implications foroverviewU.S. population, changingaging populationgenderrace/ethnicityhealth care industryimplications fororganizational behavior inhealth care leadershiphealth care organizations, transformation ofhealth care, transformational leadershipHealth Insurance Portability and Accountability Act of 1996health service organizations (HSOs)Healthcare Causal Flow Leadership ModelHealthcare Equality Index (HEI)Healthcare Executive Competencies Assessment ToolHealthcare Leadership Alliance (HLA)healthcare professionals. See employeeshealthy conflict resolution, case studyHealthy Lives ProgramHEI. See Healthcare Equality Indexhelp as political toolhelplessness, learnedHersey and Blanchard’s Situational Leadership ModelHerzberg’s Motivation-Hygiene Theoryheuristics approach to decision makinghierarchy and communicationHierarchy of Needs (Maslow)hiringHispanic populationHLA. See Healthcare Leadership AllianceHofstede’s Cultural Dimensionshomeless patientshorizontal conflictshorizontal flow of communication

horizontal integrationhorn effecthospital and health system, organizational chart forHospital Corporation of America (HCA)hostile aggressionhostile attribution styleHouse’s Path–Goal Leadership TheoryHRD. See Human Resources DepartmentHRM. See human resources managementHSOs. See health service organizationshuman process interventionsHuman Resources Department (HRD)human resources management (HRM)human resources management interventions in organization developmenthumanistic psychologyhygiene factors and dissatisfactionIIAT. See Implicit Association TestICE. See index of communication effectivenessICU. See intensive care unit identification as source of powerIFD. See Institute for Diversity in Healthcare Managementimage as political toolimmunization to demotivationimplementation of changeImplicit Association Test (IAT)impression managementindex of communication effectiveness (ICE)individual barriers to changeindividual coping strategiesindividual feedbackIndividual Psychology theory (Adler)Individual Readiness Assessmentindividual roles, in groupsindividualism–collectivism, dimension of cultureindividualized considerationindustry environmentsinequalities in employee treatmentinequity tensioninfluence and powerbases of powercase studycoalitionsemployee gains ofmotivation andorganizational politicssources of power

upward influenceinformal communicationinformal groupsinformal leaders, role ofinformation as political toolinformation for organization developmentinformation technologyIngham, Harryingratiation as political toolingratiatorsinitiating structure as dimension of leadershipinputs, employeeinspirationInstitute for Diversity in Healthcare Management (IFD)institutionalizing changeinstrumental aggressioninstrumentalityintegrated delivery networksintegrative model of negotiationsintellectual leadersintelligence (IQ)intelligence, emotional. See emotional intelligenceintensive care unit (ICU)Interaction Process Analysis (Bales)interactional conflictsinteractive model of negotiationsInterface of Me and Them (Burton and Dimbleby)intergroup conflictsinternal attributioninternal consultantinternal stressorsinterorganizational conflictsinterpersonal conflictsinterpersonal demand appraisalsinterpersonal relationshipsstress andinterpersonal skillsinterpretation. See perceptionsinterrole conflictsintervention, action researchinterview techniquesintragroup conflictsintraorganizational communication flowsintraorganizational conflictsintrapersonal conflictintuitive decision makingIQ. See intelligence

JJDS. See Job Diagnostic Surveyjealousy as communication barrierjob analysisjob autonomyjob characteristics model of work motivationjob demands–decision latitude model (Karasek)job designTwo-Factor Theory (Herzberg)Job Diagnostic Survey (JDS)job enrichmentjob satisfaction. See motivation; satisfaction, jobjob stressorsjob surveysJohari WindowJoint CommissionJung Typology TestKKarasek, RobertKelley’s Attribution TheoryKellogg FoundationKilmann and Thomas two-dimensional taxonomy of conflict handling modeskinesicskinetic powerknowledge as source of powerknowledge management and communicationKotter, JohnLlabor negotiationslabor-relations approachlaissez-faire leadership stylelanguage assistance, CLASlanguage barriers. See also cultural competencyLatham, GaryLawler, EdwardLazarus’ cognitive-transactional theoryLCME. See Liaison Committee on Medical Educationleader position powerleader–member exchange theory (LMX)leader–member relationsleadership. See also management;motivationachievement needs ofCLAS

commitment to qualitycontingency theoriescase studyFiedler’s Contingency TheoryHersey and Blanchard’s Situational Leadership ModelHouse’s Path–Goal theoryLeader-Member Exchange Theory (LMX)Tannenbaum and Schmidt’s Continuum of Leadership Behaviordiscipline of OBmanagement us.predictabilityquestionnairesstereotyping of womenstyle, case studytrait and behavioral theoriesbehavioral competenciesBig Five personality frameworkBlake and Mouton’s Managerial Gridemotional intelligence (EI)Lewin’s Behavioral StudyOhio State leadership studiestrait theoryUniversity of Michigan studiestransformational and transactional theories. See also attribution theorycharismatic leadershipcollaborative leadershipemotional intelligence (EI)servant leadershipvisionary leadershipleadership style surveylearned helplessnesslearned optimismLeast Preferred Co-worker (LPC) scalelegal issues, employeelegitimate powerLewin, KurtLiaison Committee on Medical Education (LCME)Liars Indexline-staff conflictsLinking Skills Wheellistening. See also communicationLMX. See leader–member exchange theoryloafing, socialLocke, Edwinlocus of causalitylocus of controllong-term stressloss from stressful situations

LPC scale. See Least Preferred Co-worker scaleLuft, JoelyingMmacrolevel approach, conflict researchmaintenance roles, in groupsManaged Care Factor, case studymanagement. See also leadership; teamschange and developmentorganization development (OD)common mistakesof diversityeffectivenessby exceptionexpectationsGalatea effectPygmalion effectinfluence ofknowledge management and communicationleadership us.line-staff conflictsManagerial Grid (Blake and Mouton)mistakes byphilosophy of, as communication barrierpsychological closeness, increasingof self. See self-managementstakeholders, relationships withstressindividual coping strategiesorganizational coping strategiesprograms formanagement teamsManagerial Grid (Blake and Mouton)managerial philosophyMargerison-McCann Team Management Wheelmasculinity vs. femininity, dimension of cultureMaslow’s Hierarchy of Needsmaterial appraisalsmaturity, employeeMBTI. See Myers-Briggs Type IndicatorMcClelland’s 3-Needs TheoryMcGregor, Douglasmeaning, management ofmeasurementattitudesfor selection of employees

Mechanic, Davidmental abuse in the workplacemergers, industrymessages, strategic communication planMI. See myocardial infarctionMichigan studiesmicrolevel approach, conflict researchmiddle management, stress ofmilitary healthcare environmentminorities. See also cultural competencyconflicts stress based ondiversity managementemployeepatient. See also diversityprejudicesstereotypingmistakes by managementModern HealthcareModernization Act of 2003morale. See leadership; management;motivationmotivationattributions andcognitive dissonancecontent theoriescomparisons of theoriesERG Theory (Alderfer)Hierarchy of Needs (Maslow)job design3-Needs Theory (McClelland)Two-Factor Theory (Herzberg)discipline of organizational behaviorequity theories of motivationequity theory ofprocess theories (cognitive theories)case studies forequity theory of motivationExpectancy Theory (Vroom)Goal-Setting TheoryReinforcement TheorySatisfaction–Performance Theorypromotingof self. See self-motivationmotivational attribution processes, promotingmotivational statesMotivation-Hygiene theory (Herzberg)Mouton and Blake’s Managerial Gridmultiple raters of performanceMyers-Briggs Type Indicator (MBTI)

myocardial infarction (MI)NNAHSE. See National Association of Health Services Executivesnaïve psychologistsnaïve psychologyNational Association of Health Services Executives (NAHSE)National Center for Healthcare Leadership (NCHL)National Institute for Occupational Safety and Health (NIOSH)National Quality Forum (NQF)NCHL. See National Center for Healthcare Leadershipneeds, hierarchy theory of (Maslow)negative conflictnegative reinforcementsnegative stressorsnegotiation modelsnetiquettenetworks of communicationnew employee scheduling system, case study9 Cs (Newsom)NIOSH. See National Institute for Occupational Safety and Healthnominal group techniquesnondiscrimination policiesnonverbal communicationnormative social influencenorming stage of group developmentNQF. See National Quality Forumnursing care, transformational leadership andOOB. See organizational behaviorobese patientsobligation and powerOD. See organizational developmentOffice of Minority Health (OMH)Ohio State leadership studiesombudspersonOMH. See Office of Minority Healthone-way communicationopen door policiesopenness to experienceoperant conditioning. See Reinforcement Theoryoperating room (OR)optimism, learnedoptimistic attribution styleOR. See operating room

organizational barriersorganizational behavior (OB)defineddevelopment ofgoals ofHawthorne Studieshealth care industryhistory ofTheories X and Yorganizational changeorganizational coping strategiesorganizational development (OD)action researchinterventionsOD professional, theoverviewpractitioner, role ofprocessorganizational goals (case study)organizational politicsorganizational structure and stressorganizational theory (OT)outcomesemployeestrategic communication planoutside threats to groupsoverestimation of groupPpairwise comparisonparalanguageparallel teamsparticipative decision-making. See also teamsparticipative leaderparticipative leadershipPath–Goal leadership theory (House)patient agepatient diversityDiversity and Cultural Proficiency Assessment Tool for Leaderstraining aboutPatient Protection and Affordable Care Act (PPACA) of 2010patient safety committee (PSC)patient satisfactionperceived controlPerception Processing Systemperceptionsattribution theory

of burnoutcharismatic leadershipconflict of perspectivesof controlof dependence as source of powerhalo effecthorn effectinstrumentalitymanagement ofPerception Processing Systemperceptual vigilancePygmalion effectSelection-for-Action View (Broadbent)of similaritysocial perceptionstereotypingstress andperformanceconflict andevaluation ofmanagement systemsperceived control andprofessional growth. See also risk-takingSatisfaction–Performance Theoryof team, buildingperformance coachingperformance-management systemsperformance planningperforming stage of group developmentperson-role conflictspersonal accomplishment, diminishedpersonal barriers to communicationpersonal resource appraisalspersonalities. See also attitudes;trait theory of leadershipBig Five personality frameworkstress andpersonalized powerperspectives, conflict ofpessimism vs. optimismpessimistic attribute stylephysical abuse in the workplacephysical characteristics of leaders. See also trait theory of leadershipphysical demand appraisalsphysician–patient relationshipsphysiological consequences of stressphysiological illnessesphysiological needs of employeesPink, Daniel

planning change in organization developmentpolitical decision makingpolitics, organizationalpoor patientspopulation, aging ofPorter, Lymanpositive conflictpositive reinforcementspositive stressorspositivitypotential powerpower and influencebases of powercase studycoalitionsemployee gains ofgroup, overestimation ofmotivation andorganizational politicssources of powerstatus within groupsupward influencePower Distance, dimension of culturepower posepower relationshipsPPACA of 2010. See Patient Protection and Affordable Care Act of 2010praise as political toolpredicting employee behavior. See process theories of motivationprediction capabilities of leadersprejudicesas barrier to communicationas source of stressprescriptive feedbackpresenteeismpreventive coping strategiespreventive stress management, stages ofprimary groupsPrincipal Standard, CLASPrinciples of Scientific Management, Theproactive coping strategiesprocedural conflictsprocedural feedbackprocess conflictsprocess improvementprocess model for stress and copingprocess theories of motivationcase studiesequity theory of motivation

Expectancy Theory (Vroom)Goal-Setting TheoryReinforcement TheorySatisfaction–Performance Theoryprofessional growth. See also risk-takingprofessionals, organization developmentproject teamsprojectionpromoting motivationpromotions. See also recruitmentproviders. See employeesproxemicsPSC. See patient safety committeepsychological closeness, increasingpsychological consequences of stresspsychological illnessespsychology, humanisticpsychometricspunishment and rewardpunishment reinforcementsPygmalion effectQquestionnairesRrace/ethnicityconflicts and stress based onemployeepatientstereotypingrace, populationrange of individual member satisfactionrational approach to decision makingrationality tactic as political toolRaven, Bertramreactive coping strategiesreadiness assessmentrecognition, improving team performance withrecruitmentreference groupsreferent powerreflectionrefreezing stage (implementing change)regression–frustration principlereimbursement

reinforcement schedulesReinforcement Theoryrelatedness needs of employeesrelational feedbackrelationship behaviorrelationships. See also teamsconflictsstress andrelaxation response to stressreligionreporter-advisor (team member role)representation errorrepresentativeness bias techniqueresilienceresistance response to stressresistance to changeresource appraisalsresources for employeesrestraining forcesreward powerrewards. See also motivationcontingent rewardsimproving team performance withjob satisfaction. See satisfaction, jobperformance. See performanceprofessional growth. See also risk-takingrisk-takingRoethlisberger, Frederickrole demand appraisalsrolesconflicts ofof people in groupsrumorsSS-M-C-R model of communication processsafety needs of employeessanctions. See punishment and rewardsatisfaction, job. See also motivationburnoutleadership styles, based onperceived control andSatisfaction–Performance Theorystressorstransformational leadership andSatisfaction–Performance TheoryScheff, Thomas

Schmidt and Tannenbaum’s Continuum of Leadership BehaviorScott’s dilemma (case study)screening for resiliencesecondary groupsSelection-for-Action View (Broadbent)selective perceptionself-actualization needs of employeesself-assessment of attribution styleself-awarenessself-centered roles groupself-consciousnessself-esteemself-esteem needs of employeesself-fulfilling prophecyself-managementself-motivationself-serving biasSeligman, MartinSelys, Hanssenior executive positionssenior management. See also leadership; managementseparation, action researchservant leadershipsexual harassmentshort-term stressshort-term winsshotgunsSix Sigma programsize of groupsskid row populationskill variety and employee motivationSkinner, B. F.social awarenesssocial loafingsocial perceptionsocial relationships. See equity theories of motivationsocial resource appraisalssocial skillssocial structure, leadership withinsocialization and attitudessocialization processsocialized powersociogramssource of information, evaluatingsources of powerstabilitydimensionemotional

individual’s explanatory styleperception andstaff. See employeesstaff managers and conflictsstakeholder analysisstakeholders, communications withstatus quostereotype, definedstereotypingstimulistorming stage of group developmentstrategic communicationstrategic goalsstrategic interventions in organization developmentstressburnoutcauses ofcoping withindividual coping strategiesorganizational coping strategiespositive and negative stressorsprocess model for stress and copingprograms forindividual reactionsmanagementindividual coping strategiesorganizational coping strategiesprograms forminoritiesoverviewpersonalitiespresenteeismprocess model for stress and copingstressorsthreats to groupsworkplacestress management programsstructural changesubordinates. See employeessuccess. See also achievementenablingexternal barriers togroup dynamicssuperleadershipsupport for employeessupportive leaderssurveys, employeesustainability of healthcare industry

symbol leaderssystemic changes and trendsTTABP. See Type A behavior patterns tacticiansTannenbaum and Schmidt’s Continuum of Leadership Behaviortask behaviortask conflictstask demand appraisalstask design, stress andtask feedbacktask groupstask identity and employee motivationtask-oriented roles, in groupstask significance and employee motivationtask structureTaylor, FrederickTaylorismteamsbarriers to teamworkbuildingbuilding performance ofdefinedsuccessful, characteristics ofTeam Management Wheel (Margerison-McCann)Team Role Theory (Belbin)types ofvirtualtechnical skillstechnological advancementstechnostructural interventions in organization developmenttermination of employees. See also punishment and rewardterminology, unfamiliar as communication barriertests for selection of employeesTheories X and Ythird-party negotiationsThomas and Kilmann’s two-dimensional taxonomy of conflict handling modesthreats and stressful situationsThree-Needs Theory (McClelland)thruster-organizer (team member role)tolerance for ambiguity and decision makingtotal quality managementtrainingattributional trainingin diversityin emotional intelligenceworkforce education

trait theory of leadership. See also behavioral theories of leadershipbehavioral competenciesBig Five personality frameworkemotional intelligence (EI)transactional leadershiptransactional theories of leadershiptransformational and transactional theories of leadershipattribution theorycharismatic leadershipcollaborative leadershipemotional intelligence (EI)implications on healthcare industryservant leadershipvisionary leadershiptransformational errors, list oftransformational vs. transactional leadershiptri-component model of attitudestrust, management ofTurf Battles, case studyturnoverTwo-Factor Theory (Herzberg)two-way communicationType A behavior patterns (TABP)Type A personalityType B personalityUuncertainity, discomfort withUncertainty Avoidance dimension of cultureunconstructive conflictunequal treatmentunfreeze stage (implementing change)unhealthy motivationuniformity, pressures towarduninsured populationUniversity of Michigan studiesupholder-maintainer (team member role)upward appealupward flow of communicationupward influenceurgency, establishingU.S. Census BureauU.S. Department of Health and Human ServicesU.S. populationchangingaging populationgender

race/ethnicitydemographics ofVvalencevalues and ethicscharismatic leadershipvariable-interval reinforcement schedulevariable-ratio reinforcement scheduleverbal abuse in the workplaceverbal communication. See also communicationvertical conflictsvertical integrationvertical job loadingVertical Linkage Dyad (VLD)VIE Theory (Vroom)violence in the workplace. See also stressvirtual integrationvirtual teamsvisioncommunicationdevelopingvisionary leadershipVLD. See Vertical Linkage DyadVroom. See VIE TheoryVroom-Yetton decision-making modelVroom’s Expectancy Theory (VIE)WW. K. Kellogg Foundationweak uncertainty, dimension of culturewheel pattern of communicationWhite populationwork redesignwork setting and stress managementwork teamsworkforce. See also employeesCLASfutureworkshops, attitudewritten communication. See also communicationXX model for change (Roethlisberger)X-theory management

YY-pattern network of communicationY-theory managementYerkes-Dodson curve

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