October 1, 2023

What are the five conflict modes?

First, read “Case Study 15-8, Healthy Conflict Resolution”, on page 289-90 of Organizational Behavior in Health Care.

Based on the information in Chapter 4 and your independent research, write a paper that addresses the following questions:

What is the basis/cause of the conflict in the case described?

What conflict style/handling-mode should be use to resolve the conflict?

Why is the chosen approach preferable to other approaches?

What are the advantages and disadvantages of your choice?

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 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.

Requirements: 5 pages

Case Study 15-8 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 the open patient registration window, “you are double booked for most of the afternoon because you canceled your clinic twice this month already. Many of these patients have been waiting more than three months to see you!

Jones glances furtively at the waiting room, and already half turned and heading toward the clinic exit, says, “I’m sure you will be able to smooth things over. Just tell them that I got called to an emergency.”

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 they can 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, the manager 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 involve several more individuals (the chief medical officer, the executive director of the clinic, the director of human resources, and the union representative) before Jones is ever made aware that Cindy has filed a formal complaint about him. When he is finally confronted, in a meeting with the chief medical 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 him about it. They have continued to work together, in his opinion, as if nothing were wrong. He is also surprised to find out that Cindy has been keeping a tally of the number of times that he has canceled his 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. Physician Executive, 35(1), 60–61.

FOURTH EDITIONOrganizational Behaviorin HEALTH CARENancy Borkowski, DBA, FACHE,FHFMAProfessorDepartment of Health Services AdministrationSchool of Health ProfessionsUniversity of Alabama at BirminghamBirmingham, ALKatherine A. Meese, PhDAssistant ProfessorDepartment of Health Services AdministrationSchool of Health ProfessionsUniversity of Alabama at BirminghamBirmingham, AL

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© Valex/ShutterstockBrief ContentsPrefaceAbout the AuthorsPART I IntroductionCHAPTER 1 Overview and Historyof OrganizationalBehaviorCHAPTER 2 Diversity, Equity, andInclusion in HealthCareCHAPTER 3 DiversityManagement andCultural Competencyin Health CareCHAPTER 4 Attitudes andPerceptionsCHAPTER 5 WorkplaceCommunication

PART II Understanding IndividualBehaviorsCHAPTER 6 Content Theories ofMotivationCHAPTER 7 Process Theories ofMotivationCHAPTER 8 Attribution Theoryand MotivationPART III LeadershipCHAPTER 9 Power, Politics, andInfluenceCHAPTER 10 Trait and BehavioralTheories ofLeadershipCHAPTER 11 Contingency Theoriesand SituationalModels of LeadershipCHAPTER 12 ContemporaryLeadership TheoriesPART IV Intrapersonal andInterpersonal Issues

CHAPTER 13 Stress in theWorkplace and StressManagementCHAPTER 14 Decision MakingCHAPTER 15 Conflict Managementand Negotiation SkillsPART V Groups and TeamsCHAPTER 16 Overview of GroupDynamicsCHAPTER 17 GroupsCHAPTER 18 Work Teams andTeam BuildingPART VI Managing OrganizationalChangeCHAPTER 19 OrganizationDevelopmentCHAPTER 20 Managing Resistanceto ChangeIndex

© Valex/ShutterstockContentsPrefaceAbout the AuthorsPART I IntroductionCHAPTER 1 Overview and History ofOrganizational BehaviorOverviewWhy Study Organizational Behavior in HealthCare?The Health Care IndustryHistory of Organizational BehaviorThe Hawthorne StudiesTheories X and YRelated DisciplinesDiscussion QuestionsWhat Do You Know About OrganizationalBehavior?ScoringInterpretationReferences

CHAPTER 2 Diversity, Equity, andInclusion in Health CareOverviewDiversity, Equity, and Inclusion DefinedChanging U.S. PopulationRace/EthnicityAgeGenderSexual Orientation, Gender Identity, and Gender ExpressionImplications for the Health Care IndustrySummaryDiscussion QuestionsExercise 2-1Exercise 2-2Exercise 2-3ReferencesOther Suggested ReadingsCHAPTER 3 Diversity Managementand Cultural Competency in HealthCareDiversity ManagementThe Future WorkforceDiversity in Health Care LeadershipCultural CompetencySummary

Discussion QuestionsExercise 3-1Exercise 3-2Exercise 3-3ReferencesCHAPTER 4 Attitudes andPerceptionsOverviewAttitudesCognitive DissonanceFormation of AttitudesMeasurement of AttitudesChanging AttitudesPerceptionAttribution TheorySocial PerceptionHalo EffectContrast EffectsProjectionStereotypingPygmalion EffectImpression ManagementEmployee SelectionSummaryDiscussion Questions

Case Study and ExercisesReferencesOther Suggested ReadingsCHAPTER 5 WorkplaceCommunicationOverviewCommunication ProcessFeedbackThe Johari WindowCommunication ChannelsVerbal CommunicationElectronic CommunicationNonverbal CommunicationBarriers to CommunicationEnvironmental BarriersPersonal BarriersOvercoming Barriers to ImproveCommunicationEffective Communication for KnowledgeManagementStrategic CommunicationFlows of Intraorganizational CommunicationUpward FlowDownward FlowHorizontal Flow

Diagonal FlowCommunication NetworksInformal CommunicationCross-Cultural CommunicationCommunicating with External StakeholdersSummaryDiscussion QuestionsCase StudiesReferencesPART II Understanding IndividualBehaviorsCHAPTER 6 Content Theories ofMotivationOverviewMaslow’s Hierarchy of Needs TheoryAlderfer’s ERG TheoryHerzberg’s Two-Factor TheoryJob DesignMcClelland’s Three-Needs TheoryAchievementPowerAffiliationSummaryDiscussion QuestionsCase Studies and Exercises

ReferencesOther Suggested ReadingsCHAPTER 7 Process Theories ofMotivationOverviewExpectancy TheoryEquity TheorySatisfaction–Performance TheoryGoal-Setting TheoryReinforcement TheorySummaryDiscussion QuestionsCase StudiesReferencesCHAPTER 8 Attribution Theory andMotivationOverviewAttribution TheoryAttribution StyleAttributions and Motivational StatesLearned HelplessnessAggressionEmpowermentResilience

Promoting Motivational Attribution ProcessesScreening for ResilienceAttributional TrainingImmunizationIncreasing Psychological ClosenessMultiple Raters of PerformanceConclusionDiscussion QuestionsCase Studies and ExerciseReferencesOther Suggested ReadingPART III LeadershipCHAPTER 9 Power, Politics, andInfluenceOverviewSources of PowerOther Sources of Power in an OrganizationUses of PowerDeveloping a Power BaseOrganizational PoliticsUpward InfluenceConclusionDiscussion QuestionsCase Studies

ReferencesCHAPTER 10 Trait and BehavioralTheories of LeadershipOverviewTrait TheoryLewin’s Behavioral StudyOhio State Leadership StudiesUniversity of Michigan StudiesBlake and Mouton’s Leadership GridConclusionDiscussion QuestionsCase Study and ExercisesExercise 10-1Exercise 10-2Exercise 10-3Exercise 10-4Exercise 10-5 Leadership QuestionnaireReferencesCHAPTER 11 Contingency Theoriesand Situational Models of LeadershipOverviewFiedler’s Contingency TheoryHouse’s Path–Goal Leadership Theory

Tannenbaum and Schmidt’s Continuum ofLeadership BehaviorHersey and Blanchard’s Situational LeadershipModelLeader–Member Exchange TheoryConclusionDiscussion QuestionsExercise 11-1ReferencesCHAPTER 12 ContemporaryLeadership TheoriesOverviewTransformational Versus TransactionalLeadershipTransactional LeadershipTransformational LeadershipTransformational Leadership: A ContradictoryViewThe Implications of TransformationalLeadership for the Health Care IndustryOther Contemporary Leadership ApproachesThe Charismatic LeaderServant LeadershipCollaborative LeadershipAnother Look at Traits and BehaviorBig Five Personality Factors

Emotional IntelligenceBehavioral CompetenciesSummaryDiscussion QuestionsExercise 12-1Exercise 12-2 Are You a Charismatic Leader?Exercise 12-3 What Is Your EQ?Exercise 12-4Appendix 12-A Traits and Skills of CollaborativeLeadersAppendix 12-B Six Key Practices and NecessarySteps for Leaders to Guide SuccessfulCollaborationsReferencesOther Suggested ReadingsPART IV Intrapersonal andInterpersonal IssuesCHAPTER 13 Stress in the Workplaceand Stress ManagementOverviewWork-Related StressWorkplace ViolenceStressorsPositive and Negative StressorsInternal or External Stressors/Acute or Chronic

Individuals and StressPersonalitiesUnderrepresented PopulationsGenderBeliefs About StressBurnoutPresenteeismCauses of Workplace StressCoping with StressOrganizational Coping StrategiesJoy in WorkJob DesignIndividual Coping StrategiesLearned OptimismStress Management ProgramsSummaryDiscussion QuestionsReferencesOther Suggested ReadingsCHAPTER 14 Decision MakingOverviewRational ApproachBounded Rationality ModelIntuitionHeuristics or Biases Approach

Escalation of Commitment and Framing HeuristicsDecision-Style ModelVroom-Yetton Decision-Making ModelConclusionDiscussion QuestionsExercise 14-1Exercise 14-2Exercise 14-3ReferencesOther Suggested ReadingsCHAPTER 15 Conflict Managementand Negotiation SkillsOverviewTypes of ConflictLevels of ConflictIntrapersonal ConflictInterpersonal ConflictIntragroup ConflictIntergroup ConflictInterorganizational ConflictConflict ManagementConflict Negotiation ModelsDistributive ModelIntegrative ModelInteractive Model

Benefits of Skilled Conflict Resolution andNegotiationConclusionDiscussion QuestionsCase StudiesReferencesOther Suggested ReadingsPART V Groups and TeamsCHAPTER 16 Overview of GroupDynamicsOverviewWhat Is a Group?Group InteractionWhy Do People Join Groups?Roles of Group MembersGroup NormsCohesivenessSize of the GroupSocial LoafingExperience of SuccessGroup StatusOutside Threats to the GroupConformityGroupthinkConclusion

Discussion QuestionsExercise 16-1Exercise 16-2Be the Best We Can Be Team NormsExercise 16-3ReferencesCHAPTER 17 GroupsOverviewTypes of GroupsPrimary GroupsSecondary GroupsReference GroupsInformal or Formal Group StructureInformal GroupsFormal GroupsGroup DevelopmentGroup Decision MakingRational Decision-Making ProcessesBrainstormingNominal Group TechniqueThe Delphi TechniqueIrrational Decision-Making ProcessesThe “Garbage Can” Decision-Making ProcessConclusionDiscussion Questions

Exercise 17-1Exercise 17-2ReferencesCHAPTER 18 Work Teams and TeamBuildingOverviewTeams and TeamingTypes of TeamsVirtual TeamsBuilding Team PerformanceCommon Characteristics of Successful TeamsBarriers to Effective TeamworkConclusionDiscussion QuestionsExercise 18-1Exercise 18-2Exercise 18-3ReferencesOther Suggested ReadingsPART VI Managing OrganizationalChangeCHAPTER 19 OrganizationDevelopmentOverview

Organization DevelopmentThe Organization Development ProfessionalAction ResearchSteps in the Organization Development ProcessEntering and ContractingDiagnosisPlanning and Implementing ChangeEvaluating and Institutionalizing ChangeOrganization Development InterventionsAppreciative InquiryConclusionDiscussion QuestionsReferencesCHAPTER 20 Managing Resistanceto ChangeOverviewDrivers of ChangeResistance to ChangeIndividuals’ Barriers to ChangeDiscomfort with UncertaintyPerceived Negative Effects on InterestsPerceived Breach of Psychological ContractLack of Clarity as to What Is ExpectedExcessive ChangeLewin’s Change Model

Transformation of Health Care OrganizationsSummaryDiscussion QuestionsCase StudyReferencesOther Suggested ReadingsIndex

© Valex/ShutterstockPrefaceIn the first edition of this book, Chapter 1 stated that“the U.S. health care industry has grown andchanged dramatically over the past twenty-fiveyears.” That was an understatement! Since thattime, the industry has experienced some of the mostdynamic changes that health care managers haveseen. In the coming years, more system-widechanges will occur as we continue our push forwardto achieve patient-centered, value-based healthcare. Health care managers are quickly learning thatwhat worked in the past might not work in the future.This was the compelling reason to write anorganizational behavior book specifically for healthcare managers who are on the front lines every day,motivating and leading others in a constantlychanging, complex environment. This is not an easytask, as we know firsthand!The purpose of this book is to provide health caremanagers and other professionals with an in-depthanalysis of the theories and concepts oforganizational behavior while embracing theuniqueness and complexity of the industry. Althoughhealth care is similar to other industries, it is also

very different. As the nation’s largest industry,health care employs more than 16 million people innumerous interrelated and interdependentsegments.Using an applied focus, this book provides a clearand concise overview of the essential topics inorganizational behavior from the health caremanager’s perspective. It is our goal to give you agreater understanding of why and how people andgroups behave as they do in the workplace. Withthis knowledge, you will be able to predict andeffectively influence the behavior of the people youlead. Please let me know if we accomplish our goal!You can reach us at [email protected] [email protected] have tried to ensure that we referenced all theindividuals whose work contributed to thedevelopment of this book. However, if by chance wefailed to give credit to someone along the way,please contact us so that we can make thenecessary correction.At this time, we wish to thank our families for theirpatience, understanding, and support over theyears. Finally, we wish to thank the many wonderfuland caring people employed throughout the healthcare industry with whom we have had and willcontinue to have the opportunity to work with. Our

lives continue to be blessed by these dedicatedindividuals!Thank you for purchasing (and reading) our book.We welcome your comments and suggestions, andwe wish you the best on your health caremanagement and leadership journey.With personal regards,Nancy Borkowski, DBA, FACHE, FHFMAKatherine A. Meese, PhD

© Valex/ShutterstockAbout the AuthorsNancy Borkowski, DBA, FACHE, FHFMA, isProfessor in the Department of Health ServicesAdministration at the University of Alabama atBirmingham. She received her DBA withspecializations in health services administration andaccounting from Nova Southeastern University. Dr.Borkowski has over 25 years’ experience in thehealth care industry and is a two-time past recipientof the American College of Healthcare Executives’(ACHE) Southern Florida Senior Career HealthcareExecutive Award, which recognizes individuals whohave made significant contributions to theadvancement of health management excellence.A nationally recognized author, Dr. Borkowski isalso board certified in health management and is aFellow of both the American College of HealthcareExecutives and the Healthcare FinancialManagement Association. The first edition of herbook, Organizational Behavior in Health Care,referred to as “one of the most significant advancesin the field of health services administration,” washonored with the American Journal of Nursing’s2005 Book of the Year Award for nursing leadership

and management. Dr. Borkowski is the author ofthree textbooks that are widely used in graduateand undergraduate health administration andnursing programs both nationally and internationally.Dr. Borkowski’s work has been published in theJournal of Ambulatory Care Management,Leadership in Health Services, Group &Organization Management, Organizational Behaviorand Human Decision Processes, Health CareManagement Review, Journal of HealthAdministration Education, Journal of Health andHuman Services Administration, InternationalJournal of Public Administration, and various otherjournals.Her teaching interests are leadership, organizationalbehavior, and strategic management. Dr. Borkowskiis a past recipient of the ACHE’s Excellence inTeaching Award, which is given to faculty whoengage in furthering academic excellence and theprofessional development of health managementstudents.Over the past three decades, Dr. Borkowski hasserved in various leadership roles for theAssociation of University Programs in HealthAdministration, Academy of Management’s HealthCare Management Division, the American Collegeof Healthcare Executives’ Southern Florida Regent’s

Advisory Council, the South Florida HealthcareExecutive Forum, the Alabama HealthcareExecutive Forum, and various other health-relatedorganizations. In 2013, Dr. Borkowski received theJessie Trice Hero Award for her leadership andcommitment to improving the lives of underservedand minority populations. She has also beenhonored with the Exemplary Service Award from theAmerican College of Healthcare Executives (2012)and the Frederick T. Muncie Gold Award from theHealthcare Financial Management Association(2017).Katherine A. Meese, PhD, is an AssistantProfessor in the Department of Health ServicesAdministration at the University of Alabama atBirmingham. She earned her PhD in HealthServices Administration with a specialization instrategic management from the University ofAlabama at Birmingham in 2019. Dr. Meese hasseven years of industry experience, encompassingwork in ten countries on four continents, includingmanagement positions for a large academic medicalcenter. Her work has been published in Anesthesia& Analgesia, Health Services ManagementResearch, Journal of Health AdministrationEducation, and various other journals. Her researchinterests are in wellness, burnout, quality and

safety, and delivery models that enhanceorganizational learning.

PART IIntroductionPart I includes four different but related topics. InChapter 1, the history of organizational behaviorand its importance to today’s health care managersare discussed. Chapter 2 describes the changingenvironment in which health care managers findthemselves. The chapter examines the numerousissues that have emerged within the health careindustry because of the nation’s changingdemographics. Chapter 3 focuses specifically oncultural competency and the skills that managersneed to adapt to the changing environment exploredin Chapter 2. Chapter 4 deals with attitudes andperceptions, which are the foundation forunderstanding organizational behavior. You will findthe terms “attitude” and “perception” frequentlyreferred to in the various organizational behaviortheories. Finally, Chapter 5 discusses theimportance of communication. Recent surveys haverevealed that 70% of small- to medium-sizedbusinesses claim that ineffective communication is

their primary problem. Sentinel event data from TheJoint Commission estimated that communicationfailure was the root cause for patient harm 70% ofthe time in 2400 reported negative outcomesstudied. No wonder the ability to communicateeffectively is considered an essential job skill fortoday’s health care managers and leaders.

CHAPTER 1Overview and History ofOrganizational BehaviorLEARNING OUTCOMESAfter completing this chapter, the student shouldunderstand:The definition of organizational behavior.The major challenges facing today’s andtomorrow’s health care organizations andhealth care managers.The importance of the Hawthorne Studies tothe study of organizational behavior.The importance of McGregor’s Theory X andTheory Y to the study of organizationalbehavior.The differences between organizationalbehavior, organization theory, organizationaldevelopment, and human resourcesmanagement.

▶ OverviewOrganizational behavior (OB) is an appliedbehavioral science that emerged from thedisciplines of psychology, sociology, anthropology,political science, and economics. OB is the study ofindividual and group dynamics in an organizationalsetting. Whenever people work together, numerousand complex factors interact. The discipline of OBattempts to understand these interactions so thatmanagers can predict behavioral responses and, asa result, manage the resulting outcomes.According to Ott (1996, p. 1), OB asks the followingquestions:1. Why do people behave the way they do whenthey are in organizations?2. Under what circumstances will people’sbehavior in organizations change?3. What impacts do organizations have on thebehavior of individuals, formal groups (suchas departments), and informal groups (suchas people from several departments whohave lunch together regularly)?4. Why do different groups in the sameorganization develop different behavior

norms?From Ott. Classic Readings in Organizational Behavior, 2E. © 1996South-Western, a part of Cengage Learning, Inc. Reproduced bypermission.OB has three goals. First, OB attempts to explainwhy individuals and groups behave the way they doin organizational settings. Second, OB tries topredict how individuals and groups will behave onthe basis of internal and external factors. Third, OBprovides managers with tools to assist in themanagement of individuals’ and groups’ behaviorsso that they willingly put forth their best effort toaccomplish organizational goals. In the health careindustry, OB has become more important becausepeople with diverse backgrounds and cultural valueshave to work together effectively and efficiently.

▶ Why Study OrganizationalBehavior in Health Care?The largest U.S. industry is health care, whichcurrently employs over 20 million individuals. Theindustry will account for almost a third of the nation’sprojected job growth through 2026, adding over 2million jobs. The projected 1.9% per year growthrate is the fastest among all industry sectors(Bureau of Labor Statistics, 2019).Each segment of the health care industry (e.g.,hospitals, home health, rehabilitation facilities)comprises a different mix of health-relatedoccupations, ranging from highly skilled licensedprofessionals, such as physicians and nurses, tothose with on-the-job training. Furthermore, eachsegment of the industry has various economicstructures (e.g., for-profit, not-for-profit,governmental). Therefore, today’s health caremanagers need to have the skills to communicateeffectively with, motivate, and lead diverse groups ofpeople within a large, dynamic, and complexindustry. Communication, motivation, andleadership are all concepts in the discipline of OB.Furthermore, managers need to understand thecauses of workplace problems, such as low

performance, turnover, conflict, and stress, so thatthey may be proactive and minimize theseunnecessary negative outcomes. With a greaterunderstanding of OB, managers are better able topredict and therefore influence the behavior ofemployees to achieve organizational goals.Given the service-related intensity of the health careindustry, understanding individuals’ behavior andgroup dynamics within health service organizationsis critical to a health care manager’s success.Research indicates that the primary reasons whymanagers fail stem from difficulty in handlingchange, not being able to work well in teams, andhaving poor interpersonal relations. There is asaying that employees don’t leave organizations,they leave managers!

▶ The Health Care IndustryChanges within the health care industry over thepast 30 years have been powerful, far reaching, andcontinuous. Because readers are probably familiarwith most of these changes either from their ownexperiences or from a previous health care deliverysystem course, the discussion will address some ofthe trends or future concerns that will affecttomorrow’s health care industry.Past changes and future trends are interrelatedforces that have shaped or will shape tomorrow’shealth care organizations at both the system leveland the organizational level. Decliningreimbursement and changes in payment schemesfor services have had, and will continue to have, twoof the deepest impacts on the industry. Technologyhas also caused significant changes within theindustry. Biomedical and genetic research,advances in information technology, and use of “bigdata” are producing rapid changes in clinicaltreatments. In addition, the industry hasexperienced more government mandates andsubstantial legislative changes, such as theMedicare Prescription Drug, Improvement, andModernization Act of 2003; the American Recovery

and Reinvestment Act of 2009; the PatientProtection and Affordable Care Act of 2010 (ACA)and subsequent legislation to repeal portions of theact; and the Medicare Access & ChipReauthorization Act of 2015 (MACRA). With anincreased focus on chronic disease management,patients are living longer, and requiring more long-term and home health care services now and in thefuture. Patients’ and health care workers’characteristics are also changing. Both populationsare becoming older and more diverse. Patients arebetter informed and have increasingly highexpectations of health care professionals. This trendhas changed the way in which health care servicesare delivered, with a focus on patient satisfactionand safety as well as on the quality and value ofservices provided. Physician–patient relationshipshave changed because patients are beginning tounderstand that much of the responsibility forwellness lies with them and have easy access tohealth-related information. A growth in high-deductible insurance plans places a larger financialresponsibility on patients to manage their ownhealth and reduce unnecessary health spending.The economics of health care are in a state of flux.For example, reimbursements are moving towardvalue-based payments; therefore, we see anincrease in the use of evidence-based medicine.

There are continuing shortages of staff, especially inthe areas of primary care physicians, nurses,imaging technicians, and pharmacists, leading tocompetition for well-qualified people. Changes arealso taking place in the disease environment. Manyfactors of modern life are contributing to theemergence of new diseases, reemergence of oldones, and evolution of pathogens that are immuneto many of today’s medications. In addition,because of potential terrorism attacks, health careproviders are concerned with biodisasterpreparedness. Finally, even with some states’Medicaid expansion programs and the ACA, therecontinues to be the issue of caring for the uninsuredwhich can contribute to the overuse and misuse ofhospital emergency departments.To deal with these changes, a number of healthcare organizations have adapted theirorganizational forms by restructuring themselvesinto integrated delivery networks, which may be partof a local, regional, or national system. We haveseen increased vertical, horizontal, and virtualintegration. Vertical integration focuses on thedevelopment of a continuum of care services tomeet the patient’s full range of health care needs.This integration model, in which a single entity ownsand operates all the segments providing care, mayinclude preventive services, specialized and primary

ambulatory care, acute care, subacute care, long-term care, and home health care, as well as ahealth plan. Recently, we have seen the creation ofaccountable care organizations (ACOs), in whichgroups of doctors, hospitals, and other health careproviders have joined together to providecoordinated care to predetermined patientpopulations. Horizontal integration usually occursthrough mergers, acquisitions, and/or consolidationwithin one segment of the industry. For example,during the 1990s, numerous hospitals wereacquired by the large, for-profit, publicly heldhospital chains of Hospital Corporation of America(HCA), Tenet Healthcare, and Health ManagementAssociates (now part of Community HealthSystems), and these acquisitions continue today.Consolidation in health care began to rise rapidly in2009 and doubled between 2011 and 2015 (HealthCare Financial Management Association, 2017).In addition, not-for-profit hospitals have merged withfor-profit health systems as a result of competitionand the need to reduce cost through economies ofscale. Virtual integration, which emphasizescoordination of health care services through patient-management agreements, provider incentives,and/or information systems, has increased. Thisvirtual integration has evolved to meet the need forbetter technology and information infrastructures

that allow for information sharing, patient caremanagement, and cost control.Because of the dramatic changes and the futuretrends in the health care industry, most managershave had to change the ways in which they andother employees carry out their job responsibilities.These changes have been forced on the industry bythe need to increase productivity, due to decreasingreimbursement and increasing competition. At thesame time, health care providers must deliverpatient-centered, value-based care. These are noteasy tasks to balance. As a result, many health careproviders are breaking down their traditionalhierarchical structures and moving towardmultidisciplinary team-managed environments.Employees are finding themselves in new roles withnew responsibilities. All of these changes causedisruptions in the workplace. The study of OB willassist health care managers to minimize thenegative effects (such as stress and conflict) relatedto this “new” environment and to maximize theirability to motivate staff and lead their organizationseffectively.

▶ History of OrganizationalBehaviorThe beginnings of OB can be found in the humanrelations/behavioral management movement, whichemerged during the 1920s as a response to thetraditional or classic management approach.Beginning in the late 1700s, the IndustrialRevolution was the driving force for thedevelopment of large factories employing manyworkers. Managers at that time were concerned“about how to design and manage work in order toincrease productivity and help organizations attainmaximum efficiency” (Daft, 2004, p. 24). Thistraditional approach included Frederick Taylor’s(1911) well-known framework of scientificmanagement, or “Taylorism,” as it is now labeled.Taylor believed that efficiency was achieved bycreating jobs that economized time, human energy,and other productive resources. Through his time-and-motion studies, Taylor scientifically dividedmanufacturing processes into small, efficient units ofwork. Through Taylor’s work, productivity greatlyincreased. For example, Henry Ford developed hisassembly line according to the principles ofTaylorism and was able to churn out Model Ts at a

remarkable and economical pace (Benjamin,2003).Although the classic approach to managementfocused on efficiency within organizations, Taylordid attempt to address a human relations aspect inthe workplace. In his book The Principles ofScientific Management, Taylor stated that:in order to have any hope of obtaining the initiative(i.e., best endeavors, hard work, skills and knowledge,ingenuity, and good-will) of his workmen, the managermust give some special incentive to his men beyondthat which is given to the average of the trade. Thisincentive can be given in several different ways, as, forexample, the hope of rapid promotion or advancement;higher wages, either in the form of generous pieceworkprices or of a premium or bonus of some kind for goodand rapid work; shorter hours of labor; bettersurroundings and working conditions than areordinarily given, etc., and, above all, this specialincentive should be accompanied by that personalconsideration for, and friendly contact with, hisworkmen which comes only from a genuine and kindlyinterest in the welfare of those under him. It is only bygiving a special inducement or incentive of this kindthat the employer can hope even approximately to getthe initiative of his workmen.

Although Taylor included a concern for workers inthe scientific management approach, the humanrelations or behavioral movement of managementdid not begin until after the landmark HawthorneStudies.

▶ The Hawthorne StudiesElton Mayo, Frederick Roethlisberger, and theircolleagues from Harvard Business Schoolconducted a number of experiments from 1924 to1933 at the Hawthorne Plant of the Western ElectricCompany in Cicero, Illinois. The Hawthorne Studieswere significant to the development of OB becausethe researchers demonstrated the importantinfluence of human factors on worker productivity. Itwas through these experiments that the HawthorneEffect was identified. The Hawthorne Effect is thebias that occurs when people know that they arebeing studied. Roethlisberger and Dickson (1939),in their book Management and the Worker, andHomans (1950), in his book The Human Group,provided a comprehensive account of theHawthorne Studies. The Hawthorne Studies hadfour phases: the illumination experiments, the relay-assembly group experiments, the bank-wiringobservation-room group studies, and theinterviewing program. The intent of these studieswas to determine the effect of working conditions onproductivity.The illumination experiments were conducted todetermine whether increasing or decreasing lighting

would lead to changes in productivity. Theresearchers were surprised to learn that productivityincreased in both the control group (no change inlighting) and the experimental group (lightingalternated upward and downward). The researchersdetermined that it was not the lighting that causedthe increased productivity; rather, the improvementresulted from the attention received by the group.In the relay-assembly group experiments,productivity of a segregated group of workers wasstudied as they were subjected to different workingconditions. The researchers and managementobserved the group closely for 5 years. During thefirst part of the experiment, the employees’ workingconditions were improved by extending their restperiods, decreasing the length of their workday, andproviding them a free day and lunches. In addition,the workers were consulted before any changeswere made, because their agreement had to beobtained before the change would be implemented.The workers of the group were given the freedom tointeract with one another during the workday.Furthermore, one researcher also served as theirsupervisor, who, during the experiment, expressedconcern about the workers’ physical health and well-being. The researchers eagerly sought theemployees’ opinions, hopes, and fears during theexperiment. During the improved-conditions period,

the workers’ productivity increased. In part two ofthe experiment, the original working conditions wererestored. Surprisingly, the researchers found thatthe employees’ productivity remained at the highlevel that had occurred under the improved workingconditions. This result was attributed to groupdynamics because the group was allowed todevelop socially with a common purpose.The bank-wiring observation-room experiment wassimilar to the relay-assembly experiment. A group ofworkers were segregated so that their productivityand group dynamics could be studied. The workerswere paid at a piecework rate that reflected bothgroup and individual efforts. The researchers foundthat the wage incentive did not work. The group haddeveloped its own standard as to what constituted a“proper day’s work.” As a result, the group’s level ofproductivity remained constant because they did notwant management to know that they could produceat a higher level. If a member of the group producedmore than the agreed-upon level, the othermembers influenced the “rate buster” to return theirproductivity level to the group’s norm. In addition, ifa member of the group failed to produce therequired level of output, the other members tradedjobs to ensure that the group’s output levelremained constant. The results of the bank-wiringexperiment mirrored the relay-assembly experiment

results. The researchers concluded that there wasno cause-and-effect relationship between workingconditions and productivity and that any increase ordecrease in productivity was attributed to groupdynamics.As a result of the bank-wiring experiment,researchers became very interested in exploringinformal employee groups and the social functionsthat occur within the group and influence thebehavior of the individual group members. As part ofthe Hawthorne Studies, the researchers conductedextensive interviews with the employees. Over21,000 interviews were conducted to determine theemployees’ attitudes toward the company and theirjobs. A major outcome of these interviews was thatthe researchers discovered that workers were notisolated, unrelated individuals; they were socialbeings and their attitudes toward change in theworkplace were based on (1) the personal socialconditioning (values, hopes, fears, expectations,etc.) that they brought to the workplace, formedfrom their previous family or group associations, and(2) the human satisfaction that the employeesderived from their social participation with coworkersand supervisors. What the researchers learned wasthat an employee’s expression of dissatisfactionmay be a symptom of an underlying problem in theworkplace, at home, or in the person’s past.

▶ Theories X and YAnother significant impact in the development of OBcame from Douglas McGregor (1957, 1960) whenhe proposed two theories by which managers viewtheir employees: Theory X (negative/pessimistic)and Theory Y (positive/optimistic). Theories X and Yreflect polar positions and are ways of seeing andthinking about people, which, in turn, affect theirbehavior.Theory X states that employees are unintelligentand lazy. They dislike work, avoiding it wheneverpossible. Employees should be closely controlledbecause they have little desire for responsibility,have little aptitude for creativity in solvingorganizational problems, and will resist change. Incontrast, Theory Y states that employees arecreative and competent; they want meaningful work;they want to contribute; and they want to participatein decision-making and leadership functions.Borrowing from Maslow’s Hierarchy of Needs,McGregor stated that the autocratic (Theory X)managers were no longer effective in the workplacebecause they relied on an employee’s lower needsfor motivation (physiological concerns and safety),which, in modern society, were mostly satisfied and

therefore no longer acted as motivators for theemployee. For example, managers would ask, “Whyaren’t people more productive? We pay goodwages, provide good working conditions, haveexcellent fringe benefits, and provide steadyemployment. Yet people do not seem to be willing toput forth more than minimum efforts.” The answersto these questions were embedded in Theory X’smanagerial assumptions about people. If managersbelieved that their employees had an inherentdislike for work and must be coerced, controlled,and directed to achieve organizational goals, theresulting employee behavior was nothing more thana self-fulfilling prophesy. The manager’sassumptions caused the staff’s “unmotivated”behavior.At the opposite end of the spectrum from Theory X,McGregor proposed Theory Y, which suggestedproductivity increased when managers createdopportunities, removed obstacles and encouragedgrowth and learning for their employees. McGregorstated that participative (Theory Y) managerssupported decentralization and delegation ofdecision making, job enlargement, and participativemanagement because these allowed employeessome freedom to direct their own activities and toassume responsibility, thereby satisfying theirhigher-level needs (see Figure 1-1).

Figure 1-1 McGregor X–Y Theory Diagram

▶ Related DisciplinesBefore we conclude this chapter, we would like toexplain the differences between OB and three otherrelated fields: organization theory (OT),organizational development (OD), and humanresources management (HRM). As was noted at thebeginning of the chapter, OB is the study ofindividual and group dynamics within anorganization setting and therefore is a microapproach. OT analyzes the entire organization andis a macro perspective, since the organization is theunit examined. The field of OD describes a plannedprocess of change that is used throughout theorganization with the goal of improving theeffectiveness of the organization. Since, like OT, ODinvolves the entire organization, it is a macroexamination. Finally, HRM can be viewed as amicro approach to managing people. The differencebetween HRM and OB is that the latter studieshuman behavior in various settings with anemphasis on explaining, predicting, andunderstanding behavior in organizations, whereasHRM emphasizes systems, processes, procedures,and the like for personnel management and is

usually housed in a functional unit within anorganization.Since 1960, a wealth of information has emergedwithin the study of OB, which will be addressed inthis textbook. In Part I, the issues of diversity,perceptions, attitudes, and communication arediscussed. Part II addresses motivation andindividual behaviors. Part III examines the subject ofleadership from four approaches—power andinfluence, behavioral, contingency, andtransformational. Part IV emphasizes theimportance of intrapersonal and interpersonalissues within the context of stress and conflictmanagement. Part V examines group dynamics,working in groups, and teams and team-building.Part VI provides an overview of managingorganizational change within the context oforganizational development.

Discussion Questions 1. Define organizational behavior. 2. What are some of the major challengesfacing today’s and tomorrow’s health careorganizations and health care managers?Why? 3. Why did the Hawthorne Studies have animpact on the study of organizationalbehavior? 4. Why did McGregor’s Theory X and Theory Yhave an impact on the study of organizationalbehavior? 5. Discuss the difference betweenorganizational behavior, organization theory,organizational development, and humanresources management. 6. What Do You Know About OrganizationalBehavior?

What Do You Know AboutOrganizational Behavior?QuestionsTrue/False1.OB is the study of individuals, groups, andorganizations.___________2.Under Theory Y, managers createopportunities, remove obstacles, andencourage growth and learning for theiremployees.___________3.Attitudes are very individual and subjective;therefore, we do not currently have ways tomeasure employees’ attitudes about their jobs.___________4.Extroverts do best in quiet, nonsocial jobs suchas computer work, while introverts show thebest job performance when they must work andpresent in front of large groups of people.___________5.Motivation is described as the conscious orunconscious stimulus, incentive, or motives foraction toward a goal resulting frompsychological or social factors, the factorsgiving the purpose or direction to behavior.___________6.Employee motivation has a direct impact on ahealth services organization’s performance.___________7.Process theories of motivation assist managersin predicting employees’ behavior so that thebehavior may be influenced if necessary.___________

8.An employee’s degree of job satisfaction isproportional to the actual amount of rewardsthe employee is receiving.___________9.Power may be defined as the influence overthe beliefs, emotions, and behaviors of people.___________10.A leader is a person who directs the work ofemployees and is responsible for results.___________11.Management and leadership are bothnecessary for an organization to achieve itsgoals.___________12.The leader who is able to respond to ever-increasing levels of environmental uncertaintythrough the utilization of more than one style ofleadership will be most likely to increasemotivation, satisfaction, and productivity ofemployees.___________13.Transactional leadership is all about change,innovation, improvement, and entrepreneurshipthrough vision and inspiration.___________14.Transactional and transformational leaderapproaches are clearly in opposition.___________15.Because stress is a complex and highlypersonalized process, some individuals see aspecific situation as a threat, whereas otherssee the same situation as a challenge oropportunity.___________16.Managers are under the constraints of limitedtime and resources, personal bias, and otherfactors, which make rational decision makingunrealistic.___________

17.Conflict is inevitable and unavoidable.___________18.Individuals join groups to satisfy their need forsafety and social interaction.___________19.Barriers to effective teamwork fall within fourcategories: (1) lack of management support,(2) lack of resources, (3) lack of leadership,and (4) lack of training.___________20.The two primary forces influencing anindividual’s perception, attitude, and responsetoward change are cumulative life experiencesand social (informal group) forces.___________

ScoringThe correct answers to the above 20 questions are:1. False2. True3. False4. False5. True6. True7. True8. False9. True10. False11. True12. True13. True14. True15. True16. True17. True18. True19. True20. True

InterpretationHow much do you know about organizationalbehavior? If you scored well—good for you!However, the above questions represent only a verysmall part of organizational behavior. If you didn’tscore high, don’t be concerned. You will learn themany theories and concepts of organizationalbehavior that will provide you with the necessaryskill set to successfully manage 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. (2019).Employment projections to 2016–2026. Available fromhttps://www.bls.gov/emp/Daft, R. L. (2004). Organization theory and design (8th ed.).Mason, OH: Thomson South-Western.Health Care Financial Management Association. (2017, March 8).Mergers and acquisitions: Strategy takes precedence overscale. HFMA Buyer’s Resource Guide. Available fromwww.hfma.orgHomans, G. C. (1950). The human group. New York, NY:Harcourt, Brace and Company.McGregor, D. M. (1957). The human side of enterprise.Management Review, 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 (2nded.). Albany, NY: Wadsworth Publishing Company.Roethlisberger, F. J., & Dickson, W. J. (1939). Management andthe worker. Cambridge, MA: Harvard University Press.Taylor, F. W. (1911). The principles of scientific management.New York, NY: Harper and Brothers.

CHAPTER 2Diversity, Equity, andInclusion in HealthCare*LEARNING OUTCOMESAfter completing this chapter, the student shouldbe able to:Define diversity, equity, and inclusion.Understand major trends in U.Sdemographics.Understand why changes in U.S.demographics affect the health care industry.Understand the unique challenges facingdifferent groups of people. We would like to thank Dr. Justin Lord for his contribution to thischapter. We wish to acknowledge and thank Dr. Jean Gordon,who was the contributing author of an earlier version of this*

chapter, which appeared in Organizational Behavior in HealthCare (2014), Jones & Bartlett Learning.

▶ OverviewDemographics of the U.S. population have changeddramatically in the past three decades. Thesechanges directly affect the health care industry inregard to the patients we serve and our workforce.Over the next 40 years, there is expected to be afundamental shift in which demographic groupsrepresent majority and minority percentages of theU.S. population. According to the U.S. CensusBureau, by midcentury the White, non-Hispanicpopulation will make up less than 50% of thenation’s population. The health care industry needsto change and adopt new ways to meet the diverseneeds of our current and future patients andemployees.This chapter is presented in three parts. First, wedefine the terms “diversity,” “equity,” and “inclusion.”Second, we discuss the changing demographics ofthe nation’s population. Last, we examine how thesechanges are affecting the delivery of health servicesfrom both the patient’s and the employee’sperspectives. Because diversity challenges faced bythe health care industry are not limited to quality-of-care and access-to-care issues, in part three of ourdiscussions we explore how these changes will

affect the health services workforce and, morespecifically, the current and future leadership withinthe industry.

▶ Diversity, Equity, andInclusion DefinedThe American Heritage Dictionary of the EnglishLanguage (4th ed.) defines diversity as “(1) the factor quality of being diverse; difference, and (2) apoint in which things differ.” Dreachslin (1998)provides a more specific definition of diversity as“the full range of human similarities and differencesin group affiliation including gender, race/ethnicity,social class, role within an organization, age,religion, sexual orientation, physical ability, andother group identities” (p. 813). Therefore, diversitycan mean a great many things, from differences ineducation, language, and background to race andgender identity. For our discussions, we will focuson the following characteristics: (1) race/ethnicity,(2) age, (3) biological sex at birth, and (4) sexualorientation, gender identity, and gender expression.Equity is providing fair treatment, access,opportunity, and advancement for all people while atthe same time striving to identify and eliminatebarriers that have prevented the full participation ofsome groups. Improving equity involves increasingfairness of the procedures and processes within theorganization as well as in their distribution of

resources. Tackling equity issues requires anunderstanding of the root causes of outcomedisparities within our society and organizations(Kapila, Hines, & Searby, 2016).Inclusion refers to the act of creating environmentsin which any individual or group can feel welcomed,respected, and supported and can fully participate.An inclusive and welcoming climate embracesdifferences and offers respect in words and actionsto all people (Kapila et al., 2016). Inclusion allowspeople to have a sense of belonging.A diverse environment with many different types ofpeople might not be equitable or inclusive.Therefore, just increasing diversity is not enough.For example, if a manager does not offer the samementorship and coaching to employees fromunderrepresented populations and therefore theseemployees do not get the same opportunities forpromotion as nonminority employees do, that is notan equitable environment. An environment can bediverse and equitable but not inclusive. Forexample, maybe all employees have access to thesame coaching and career developmentopportunities, but the manager plans a celebratorylunch during an important Jewish religious holiday.This lunch would not be inclusive because Jewishemployees could not attend as a result of theirreligious obligations. One way to remember the

differences between diversity, equity, and inclusionis by thinking about going to a dance. Diversitymeans that everyone is invited to the dance. Equitymeans that each person gets to contribute to theplaylist. Inclusion means everyone gets asked todance (Meyers, 2017; University of Michigan,2018; see Case 2-1).CASE STUDY 2-1 Diverse butNot InclusiveJill, a young White female, was hired to workat a health care consulting firm. The team wasvery diverse, with people from all over theworld who had a variety of educations andbackgrounds. Jill’s coworkers had differentreligious and cultural beliefs, races,languages, and countries of origin. Jill felt thatshe connected well with all of her colleaguesand really appreciated the uniqueperspectives they all brought to the team.However, she started to notice that the seniorvice president, Mark, had a small group offavorites. The only people whom he wouldinvite to lunch or have coaching sessions withwere the younger White employees. In fact, asindividuals started to get promoted, the Whiteemployees were promoted much higher and

more quickly than anyone else. Althoughthese employees’ promotions were usuallydeserved, other employees seemed to have aharder time gaining promotion even if they hadperformed equally well. When Jill had been atthe company for almost a year, Markscheduled a team lunch at an expensiverestaurant to thank the entire team forsurpassing productivity targets. The lunch wasscheduled during Ramadan, which is animportant religious time for Muslims, andinvolves fasting during the day. Jill overheadone of her Muslim coworkers whispering toanother coworker, “Doesn’t he know howinsulting it is to invite us knowing that we can’teat anything? I mean if he had just waited onemore week to schedule the lunch, we could allenjoy it.” Jill thought that Mark might havebeen unaware of the poor timing, so shebrought it to his attention at their next one-on-one meeting. When Jill raised the issue, Markreplied, “Well, I’ve got to keep the numbersdown somehow if I want us to go somewhereexpensive. They are invited. It’s not myproblem if they choose not to eat.”Was this environment diverse, equitable, andinclusive? Why or why not?

Unfortunately, we all have implicit or unconsciousbiases that can affect how we treat people of certaingenders, gender identities, sexual orientations,races, ethnicities, and ages. Despite our bestintentions, these implicit biases are often unknowneven to ourselves, and they can lead us to create oraccept environments in which certain people aretreated poorly or are discriminated against. “Think ofimplicit bias as the thumbprint of the culture on ourbrain,” says Harvard University social psychologistMahzarin Banaji (Joplin & Kunitz, 2018). HarvardUniversity’s Project Implicit provides a series of freeonline implicit association tests to help peopledetermine what implicit biases they hold. Ananalysis of almost 8000 participants found thatpeople tend to demonstrate a moderate implicitpreference for Whites over Blacks and forheterosexuals over homosexuals and a strongimplicit preference for young over old people.People also have a stronger implicit association withmen and science than with women and science(Project Implicit, 2019; see Case 2-2). It is only byrecognizing our unconscious and implicit biases thatwe can hope to change them. Instead of denyingtheir existence—we all have them—we mustactively work to eliminate our own blind spots thatmight be leading us to treat certain types of peopledifferently.

CASE STUDY 2-2 You Don’tLook Like a DoctorTamika Cross, a young African Americanphysician who worked in Houston, was flyinghome from a wedding in Detroit. When theflight attendants asked for any physicians onboard to help a passenger who had becomeunresponsive, Dr. Cross raised her hand andoffered to help. The flight attendantresponded, “Sweetie, put [your] hand down.We are looking for actual physicians or nursesor some type of medical personnel, we don’thave time to talk to you.”When Dr. Cross tried to inform the flightattendant that she was a physician, she wasrepeatedly dismissed and asked to showcredentials. When she insisted that she was adoctor, the flight attendants responded withsurprise and disbelief. The crew continued toask any physicians on board to press their callbuttons. A few moments later, a white malephysician told the flight attendant that he wasa physician, and Dr. Cross was sent back toher seat.Dr. Cross posted the account to her Facebookpage, which then went viral on a number of

social media sites and news outlets, sparkingthe #WhataDoctorLooksLike movement.What implicit biases do you think the flightattendant held about what a physician shouldlook like?Reproduced fromhttps://www.washingtonpost.com/national/health-science/tamika-cross-is-not-the-only-black-doctor-ignored-in-an-airplane-emergency/2016/10/20/3f59ac08-9544-11e6-bc79-af1cd3d2984b_story.html accessed September 2, 2019.

▶ Changing U.S. PopulationTo better appreciate the need for more diverse,equitable, and inclusive environments, it is importantto understand how our population is changing. Thedemographic profile of the U.S. population isprojected to undergo significant alterations over thenext 40 years in age, gender, and ethnicity (seeTable 2-1).Table 2-1 Projected Population of the United States byAge, Gender, and Race/Ethnicity (in Millions)a

In 2016, 323.1 million people resided in the UnitedStates, an increase of 41.7 million people, or 14.8%,between 2000 and 2016. The 2016 census datashowed a decline in the White, non-Hispanicpopulation for the first time in history since the firstcensus in 1790. This decline was almost a decadeahead of earlier projections. Additionally, there arecurrently more non-White children than Whitechildren under 10 years old for those born after2007 (Frey, 2018). This means that as the youngestgeneration ages, we are on the verge of afundamental shift in the diversity of both patientsand workers in the United States. In addition to thechanging ethnic and racial composition of America,another trend is the aging population. Thepercentage of the population over age 65 isprojected to increase from 15% to 23% by the year2060, an increase of 45.5 million people (see Table2-1). Finally, by the year 2030, internationalmigration is projected to outpace the naturalincrease (excess of births over deaths) as the maincause of population growth (Vespa, Armstrong, &Medina, 2018).Males and females are almost evenly divided in thetotal population, representing 49.2% and 50.8%,respectively (see Table 2-1); however, in thepopulation under age 25 years, males outnumberfemales. Among older adults, the male–female ratio

reverses, with women outnumbering men, typicallydue to longer life spans (Vespa, Armstrong, &Medina, 2018). This imbalance is expected topersist through 2060 and beyond. However, the gapbetween males and females over age 65 isnarrowing as men are living longer than men inprevious generations.Race/EthnicityThe U.S. population continues to diversify racially asminority populations continue to increase at a fasterrate than the White population. Although the non-Hispanic White population still represents thelargest group (61.3%) of the U.S. population, thisnumber is expected to decrease by almost 10% by2060 (see Table 2-1).In 2016, the Hispanic or Latino populationrepresented the largest minority in the UnitedStates, at almost 18% of the population. By 2060,Hispanics are expected to make up over a quarterof the U.S. population (27.5%), almost doubling innumber. The remaining population is composed of13% Black or African American, 6% Asian andPacific Islanders, 1% American Indians and AlaskaNatives, and 3% people who identify themselves asbelonging to another or more than one race (seeTable 2-1).

The Asian population in the United States isincreasing rapidly as a percentage of the totalpopulation. From 2000 to 2010, the population ofpeople who identified themselves as being Asian(either alone or in combination with another race)grew 43.3%, while the total population grew only9.7% (U.S. Census Bureau, 2010). After peopleidentifying as more than one race, the Asianpopulation is expected to be the fastest-growingsegment, doubling in size by 2060 (see Table 2-1).In addition to the resident population in the UnitedStates, health care organizations may encounter aneven more diverse patient population, due to thestrong reputation of U.S. health care and itspopularity as a destination for medical travel andmedical tourism. The United States is a highlydesirable destination for health care for peoplearound the world who might not be able to accessvarious types of procedures or treatments in theirhome countries. Hundreds of thousands of visitsfrom international patients from almost everycountry occur at U.S. hospitals every year(Johnson & Garman, 2010). As the middle classexpands in countries such as China and India, thistrend is expected to continue as more patientsaround the world are able to afford to travel fortreatment. This means that health care workers willneed additional skills and tools for dealing with a

vastly more diverse population of patients comingfrom other countries in addition to the growingdiversity in the domestic population.Unfortunately, people from underrepresented racialand ethnic groups often face additional challengeswhen they interact with the U.S. health care system.A survey by the Commonwealth Fund (2002) foundthat Black non-Hispanics, Asian Americans, andHispanics are more likely than White non-Hispanicsto experience difficulty communicating with theirphysician, to feel that they are treated withdisrespect when receiving health care, toexperience barriers to access to care such as lackof insurance or not having a regular physician, andto feel that they would receive better care if theywere of a different race or ethnicity. In addition, thesurvey found that Hispanics were more than twiceas likely as White non-Hispanics (33% versus 16%)to cite one or more communication problems, suchas not understanding the physician, not beinglistened to by the physician, or not asking questionsthey needed to ask. Twenty-seven percent of AsianAmericans and 23% of Black non-Hispanicsexperience similar communication difficulties.AgeThe world’s population is aging at unprecedentedrates. Slow population growth brought about by

reductions in fertility leads to population aging; thatis, it produces populations in which the proportion ofolder persons increases while that of youngerpersons decreases. For the first time in history, in2018 the number of people over age 65 in the worldoutnumbered the number of children under age 5.By 2050, the number of people over age 65 isprojected to be double the number of people underage 5 (United Nations, 2019).The United States is experiencing the same trend.Between 2016 and 2060, the U.S. population underage 18 is expected to grow by 8%, and thepopulation aged 45–64 is expected to grow byalmost 15%. In stark contrast, the country isexperiencing substantially faster growth rates forolder ages. For example, the population over age 65is expected to almost double (U.S. Census Bureau,2018, see Table 2-1). The large growth in this agegroup is primarily attributable to the aging of theBaby Boom population and longer life spans due todisease control and advances in medicaltechnology.One of the most striking characteristics of the olderpopulation is the change in the ratio of men towomen as people age. As Howden and Meyer(2011, p. 3) point out, this is a result of differencesin mortality rates for men and women, in thatwomen tend to live longer than men. For example,

life expectancy for men in the United States is 76.1years, whereas women’s life expectancy is 81.1years.While the elderly population is not as racially andethnically diverse as younger generations, its racialand ethnical makeup is projected to diversify overthe next four decades. As in the past, the largestproportion of the U.S. population age 65 and over isWhite. However, the racial composition of the olderpopulation is changing; the percentage of Whites isprojected to decrease by 2060, and the percentagesof all other race groups will increase (Vespa et al.,2018).Technology and other medical advances have givenus the ability to increase longevity. As our citizensgrow older, more services are required for thetreatment and management of both acute andchronic health conditions. Health care professionalsmust devise strategies to care for the growingelderly patient population. America’s older citizensare often living on fixed incomes and have small ornonexistent support groups. Although this may beconsidered an infrastructure dilemma, the reality isthat medical professionals must be able tounderstand and empathize with poor, sick, elderlypeople of all races, sexes, and creeds.

The term “ageism” was coined in 1968 by Robert N.Butler, MD, a pioneer in geriatric medicine and afounding director of the National Institute on Aging(NIA). Butler (1969) was among the first to identifythe phenomenon of age prejudice, initiallydescribing it as “a systematic stereotyping of anddiscrimination against people because they are old”(p. 12).Ageism can be defined as “any attitude, action, orinstitutional structure, which subordinates a personor group because of age or any assignment of rolesin society purely on the basis of age” (Traxler,1980, p. 4). Health care professionals often makeassumptions about their older patients on the basisof age rather than functional status (Bowling,2007). This may be due to the limited trainingphysicians receive in the care and management ofgeriatric patients. For example, Warshaw andcolleagues (2002, 2006) related that medicalresidents have only limited training in geriatricmedicine. Findings from Warshaw et al.’s 2006study were compared with those from a similar 2002survey to determine whether any changes hadoccurred. Of the participating 3-year residencytraining programs, only 9% required 6 weeks ormore of training. As in 2002, the residencyprograms continue to depend on nursing homefacilities, geriatric preceptors in nongeriatric clinical

ambulatory settings, and outpatient geriatricassessment centers for the medical residents’geriatrics training. A report from the Alliance forAging Research (2003) related that there continuesto be shortcomings in medical training, prevention,screening, and treatment patterns that disadvantageolder patients. The report outlined five domains ofageism in health care:1. Health care professionals do not receiveenough training in geriatrics to properly carefor many older patients.2. Older patients are less likely than youngerpeople to receive preventive care.3. Older patients are less likely to be tested orscreened for diseases and other healthproblems.4. Proven medical interventions for olderpatients are often ignored, leading toinappropriate or incomplete treatment.5. Older people are consistently excluded fromclinical trials, even though they are thelargest users of approved drugs.On a positive note, Perry (2012) relates thatprogress against systematic ageism in health carehas begun, in part, as a result of the passing of the2010 Affordable Care Act (ACA). He notes that thelaw’s various provisions, such as Medicare’s

increased focus on chronic disease prevention, newmodels of care for reducing rehospitalizations, andimproved care coordination, as well as annualscreening for cognitive impairment, will assist inchanging attitudes toward elderly patients.GenderAs was previously noted, according to the U.S.Census Bureau, in 2016, 50.8% of the U.S.population was female and 49.2% was male—almost identical to percentages in the 2000 Census.That translates to 96 men for every 100 women.However, the ratio of men to women variessignificantly by age group. There were about 105males for every 100 females under age 25 in 2010(U.S. Census Bureau, 2010), reflecting the fact thatmore boys than girls are born every year and thatboys continue to outnumber girls through earlychildhood and young adulthood. However, themale–female ratio declines as people age. Amongolder adults, the male–female ratio falls as womenincreasingly outnumber and outlive men. When welook at education, it appears that females and malesare somewhat equal. Among the population age 25and older, 90% of both men and women were highschool graduates, with 34% of men and 35% ofwomen graduating from college (U.S. CensusBureau, 2017).

Sexual Orientation, Gender Identity,and Gender ExpressionAnother important aspect of diversity to consider inhealth care is sexual orientation, gender identity,and gender expression. The last decade has led toan increased focus on disparities that exist in thelesbian, gay, bisexual, transgender, and questioningcommunity (LGBTQ). Various surveys estimate thatpeople over age 18 who identify as LGBT make up2.8%–4.1% of the total population, or 5–10 millionindividuals in the United States, according to aKaiser Family Foundation Report (Kates, Ranji,Beamesderfer, Salganicoff, & Dawson, 2018).The term “LGBTQ” may encompass elements ofsexual orientation, gender identity, and genderexpression. Sexual orientation is defined by theInstitute of Medicine report as “an enduring patternof or disposition to experience sexual or romanticdesires for, and relationships with, people of one’ssame sex, the other sex, or both sexes” (Graham etal., 2011, p. 27). For many people, sexualorientation does not fall neatly into any specificcategory and may be better described as belongingsomewhere along a spectrum. Gender identityrefers to one’s internal sense of being male, female,or something else (Kates et al., 2018). Becausegender identity is internal, it is not necessarily visibleto others. Gender expression refers to the outward

and external portrayal of gender. Gender expressionmay include clothing, hairstyles, mannerisms, andtaking on gender roles that are defined by one’sculture. Both gender identity and gender expressionmay be different from one’s biological sex at birth.These aspects of identity and orientation can spanall ages, races, and biological genders. According tothe Kaiser Family Foundation report, “while sexualorientation and gender identity are importantaspects of an individual’s identity, they interact withmany other factors, including sex, race/ethnicity,and class. The intersection of these characteristicshelps to shape an individual’s health, access tocare, and experience with the health care system”(Kates et al., 2018, p. 2).Individuals who identify as LGBTQ may experienceunique health challenges that cannot be explainedby differences in race/ethnicity, age, or genderalone. Because of discrimination and a variety ofother factors, research has shown that self-identifiedlesbian, gay, and bisexual individuals are morelikely to rate their health as poor and have higherprevalence of many chronic diseases such ascancer and cardiovascular disease, as well asasthma, allergies, headaches, and disabilities. Inaddition to concerns about physical health, studieshave found that people who identify as LGBT are ata higher risk for mental health conditions, often as a

result of prejudice, discrimination, and stigma.Various studies show that LBGT individuals are 2.5times more likely to suffer anxiety, depression, andsubstance misuse; are more likely to haveexperienced both sexual and physical violence; andhave a substantially higher rate of suicidal ideationor attempts. In addition to stigma and discrimination,LGBTQ individuals may face additional healthdisparities resulting from practices that pose barriersto accessing health services. For example, someinsurance companies will not pay for mental healthservices for transgender individuals. Additionally,between 6% and 15% of employers reported notoffering same-sex spousal benefits to workers.Although these numbers are improving, there is stilla substantial disparity in this area (Kates et al.,2018).However, there has been some progress in thisarea. Since 2007, the Healthcare Equality Index(HEI) of the Human Rights Campaign (HRC)Foundation has been available for use by hospitalsand other organizations. This survey is a resourcefor health care organizations that are seeking toprovide equitable, inclusive care to LGBTQAmericans and for LGBTQ Americans who areseeking health care organizations that have ademonstrated commitment to their care (HRC,2019). In 2018, 680 facilities across the country

participated in the HEI survey, with 60% designatedas leaders and 22% as top performersdemonstrating that they have varying inclusiveLGBT patient and employment policies. Thesenondiscrimination policies are required for JointCommission accreditation. In addition, both TheJoint Commission and the Centers for Medicare andMedicaid Services require that facilities allowvisitation without regard to sexual orientation orgender identity. The HEI has two sections: (1) thecore four leader criteria and (2) the additional bestpractices checklist. The core four leader criteria arereflected in Table 2-2. Additionally, patient formsshould reflect diverse gender identities, allowingpatients to identify both their biological sex at birthand their gender identity. The additional bestpractices checklist is designed to familiarize HEIparticipants with other expert recommendations forLGBT patient-centered care, to help identify andremedy gaps.Table 2-2 Healthcare Equality Index’s Core Four LeaderCriteriaCriteriaNon-discrimination andstaff trainingPatient non-discriminationEqual visitationEmployment non-discriminationStaff training

Patient services andsupportLGBTQ patient services & supportTransgender services and supportPatient self-identificationMedical decision makingEmployee benefits andpoliciesEqual benefitsAdditional support for LGBTQ employeesHealthcare benefits impactingtransgender EmployeesPatient and communityengagementLGBTQ community engagement andmarketingUnderstand the needs of LGBTQpatients and community© 2019 by the Human Rights Campaign Foundation.

▶ Implications for the HealthCare IndustryThe changing demographics of the U.S. populationaffect the healthcare industry significantly. Healthcare organizations need to work to reducedisparities in care and treatment provided tounderrepresented populations as well as ensuringthat our health care systems are diverse, equitable,and inclusive places for both patients andemployees.Consider the following:Scenario One: An insulin-dependent, indigent blacknon-Hispanic male was treated at a predominantlyHispanic border clinic. Later, he was brought back tothe clinic in a diabetic coma. When he awoke, thenurse who had counseled him asked whether he hadbeen following her instructions. “Exactly!” he replied.When the nurse asked him to show her, themonolingual Spanish-speaking nurse was startledwhen the patient proceeded to inject an orange andeat it.Scenario Two: As Maria (an elderly, monolingualHispanic female) was being prepared for surgery,which was not why she had come to the hospital, herdesignated interpreter (a young female relative) was

told by an English-speaking nurse to tell Maria that thesurgeon was the best in his field and Maria would getthrough this fine. The young interpreter told Maria,“The nurse says the doctor does best when he’s in thefield, and when it’s over you’ll have to pay a fine!”At first glance, these might seem rather humorousmisunderstandings, but there is nothing funny abouta diabetic coma or the possibility of undergoingunneeded surgery, and real-life experiences suchas these happen every day in the United States(Howard, Andrade, & Byrd, 2001). Culturaldifferences between providers and patients affectthe provider–patient relationship. For example,Fadiman (1998) related a true and poignant story ofcultural misunderstanding within the health careprofession. Fadiman described the story of a youngfemale epileptic Hmong immigrant whose parentsbelieved that their daughter’s condition was causedby spirits called “dabs,” which had caught theirdaughter and made her fall down, hence the nameof Fadiman’s book The Spirit Catches You and YouFall Down. The patient’s parents struggled tounderstand the prescribed medical care, whichrecognized only the scientific necessities butignored the family’s personal beliefs about thespirituality of one’s soul in relationship to theuniverse. From a unique perspective, Fadimanexamined the roles of the caregivers (physicians,

nurses, and social workers) in the treatment of illchildren. She studied the way in which the medicalcare system responded to its own perceptions thatthe family was refusing to comply with medicalorders without understanding the meaning of thoseorders in the context of the Hmong culture,language, and beliefs. Health and health caredisparities in the United States have beendocumented for many decades (see Exhibit 2-1).Kaiser Family Foundation and the Institute ofMedicine both note that although manyimprovements in population health have occurred,numerous disparities have persisted and, in somecases, widened across many dimensions, includingrace/ethnicity, socioeconomic status, age, location,gender, disability status, and sexual orientation(Orgera & Artiga, 2018; Weinstein, Geller,Negussie, & Baciu, 2017). As noted by Orgera andArtiga (2018), there is a complex and interrelatedset of not only individual and provider factors, butalso a broad array of social and environmentalfactors both inside and outside of the health caresystem that affect individuals’ health and ability toengage in healthy behaviors, such as economicstatus, neighborhood/physical environment,educational levels, and access to healthy food.Exhibit 2-1 Unequal Treatment

A 2002 study by the Institute of Medicine titledUnequal Treatment: Confronting Racial andEthnic Disparities in Health Care found that aconsistent body of research demonstratessignificant variation in the rates of medicalprocedures by race even when insurancestatus, income, age, and severity of conditionsare comparable. This research indicated that inthe United States, members ofunderrepresented racial and ethnic groupsreceive fewer routine medical procedures andexperience a lower quality of health servicesthan the majority of the population. Forexample, members of minorities are less likelyto be given appropriate cardiac medications orto undergo bypass surgery and are less likelyto receive kidney dialysis or transplants. Bycontrast, they are more likely to be subjected tocertain less desirable procedures, such aslower-limb amputations for diabetes. Thestudy’s recommendations for reducing racialand ethnic disparities in health care includedincreasing awareness about disparities amongthe general public, health care providers,insurance companies, and policy makers.Modified from Unequal treatment: Confronting racial and ethnicdisparities in health care (p. 3), by B. D. Smedley, A. Y. Stitch, and A.

R. Nelson (Eds.), 2002, Washington, DC: National Academy ofSciences, Institute of Medicine Committee on Understanding andEliminating Racial and Ethnic Disparities in Health Care.

▶ SummaryHealth care organizations need to buildenvironments that are diverse, equitable, andinclusive for the well-being of their patients andemployees. The slower growth of the youngerpopulation of the United States will have a directeffect on the health care industry’s ability to recruitprofessionals to provide sufficient services in thefuture for a large elderly population. Young peopleof all races, ethnicities, and genders must beattracted to the health care industry as a careerchoice to meet the health care needs of thecountry’s growing, aging, and increasingly diversepopulation.

Discussion Questions 1. Discuss what the terms “diversity,” “equity,”and “inclusion” mean. 2. Explain why and how changes in U.S.demographics affect the health care industry. 3. What are the differences between diversity,equity, and inclusion? 4. Describe a situation that is diverse but notequitable or inclusive. 5. Describe a situation that is diverse andequitable but not inclusive.

Exercise 2-1In 2012, the Alliance of Aging Research establishedthe Healthspan Campaign, a coalition oforganizations committed to solving the challengesbrought about by the aging of the Americanpopulation. With each passing year, the percentageof people in the United States—and much of theworld—over age 65 increases. This “SilverTsunami” is expected to bring a flood of chronicdisease and disabilities due to aging that couldoverwhelm the health care systems of manynations. Watch the films The Healthspan Imperativeand What Is the Silver Tsunami? atwww.healthspancampaign.org. Discuss the effectof the aging population on our health system, andpresent recommendations for how these challengescould be addressed.

Exercise 2-2In December 2012, the American College ofHealthcare Executives released its fifth report in aseries of research surveys designed to compare thecareer attainments of male and female health careexecutives. View this report, titled A Comparison ofthe Career Attainments of Men and WomenHealthcare Executives: 2012, at www.ache.org. Insmall groups, discuss the changes (if any) regardingwomen advancing to senior leadership positionsthat have occurred in the health care industry sincethe previous report in 2006.

Exercise 2-3In 2019, Modern Healthcare published its biennialrecognition of the Top 25 Women in Healthcare.The previous lists appeared in 2017 and 2015 andcan be found by searching for the list on the websitemodernhealthcare.com. In small groups, discussthe changes (if any) over the past 9 years of theselected awardee population (i.e., employment inwhat sectors of the health industry, the positionsthey do or did hold, race/ethnicity groups, and soon).

ReferencesAlliance for Aging Research. (2003). Ageism: How healthcare failsthe elderly. Available from www.agingresearch.orgBowling, A. (2007). Honour your father and mother: Ageism inmedicine. British Journal of General Practice, 57(538), 347–348.Butler, R. (1969). Ageism: Another form of bigotry. TheGerontologist, 9, 243–246.Commonwealth Fund. (2002). International health policy survey ofadults with health problems. Available from www.cmwf.orgDreachslin, J. L. (1998). Conducting effective focus groups in thecontext of diversity: Theoretical underpinnings and practicalimplications. Qualitative Health Research, 8(6), 813–820.Fadiman, A. (1998). The spirit catches you and you fall down.New York, NY: Farrar, Straus and Giroux.Frey, W. (2018). US white population declines and Generation ‘Z-Plus’ is minority white, census shows. Brookings Institution.Available from https://www.brookings.edu/blog/the-avenue/2018/06/21/us-white-population-declines-and-generation-z-plus-is-minority-white-census-shows/Graham, R., Berkowitz, B., Blum, R., Bockting, W., Bradford, J.,de Vries, B. … Makadon, H. (2011). The health of lesbian,gay, bisexual, and transgender people: Building a foundationfor better understanding. Washington, DC: Institute ofMedicine.

Howard, C., Andrade, S. J., & Byrd, T. (2001). The ethicaldimensions of cultural competence in border healthcaresettings. Family and Community Health, 23(4), 36–49.Howden, L. M., & Meyer, J. A. (2011). Age and sex composition:2010. U.S. Department of Commerce, Economics andStatistics Administration, U.S. Census Bureau, Washington,DC.Human Rights Campaign. (2019). Healthcare equality index.Available from https://www.hrc.org/hei/about-the-heiJohnson, T. J., & Garman, A. N. (2010). Impact of medical travelon imports and exports of medical services. Health Policy,98(2–3), 171–177.Joplin, A., & Kunitz, D. (2018). Can you change implicit bias?Washington Post. Available fromhttps://www.washingtonpost.com/video/national/can-you-change-implicit-bias/2018/05/29/e1d28542-604d-11e8-b656-236c6214ef01_video.htmlKapila, M., Hines, E., & Searby, M., (2016, October 16). Whydiversity, equity, and inclusion matter. Retrieved fromhttps://independentsector.org/resource/why-diversity-equity-and-inclusion-matter/Kates, J. Ranji, U., Beamesderfer, A., Salganicoff, A., & Dawson,L. (2018). Health and access to care and coverage for lesbian,gay, bisexual, and transgender (LGBT) individuals in the U.S.Kaiser Family Foundation. Retrieved fromhttps://www.kff.org/disparities-policy/issue-brief/health-and-access-to-care-and-coverage-for-lesbian-gay-bisexual-and-transgender-individuals-in-the-u-s/

Meyers, V. (2017). The Verna Meyers company. Available fromhttps://learning.vernamyers.com/pages/about-vern-myersOrgera, K., & Artiga, S. (2018). Disparities in health and healthcare: five key questions and answers. Kaiser FamilyFoundation. Available from https://www.kff.org/disparities-policy/issue-brief/disparities-in-health-and-health-care-five-key-questions-and-answers/Perry, D. (2012). Entrenched ageism in healthcare isolates,ignores and imperils elders. Aging Today, 33(2), 1.Project Implicit. (2019). Explore the data: Implicit association test.Available from https://pi-liz.shinyapps.io/explore-iat/Traxler, A. J. (1980). Let’s get gerontologized: Developing asensitivity to aging. The multi-purpose senior center concept:A training manual for practitioners working with the aging.Springfield, IL: Illinois Department of Aging.United Nations, Department of Economic and Social Affairs,Population Division. (2019). World population prospects 2019:Highlights (ST/ESA/SER.A/423). Available fromhttps://population.un.org/wpp/Publications/Files/WPP2019_Highlights.pdfUniversity of Michigan. (2018). Defining DEI. Diversity, equity andinclusion. Available fromhttps://diversity.umich.edu/about/defining-dei/U.S. Census Bureau. (2010). DP-1 – United States: Profile ofGeneral Population and Housing Characteristics: 2010Demographic Profile Data: U.S. Census Bureau 2000 CensusData as shown I the 2009 Population Estimates table: U.S.Census Bureau: National Population Estimates; DecennialCensus.

U.S. Census Bureau. (2017). Educational Attainment in the UnitedStates: 2017. 2017 National population projections tables.Available fromhttps://www.census.gov/data/tables/2017/demo/education-attainment/cps-detailed-tables.htmlU.S. Census Bureau. (2018). 2017 National population projectionstables. Available fromwww.census.gov/data/tables/2017/demo/popproj/2017-summary-tables.htmlVespa, J., Armstrong, D. M., & Medina, L. (2018). Demographicturning points for the United States: Population projections for2020 to 2060 (Current Population Reports, P25-1144). U.S.Census Bureau, Washington, DC.Warshaw, G. A. (2002). Academic geriatrics programs in USallopathic and osteopathic medical schools. Journal of theAmerican Medical Association, 288, 2313–2319.Warshaw, G. A., Bragg, E. J., Thomas, D. C., Ho, M. L., &Brewer, D. E. (2006). Are internal medicine residencyprograms adequately preparing physicians to care for theBaby Boomers? A national survey from the Association ofDirectors of Geriatric Academic Programs Status of GeriatricsWorkforce Study. Journal of the American Geriatrics Society,54(1), 1603–1609.Weinstein, J. N., Geller, A., Negussie, Y., & Baciu, A. (2017).Communities in action: Pathways to health equity.Washington, DC: National Academies Press.

Other Suggested ReadingsInstitute of Medicine. (2004). In the nation’s compelling interest:Ensuring diversity in the healthcare workforce. Available fromhttp://www.nap.edu/catalog/10885.htmlLantz, P. (2008). Gender and leadership in healthcareadministration: 21st century progress and challenges. Journalof Healthcare Management, 53(5), 291–304.Information relating to Anne Fadiman’s book The Spirit CatchesYou and You Fall Down may be viewed atwww.spiritcatchesyou.com

CHAPTER 3Diversity Managementand CulturalCompetency in HealthCareLEARNING OUTCOMESAfter completing this chapter, the student shouldbe able to:Define diversity management.Define cultural competency.Understand the importance of a culturallycompetent workforce in meeting the needs ofpatients.The population of the United States is changingrapidly and is becoming increasingly diverse. Inresponse to the growing diversity of the generalpopulation, health care organizations must be

prepared to handle the unique needs of a changingpopulation in two key ways. First, organizationsmust ensure that diversity management programsare in place to provide an environment wherepeople of all demographic types have theopportunity to succeed within the organization andto feel a sense of belonging. Second, health careorganizations must ensure that their workforce isequipped to handle the needs of an increasinglydiverse patient population by developing culturalcompetency. Diversity management strategies andcultural competency are the focus of this chapter.Health care organizations need to be flexible tochange and meet diversity challenges. The greatestbarrier to the industry’s success may be its inabilityto understand and appreciate the increasingdiversity within our population, whether relating topatients or employees. As Kochan and colleagues(2003, p. 18) related,Diversity is a reality in labor markets and “customer”markets today. To be successful in working with andgaining value from this diversity requires a sustained,systemic approach and long-term commitment.Success is facilitated by a perspective that considersdiversity to be an opportunity for everyone in anorganization to learn from each other how better toaccomplish their work and an occasion that requires asupportive and cooperative organizational culture as

well as group leadership and process skills that canfacilitate effective group functioning. Organizations thatinvest their resources in taking advantage of theopportunities that diversity offers should outperformthose that fail to make such investments.

▶ Diversity ManagementDiversity management is a challenge for allorganizations. Diversity management is “astrategically driven process whose emphasis is onbuilding skills and creating policies that will addressthe changing demographics of the workforce andpatient population” (Svehla, 1994; Weech-Maldonado, Dreachslin, Dansky, DeSouza, &Gatto, 2002). In 2004, the National Urban Leaguepublished its first study on employees’ perceptionsof the effectiveness of their companies’ diversityprograms. The results of the organization’s 2009follow-up survey showed progress in certain areas.However, leadership commitment to diversity andcompanies clearly communicating their platform onhow they value diversity are still lagging (see Figure3-1).

Figure 3-1 American Workers’ PerceptionsData from National Urban League. (2009). Diversity practices thatwork: The American worker speaks II.As reflected in Figure 3-1, organizations haveimproved in communicating effectively regardingtheir diversity platforms but need to focus on their(1) commitment to, (2) accountability for, (3) actionon, and (4) measurement of these initiatives. The

good news is the notable increases reflecting theintrinsic acceptance of diversity and inclusion byU.S. workers. As the National Urban League (2009)reported, the playing field appears more level,diverse talent is being developed and retained, andcustomer/consumer diversity is being recognized.While some gains have been made in increasingdiversity in the field of health care management,recent studies suggest that there is still ample roomfor improvement. The Institute for Diversity in HealthManagement, an affiliate of the American HospitalAssociation, was formed in 1994 to address theproblem, disclosed in a 1992 study, that minoritiesheld fewer than 1% of top management positions inthe industry. In addition, the study revealed thatAfrican American health care executives made lessmoney, held lower positions, and had less jobsatisfaction than their White counterparts. A 1997follow-up study, expanded to include Latinos andAsians, found that although the gap had narrowed insome areas, not much had changed. As examples,a study by Motwani, Hodge, and Crampton (1995)found that only 27.7% of health care workers in sixMidwestern hospitals thought that their institutionshad a program to improve employee skills in dealingwith people of different cultures, and only 38.9%thought 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 in employing diversitymanagement practices and that equal employmentrequirements were the main driver of diversitymanagement policy. Five years later, Weech-Maldonado and colleagues (Weech-Maldonado etal., 2007; Weech-Maldonado, Elliott, Schiller,Hall, & Hays, 2007) continued to find low levels ofdiversity management activity in California hospitals.Since that time, the Institute for Diversity in HealthManagement, in collaboration with otherorganizations, has designed several initiatives toexpand health care leadership opportunities forethnically, culturally, and racially diverse individuals,thus increasing the number of these individualsentering and advancing in the field.

▶ The Future WorkforceFor the first time in modern history, the U.S.workforce consists of four separate generationsworking side by side, and the differences amonggenerations are one of the greatest challengesfacing managers today (Wasserman, 2007). BonnieClipper (2012, p. 45), author of The NurseManager’s Guide to an Intergenerational Workforce,provides a humorous example for understanding thegenerations’ differences.A nurse manager desperate for more staff, telephonesfour nurses to ask whether they will pull an extra shift:The first nurse says, “What time do you needme?”The second nurse says, “Call me back if youcan’t find anyone else.”The third nurse says, “How much will you payme?”The fourth nurse says, “Sorry, I have plans.Maybe next time.”Stokowski, L. A. (2013). The 4-generation gap innursing. Medscape. Available fromwww.medscape.com/viewarticle/781752.

These different responses are typical of the fourgenerations of nurses currently working side by sideat the bedside. The first response is from thetraditionalist generational cohort. This generation,born between 1925 and 1942, is typicallycharacterized as dedicated, hardworking, and loyal.The second response is from the Baby Boomergeneration. Born between 1943 and 1960, BabyBoomers are viewed as optimistic, productive, andworkaholics. The third response is from GenerationX; this generation, born between 1961 and 1981, istypically referred to as cynical, independent, andinformal. The fourth response is reflective of theMillennial generational cohort, born between 1982and 2000. Millennials are viewed as confident,inpatient, and social. Becton, Walker, and Jones-Farmer (2014) point out that although much hasbeen written about their differences, there remains agap in our understanding of each generationalcohort’s values and beliefs. Therefore, generationaldifferences may best be explained by “age, lifestage, or career stage effects” (Becton et al., 2014,p. 176).As part of diversity management, health caremanagers need to devise strategies for attractingyounger workers to the health care field whilemaintaining positive relationships with olderworkers. For example, Barney (2002, p. 83) points

out that Generation X workers want “managers wholisten, consider their ideas, and treat them as peers.They want to be part of the decision-making processand want flexibility in their work environmentbecause they value their time and freedom.”What about the Millennials, sometimes referred toas Generation Y? Millennials make up the largestportion of today’s workforce, comprising 35% of theU.S. labor force (Fry, 2018). Although it isimpossible to generalize about the wants and needsof the millions of people in each generation,workplace experts tend to use the followingcharacteristics to describe Millennials (Martin &Tulgan, 2006):High expectations of self: They aim to workfaster and better than other workers.High expectations of employers: They want fairand direct managers who are highly engaged intheir professional development.Ongoing learning: They seek out creativechallenges and view colleagues as vastresources from whom to gain knowledge.Immediate responsibility: They want to make animportant impact on day one.Goal oriented: They want small goals with tightdeadlines so that they can build ownership oftasks.

Health care managers must also consider the needsof older workers. For example, in a Robert WoodJohnson Foundation study, Hatcher and colleagues(2006) suggested that hospitals that want to recruitand retain older nurses need to implement certainstrategies, such as flexible work hours, increasedbenefits, newly created professional roles, and anatmosphere of respect for nurses.Generational diversity poses challenges for today’sand tomorrow’s employers. Younger workers have astrong need for immediate feedback, workers now intheir 30s and 40s demand greater work–life balanceand flexibility, and older workers expect increasedbenefits and professionalism. With amultigenerational workforce, employers will need todevelop age-diversity training programs for theirmanagers so they can better understand the needsand expectations of each generation (Martin &Tulgan, 2006).

▶ Diversity in Health CareLeadershipThe American College of Healthcare Executives(ACHE), the National Association of Health ServicesExecutives (NAHSE), the Institute for Diversity inHealthcare Management (IFD), the National Forumfor Latino Healthcare Executives, and the AsianHealth Care Leaders Association released a studyin 2015 that measured the representation of Blacknon-Hispanics, Hispanics, women, and otherminorities in health care executive leadership roles.This study was a follow-up to similar studies thatwere completed in 1992, 1997, 2002, and 2008. Thestudy, completed in 2014, was based on a random-sample survey of 1409 health care executives.Respondents worked in a variety of settings:hospitals, health care provider organizations,government health agencies, and consulting andeducational institutes (see Table 3-1).Table 3-1 American College of Healthcare Executives 2014Diversity Study

Although there have been improvements since theinitial 1992 survey, the health care industry did notdo as well in promoting minorities and women tochief executive officer (CEO) and chief operatingofficer (COO)/senior vice president positions. In the2014 ACHE study, reflected in Table 3-1, 32% ofWhite men are CEOs, compared to 25% of Hispanicmen, 20% of Black men, and 9% of Asian men.These disparities are not as apparent among

women; roughly 8%–15% of women in each racehold CEO positions. Additionally, in 2014, membersof minorities still reported the effects ofdiscrimination in the workplace. Between 15% and29% of minority respondents believed that they hadnot been hired for a position because of their race orethnicity compared to 2% of White respondents.In the 2015 Benchmarking Survey by the Institute ofDiversity and Health Equity, the results highlightedthat although there was some limited increase in thediversity of hospitals’ leadership and governance,more positive movement is needed. The studyreported that minorities composed:14% of hospital board members (unchangedfrom 2013).11% of executive leadership positions(decrease from 12% in 2013).19% of first- and middle-level managementpositions (up from 15% in 2011).Dreachslin and Curtis (2004) noted that careeradvancement of women and racially and ethnicallydiverse individuals in health care management wascharacterized by (1) underrepresentation, especiallyin senior-level management positions; (2) lowercompensation, even controlling for education andexperience; and (3) more negative perceptions ofequity and opportunity in the workplace. The

researchers identified three areas that are keyorganization-specific factors for shaping careeroutcomes for women and racially and ethnicallydiverse individuals: (1) leadership and strategicorientation (i.e., senior management’s commitmentto successful implementation of diversity initiatives),(2) organizational culture and climate (i.e., the depthand breadth of the organization’s strategiccommitment to diversity leadership and culturalcompetency), and (3) human resources practices(i.e., establishing best practices in advancing themanagement careers of women and racially andethnically diverse individuals, such as formalmentoring programs, professional development,work–life balances, and flexible benefits).To best serve their patient base, health careorganizations and providers must be willing to investthe time, money, and effort needed to educate alltheir employees. Educating senior staff is important,but so is educating the entire health care workforce.Wilson-Stronks and Murtha (2010), Cejka Searchand Solucient (2005), and Kochan et al. (2003) havelinked the effects of diversity to businessperformance. Kochan and colleagues (2003)concluded that the impact of diversity depends onorganizational culture, human resource practices,and strategy. In other words, the impact of diversityis directly related to the organization’s ability to

successfully adapt to a diverse environment, and itcan have negative effects if the adaptation is notdone well. For example, Witt/Kieffer’s 2011national survey of 454 health care professionals,54% of whom represented senior executives,provides a deeper understanding of how diversity isconnected to measurable business benefits:Patient satisfaction: Nearly two-thirds (62%)believed that cultural differences improvepatient satisfaction.Successful decision making: More than half(57%) believed that cultural differences supportsuccessful decision making.Strategic goals: More than half of theserespondents (54%) acknowledged that diversityrecruiting enables the organization to reach itsstrategic goals.Clinical outcomes: Nearly half (46%) believedthat diversity improves clinical outcomes.Dreachslin (2007) reinforces the need for masscustomization of diversity practices to be inclusive ofdisparities that are represented in the communitiesthat health care organizations serve. In order toactively support business strategy, organizations willneed to provide employees with skills that areinclusive of conflict-management skills, self-awareness, understanding of cultural differences,validation of alternative points of view, and methods

to manage bias through effective human resourcetraining and development.For health care managers to transform theirorganizations to provide an inclusive culture whereall employees feel the opportunity to reach their fullpotential, Guillory (2004, pp. 25–30) recommendeda 10-step process:1. Development of a customized business casefor diversity for your organization. In otherwords, how does diversity relate to theoverall success of the organization?2. Education and training for your staff todevelop an understanding of diversity, itsimportance to your organization’s success,and diversity skills to apply on a daily basis.3. Establishment of a baseline by conducting acomprehensive cultural survey that integratesperformance, inclusion, climate, and work/lifebalance.4. Selection and prioritization of the issues thatlead to the greatest breakthrough intransforming the culture.5. Creation of a three- to five-year diversitystrategic plan that is tied to organizationalstrategic business objectives.6. Leadership’s endorsement of and financialcommitment to the plan.

7. Establishment of measurable leadership andmanagement objectives to hold managersaccountable to top leadership for achievingthese objectives.8. Implementation of the plan, recognizing thatsurprises and setbacks will occur along theway.9. Continued training in concert with the skillsand competencies necessary to successfullyachieve the diversity action plan.10. Survey one to one-and-a-half years afterinitiation of the plan to determine howinclusion has changed.Reproduced from Guillory, W. A. (2004). The roadmap to diversity,inclusion, and high performance. Healthcare Executive, 19 (4), 24–30.Dreachslin (2007) stresses the need fororganizations to manage diversity and invest inprofessional development so that team membershave the tools needed to navigate their differencesand effectively manage their bias. As Dreachslinnotes, “[I]f left unmanaged, demographic diversitywill interfere with team functioning.”

▶ Cultural CompetencyIn addition to supporting a diverse workforce, healthcare organizations must ensure that theiremployees can handle the diverse needs of theirpatient population. First, health care professionalsand organizations need to have cultural andlinguistic competence to provide effective andefficient health services to diverse patientpopulations. However, before we continue ourdiscussion, we need to define what is meant bycultural and linguistic competence. Over the years,the term “cultural competency” has been defined inmany ways, such as “ongoing commitment orinstitutionalism of appropriate practice and policiesfor diverse populations” (Brach & Fraser, 2000;Weech-Maldonado et al., 2002; see Hofstede’sCultural Dimensions, Exhibit 3-1). The term“linguistic competency” has been defined as “thecapacity of an organization and its personnel tocommunicate effectively, and convey information ina manner that is easily understood by diverseaudiences including persons of limited Englishproficiency, those who have low literacy skills or arenot literate, and individuals with disabilities” (Goode& Jones, 2004). For our discussions, we have

adopted the definition used by the Office of MinorityHealth (OMH) of the U.S. Department of Health andHuman Services, which defines “cultural andlinguistic competence as a set of congruentbehaviors, attitudes, and policies that come togetherin a system, agency, or among professionals andthat enables effective work in cross-culturalsituations.” (U.S. Department of Health andHuman Services, 2013).Exhibit 3-1 Hofstede’s CulturalDimensionsOne of the most extensive cross-culturalsurveys ever conducted is Hofstede’s (1983)study of the influence of national culture onorganizational and managerial behaviors.National culture is deemed to be central toorganizational studies, because nationalcultures incorporate political, sociological, andpsychological components.Hofstede’s research was conducted over an11-year period, with more than 116,000respondents in more than 40 countries. Theresearcher collected data about “values” fromthe employees of a multinational corporationlocated in more than 50 countries. On the basisof his findings, Hofstede proposed that there

are four dimensions of national culture withinwhich countries could be positioned that areindependent of one another. Hofstede’s (1983,pp. 78–85) four dimensions of national culturewere labeled and described as follows:Individualism–collectivism:Individualism–collectivism measuresculture along a self-interest versusgroup-interest continuum. Individualismstands for a preference for a loosely knitsocial framework in society whereinindividuals are supposed to take care ofthemselves and their immediate familiesonly. Its opposite, collectivism, standsfor a preference for a tightly knit socialframework in which individuals canexpect their relatives, clan, or other in-group to look after them in exchange forunquestioning loyalty. Hofstede (1983)suggested that self-interested cultures(e.g., individualism) are positively relatedto the wealth of a nation.Power distance: Power distance is themeasure of how a society deals withphysical and intellectual inequalities andhow the culture applies power andwealth relative to its inequalities. Peoplein societies with a large power distance

accept a hierarchical order in whicheverybody has a place, which needs nofurther justification. People in societieswith a small power distance strive forpower equalization and demandjustification for power inequalities.Hofstede (1983) indicated that group-interest cultures (e.g., collectivism) havelarge power distance.Uncertainty avoidance: Uncertaintyavoidance reflects the degree to whichmembers of a society feel uncomfortablewith uncertainty and ambiguity. Thescale runs from tolerance of differentbehaviors (i.e., a society in which thereis a natural tendency to feel secure) to asociety in which institutions createsecurity and minimize risk. Societieswith strong uncertainty avoidancemaintain rigid codes of belief andbehavior and are intolerant of deviantpersonalities and ideas. Societies withweak uncertainty avoidance maintain amore relaxed atmosphere in whichpractice counts more than principles anddeviance is more easily tolerated.Masculinity versus femininity:Masculinity versus femininity measures

the division of roles between thegenders. The masculine side of thescale is a society in which the genderdifferences are maximized (e.g., needfor achievement, heroism,assertiveness, and material success).Feminine societies are those in whichthere are preferences for relationships,modesty, caring for the weak, and thequality of life.Hofstede proposed that the most importantdimensions 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 ina country’s culture regarding change. Forexample, Nahavandi and Malekzadeh (1999,pp. 495–496) point out that countries such asGreece, Portugal, and Japan have nationalcultures that do not easily tolerate uncertaintyand ambiguity. These cultures emphasizeuncertainty avoidance and the importance ofplanned and well-managed activities. Othercountries, such as Sweden, Canada, and theUnited States, have cultures that are willing totolerate change because of the potential fornew opportunities that may come with change.

A question that is frequently asked is whetherHofstede’s (1983) cultural dimensions are stillapplicable today. Patel (2003) found that thecharacteristics of Chinese, Indian, andAustralian cultures corroborated Hofstede’sstudy results. Patel’s study of the relationshipbetween business goals and culture, measuredby correlating the relative importance attachedto the various business goals with the nationalculture dimension scores from Hofstede’sstudy, found that although the four culturaldimension scores were nearly 20 years old,they were validated in this large, cross-nationalsurvey. In a study that measured 1800managers and professionals in 15 countries,statistically significant correlations with theHofstede indices validated the applicability ofthe first study’s cultural dimension findings(Hofstede, Van Deusen, Mueller, & Charles,2002). The findings from these studies suggestthat Hofstede’s cultural dimensions continue tobe robust and are still applicable measurecomponents of national culture differences.Note: Hofstede (1991) subsequently included an additional dimensionbased on Chinese values referred to “Confucian dynamism.” Hofstederenamed this dimension as a long-term versus short-term orientationin life.

Because of the changing demographics of thenation’s population, the health care industry needsto ensure that the health care workforce mirrors thepatient population that it serves, both clinically andmanagerially. As Weech-Maldonado et al. (2002)noted, health care organizations must developpolicies and practices aimed at recruiting, retaining,and managing a diverse workforce in order toprovide both culturally appropriate care andimproved access to care for racial/ethnic minorities.Because of our increasingly diverse population,health care professionals need to be concernedabout their own cultural competency, which is morethan just cultural awareness or sensitivity. Althoughformal cultural training has been found to improvethe cultural competency of health care practitioners,Kundhal (2003) reported that only 8% of U.S.medical schools and no Canadian medical schoolshad formal courses on cultural issues. However,changes are occurring within the industry to assisthealth care practitioners in developing their culturalcompetency as they encounter more diversepatients. For example, in 2000, the LiaisonCommittee on Medical Education (LCME), theaccrediting body of medical schools, introduced thefollowing accreditation standard for culturalcompetence:

The faculty and students must demonstrate anunderstanding of the manner in which people ofdiverse cultures and belief systems perceive healthand illness and respond to various symptoms,diseases, and treatments. Medical students shouldlearn to recognize and appropriately address genderand cultural biases in healthcare delivery, whileconsidering first the health of the patient.This standard has given added impetus andemphasis to medical schools to introduce educationin cultural competency into the undergraduatemedical curriculum (Association of AmericanMedical Colleges, 2005, p. 1). In addition, TheJoint Commission has implemented patient-centered communication accreditation standards,which require hospitals to meet certain mandatesrelated to qualifications for language interpretersand translators, identifying and addressing patientcommunication needs, collecting patient race andethnicity data, patient access to a support individual,and nondiscrimination in care (The JointCommission, 2014).Over the past decade, the Commonwealth Fund hasbeen a leader in the effort “to eliminate the culturaland linguistic barriers between health care providersand patients, which can interfere with the effectivedelivery of health services” (Beach, Saha, &Cooper, 2006, p. vi). The Commonwealth Fund

(2003), in addition to funding initiatives regardingquality of care for underserved populations, hasinitiated an educational program that assists healthcare practitioners in understanding the importanceof communication between culturally diversepatients and their physicians, the tensions betweenmodern medicine and cultural beliefs, and theongoing problems of racial and ethnicdiscrimination. The goals of this program are forclinicians to:1. Understand that patients and health careprofessionals often have differentperspectives, values, and beliefs abouthealth and illness that can lead to conflict,especially when communication is limited bylanguage and cultural barriers.2. Become familiar with the types of issues andchallenges that are particularly important incaring for patients of different culturalbackgrounds.3. Think about each patient as an individual,with many different social, cultural, andpersonal influences, rather than usinggeneral stereotypes about cultural groups.4. Understand how discrimination and mistrustaffect the interaction of patients withphysicians and the health care system.

5. Develop a greater sense of curiosity,empathy, and respect toward patients whoare culturally different, and thus beencouraged to develop better communicationand negotiation skills through ongoinginstruction.Reproduced from Worlds Apart, Facilitator’s Guide by AlexanderGreen, 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 Foundation has led efforts to lessen therecognized disparity of racial and ethnic minoritygroups’ representation among the nation’s healthprofessionals. It was the Kellogg Foundation thatrequested the Institute of Medicine’s (2004) studyentitled In the Nation’s Compelling Interest:Ensuring Diversity in the Health Care Workforce.The Institute of Medicine found that racial and ethnicdiversity is important in the health professions forthe following reasons:1. Health care professionals who are membersof racial and ethnic minorities are significantlymore likely than their peers to serve minorityand medically underserved communities,thereby helping to improve problems oflimited minority access to care.

2. Minority patients who have a choice are morelikely to select health care professionals oftheir own racial or ethnic background.Moreover, patients who are members ofracial and ethnic minorities are generallymore satisfied with the care that they receivefrom minority professionals, and minoritypatients’ ratings of the quality of their healthcare are generally higher in raciallyconcordant settings than in raciallydiscordant settings.3. Diversity in health care training settings mayassist in efforts to improve the cross-culturaltraining and competencies of all trainees.In addition to the Commonwealth Fund and the W.K. Kellogg Foundation, other organizations areactive in bridging cultural differences in an attemptto lessen health disparities. For example, in 2000,the OMH developed a list of standards for Culturallyand Linguistically Appropriate Services (CLAS),which health care organizations and practitionersshould use to ensure equal access to high-qualityhealth care by diverse populations. In 2013, thesestandards were expanded to reflect the growth inthe field of cultural and linguistic competence. Thereare now 15 standards under four categories: (1)Principal Standard, (2) Governance, Leadership,and Workforce, (3) Communication and Language

Assistance, and (4) Engagement, ContinuousImprovement, and Accountability.Principal Standard1. Provide effective, equitable, understandableand respectful quality care and services thatare responsive to diverse cultural healthbeliefs and practices, preferred languages,health literacy and other communicationneeds.Governance, Leadership, and Workforce1. Advance and sustain organizationalgovernance and leadership that promotesCLAS and health equity through policy,practices, and allocated resources.2. Recruit, promote, and support a culturallyand linguistically diverse governance,leadership and workforce that are responsiveto the population in the service area.3. Educate and train governance, leadershipand workforce in culturally and linguisticallyappropriate policies and practices on anongoing basis.Communication and Language Assistance1. Offer language assistance to individuals whohave limited English proficiency and/or other

communication needs, at no cost to them, tofacilitate timely access to all health care andservices.2. Inform all individuals of the availability oflanguage assistance services clearly and intheir preferred language, verbally and inwriting.3. Ensure the competence of individualsproviding language assistance, recognizingthat the use of untrained individuals and/orminors as interpreters should be avoided.4. Provide easy-to-understand print andmultimedia materials and signage in thelanguages commonly used by thepopulations in the service area.Engagement, Continuous Improvement, andAccountability1. Establish culturally and linguisticallyappropriate goals, policies and managementaccountability, and infuse them throughoutthe organizations’ planning and operations.2. Conduct ongoing assessments of theorganization’s CLAS-related activities andintegrate CLAS-related measures intoassessment measurement and continuousquality improvement activities.

3. Collect and maintain accurate and reliabledemographic data to monitor and evaluatethe impact of CLAS on health equity andoutcomes and to inform service delivery.4. Conduct regular assessments of communityhealth assets and needs and use the resultsto plan and implement services that respondto the cultural and linguistic diversity ofpopulations in the service area.5. Partner with the community to design,implement and evaluate policies, practicesand services to ensure cultural and linguisticappropriateness.6. Create conflict- and grievance-resolutionprocesses that are culturally and linguisticallyappropriate to identify, prevent and resolveconflicts or complaints.7. Communicate the organization’s progress inimplementing and sustaining CLAS to allstakeholders, constituents and the generalpublic.Reproduced from the National CLAS Standards, Office of MinorityHealth, U.S. Department of Health and Human Services, 2018.We pause to provide a brief overview of the effortsbeing made regarding the measuring and reportingof cultural competency. Measurement and reportingare needed to ensure that culturally competent care

can be translated into (1) improved health outcomesand more patient-centered care and (2) actionableinitiatives for providers that result in meaningfulimprovement. Through the support of the RobertWood Johnson Foundation (RWJF), in 2009, theNational Quality Forum (NQF) endorsed acomprehensive national framework based on a setof seven interrelated domains (and multiplesubdomains) for evaluating cultural competencyacross all health care settings as well as a set of 45recommended practices based on the framework.This was followed by RAND’s development of acultural competency implementation measurementtool. This tool is an organizational survey designedto assist health care organizations in identifying thedegree to which they are providing culturallycompetent care and addressing the needs ofdiverse populations as well as their adherence to 12of the 45 NQF-endorsed cultural competencypractices. In 2012, NQF endorsed 12 qualitymeasures that address health literacy, languageaccess, cultural competency, leadership, andworkforce development (Robert Wood JohnsonFoundation, 2014). These quality measures are thefirst endorsed by NQF that specifically addresshealth care disparities and cultural competency.On the basis of Dreachslin’s and others’ research,the NCHL, ACHE, IFD, and the American Hospital

Association developed the Diversity, Equity, andCultural Competency Assessment Tool for Leaders(see Exhibit 3-2). The assessment tool begins theprocess of developing a cultural awareness for theorganization’s workforce. Going forward, managerswill need to develop models that establishbenchmarks for cultural competency to enable theirorganizations to develop competent interventions,thereby improving the quality of health care(Betancourt, Green, & Carrillo, 2002).Exhibit 3-2 A Diversity, Equity, andCultural Competency Assessment Tool forLeadersCHECKLISTAs Diverse as the Community You ServeDo you monitor at least every three years the demographics of your community to track change in gender and racial and ethnicdiversity?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 serveracial and ethnic minorities for outreach and educational purposes?Do you have a strategy to partner with them to work on health issues important to them?Has a team from your hospital met with community leaders to gauge their perceptions of the hospital and to seek their advice onhow you can better serve them, in both patient care and community outreach?Have you done focus groups and surveys within the past three years in your community to measure the public’s perception of yourhospital as being sensitive to diversity and cultural issues?

Do you compare the results among diverse groups in your community and act on the information?Are the individuals who represent your hospital in the community reflective of the diversity of the community and your organization?Do you have a strategy in place to partner with organizations who represent and relate to the diverse groups in your community forhealth outreach and other initiatives of importance to the community?Do you have a supplier diversity strategy that helps ensure that minority-, women-, and veteran-owned businesses have anopportunity to serve your organization?Are your public communications, community reports, advertisements, health education materials, websites, etc. accessible to andreflective of the diverse community you serve?Culturally and Linguistically Proficient and Equitable Patient CareDo you regularly monitor the your patient population to properly care for and serve gender, racial, ethnic, language, religious, andsocio-economic differences and needs?Does your hospital/health system emphasize the importance of accurate, consistent and systematic collection of data on patientrace, ethnicity and primary language?Do your patient satisfaction surveys take into account the diversity of your patients?Does your review of quality and patient safety data take into account the diversity of your patients in order to detect and eliminatedisparities?Do you compare patient satisfaction ratings among diverse groups and act on the information?Have your patient representatives, social workers, discharge planners, financial counselors, and other key patient and familyresources received special training in diversity issues?Does your hospital/health system provide language services, including identifying qualified individuals inside and outside yourorganization, who can help staff communicate with patients and families from a wide variety of nationalities and ethnic backgrounds?Does your hospital/health system provide ongoing training for staff on how to identify and access the need for language services,and have policies and procedures in place for the providing language services to a linguistically diverse patient populationsAre your written communications with patients and families available in a variety of languages that reflects the ethnic and culturalfabric of your community?Depending on the racial and ethnic diversity of the patients you serve, do you educate your staff at orientation and on a continuingbasis on cultural issues important 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 you care for?Does your hospital account for complementary and alternative treatments in planning care for your patients?Strengthening Your Workforce DiversityDo your recruitment efforts include strategies to reach out to diverse candidates, including gender, racial, ethnic, religious, disabilitystatus, sexual orientation, gender identity, veteran status, and socio-economic diversity?Does the team that leads your workforce recruitment initiatives reflect the diversity you need in your organization?Do your policies about time off for holidays and religious observances take into account the diversity of your workforce?Do you acknowledge and honor diversity in your employee communications, awards programs, and other internal celebrations?Have you done employee surveys or focus groups to measure their perceptions of your hospital’s policies and practices on diversityand to surface potential problems?Do you compare the results among diverse groups in your workforce? Do you communicate and act on the information?Does your hospital/health system provide staff at all levels and across all disciplines training about how to address the uniquecultural and linguistic factors affecting the care of diverse patients and communities?Is the diversity of your workforce taken into account in your performance evaluation system?Does your human resources department have a system in place to measure diversity progress and report it to you and your board?Do you have a mechanism in place to look at employee turnover rates for variances according to diverse groups?Do you ensure that changes in job design, workforce size, hours, and other changes do not affect diverse groups disproportionately?Collaborating and Creating Strong PartnershipsIs your hospital/health system leveraging assets to address priority needs of the community, including food, education, employment,housing, transportation, violence prevention and other social determinants of health?Has your hospital/health system developed governance processes to share community resources and accountabilities in your effortsto improve the health of the population?Has your hospital/health system created successful partnerships to reach population health goals of the community?Does your hospital/health system develop your Board and leaders’ ability to contribute to community health, workforce developmentand economic investment solutions within the community?Does your hospital/health system invest in change management processes to grow engagement, relationships and capacity of

leaders to take action on the social determinants of health in community?Expanding the Diversity of Your Leadership TeamHas your Board of Trustees discussed the issue of the diversity of the hospital’s board? 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 on documents seen by your employees and the public?Have you told your management team that you are personally committed to achieving and maintaining diversity across yourorganization?Does your strategic plan emphasize the importance of diversity at all levels of your workforce?Has your board set goals on organizational diversity, culturally proficient care, and eliminating disparities in care to diverse groups aspart of your strategic plan?Does your organization have a process in place to ensure diversity reflecting your community on your Board and subsidiary andadvisory boards?Have sufficient funds been allocated to achieve your diversity goals?Is diversity awareness and cultural proficiency training mandatory for all senior leadership, management, and staff?Have you made diversity awareness part of your management and board retreat agendas?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 best talent, regardless of gender, race, or ethnicity?Do you provide tuition reimbursement to encourage employees to further their education?Do you have a succession/advancement plan for your management team linked to your overall diversity goals?Are search firms required to present a mix of candidates reflecting your community’s diversity?© Used with permission of the American Hospital Association. Strategies for Leadership: a Diversity and Cultural Proficiency AssessmentTool for Leaders. 2017. Retrieved fromhttp://www.diversityconnection.org/diversityconnection/membership/Resource%20Center%20Docs/Assessment%20Tool%20v4(20-page%20bklt).pdf

▶ SummaryAs the population of the United States changes andcontinues to become more diverse, health careorganizations must ensure that they are managingdiversity and ensuring the cultural competency oftheir employees. Dobson (2012) states thatalthough more research is needed, it makes goodbusiness sense for organizations to invest inleadership diversity. She argues that there are threeinterrelated strategies for organizations to consider:(1) linking diversity with performance, (2) linkinginvestments in diversity to financial outcomes andorganizational metrics of success, and (3) makingorganizational leadership responsible for culturalcompetency as a performance measure. Whenoperational measures are connected with aculturally competent organization, the results will bea reduction in health disparities, increased patientsatisfaction, and a more engaged workforce.

Discussion Questions 1. Explain the meaning of cultural competency. 2. What is diversity management? 3. Why do health care organizations need tohave a diverse workforce?

Exercise 3-1Visit the Hofstede Centre(https://geerthofstede.com/culture-geert-hofstede-gert-jan-hofstede/6d-model-of-national-culture/) and review the scores by country for thevarious cultural dimensions that Hofstede identified.In light of these scores, think about someinteractions that you have had with people(colleagues, patients, friends, etc.) who were bornand raised in other countries. Do your interactionsmake more sense given this new insight?

Exercise 3-2You have been asked to join the hospital’s taskforce for developing a plan to increase theorganization’s workforce diversity from its current20% level to 40% over the next 5 years. How doesyour task force define diversity? Whatrecommendations would you make as a member ofthe task force?

Exercise 3-3With diverse patient populations come languagetranslation issues. Medical interpretation is achallenge facing most health organizations. Medicalinterpretation and translation services are costly.You are a member of your hospital’s task forcechallenged to establish customer-focused, cost-efficient communication programs(https://www.jointcommission.org/assets/1/6/ARoadmapforHospitalsfinalversion727.pdfWhat recommendations would you make as amember of the task force?

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CHAPTER 4Attitudes andPerceptionsPeople may hear your words, but they feel your attitude– John C. MaxwellLEARNING OUTCOMESAfter completing this chapter, the student shouldbe able to:Appreciate the importance of attitudes tounderstanding behavior.Understand the three components of attitude.Understand how attitudes can be changed.Understand how perceptions allow individualsto simplify their worlds.Understand the four stages of the perceptionprocess.Understand social perception and the varioussubgroups.

Understand the importance of using objectivemethods for employee selection.

▶ OverviewThis chapter explains how understanding thepsychology of attitudes and perceptions can help usbetter manage the employees of the health servicesorganizations in which we work. Psychologicalprinciples, when applied to organizational behaviorissues, can help health care managers to deal withstaff fairly, make jobs interesting and satisfying, andmotivate employees to higher levels of productivity.By the end of this chapter, you will gain some keyinsights into attitudes and perceptions and how theyrelate to human behavior.

▶ AttitudesWhat is an attitude? Gordon Allport (1935) definedan attitude as a mental or neural state of readiness,organized through experience, exerting a directiveor dynamic influence on the individual’s response toall objects and situations to which it is related. Asimpler definition of attitude is a mind-set or atendency to act in a particular way toward an objector entity (i.e., a person, place, or thing) due to anindividual’s experience and temperament.Typically, when we refer to a person’s attitudes, weare attempting to explain their behavior. Attitudesare a complex combination of an individual’spersonality, beliefs, values, behaviors, andmotivations. For example, we understand whensomeone says, “She has a positive attitude towardwork” versus “She has a poor work attitude.” Whenwe speak of someone’s attitude, we are referring tothe person’s emotions and behaviors. A person’sattitude toward preventive medicine encompassestheir point of view about the topic (e.g., thought) andhow the person feels about this topic (e.g., emotion)as well as the actions (e.g., behaviors) in which theyengage as a result of attitude to preventing healthproblems. This is the tricomponent model of

attitudes (see Figure 4-1). An attitude includesthree components: an affect (a feeling), cognition (athought or belief), and behavior (an action).Figure 4-1 Tricomponent Model of AttitudesAttitudes help us to define how we see situations aswell as how we behave toward the situation orobject. As the tricomponent model illustrates,attitudes include feelings, thoughts, and actions.Attitudes may simply be an enduring evaluation of aperson or object (e.g., “I like John best of mycoworkers”) or other emotional reactions to objectsand to people (e.g., “I dislike working on thedepartment’s annual budget” or “Jane makes meangry ”). Attitudes also provide us with internal

cognitions or beliefs and thoughts about people andobjects (e.g., “Jane needs to work harder” or “Samdoes not enjoy working in this department”).Attitudes cause us to behave in a particular waytoward an object or person (e.g., “I return emailmessages within 24 hours because it upsets mewhen others do not follow up with me in a timelyfashion”). Although the feeling and beliefcomponents of attitudes are internal to a person, wecan often determine a person’s attitude from theirbehavior.

▶ Cognitive DissonanceAlfred Adler (1870–1937), a Viennese physicianwho developed the theory of individual psychology,emphasized that a person’s attitude toward theenvironment had a significant influence on theirbehavior. Adler suggested that a person’s thoughts,feelings, and behaviors were transactions with theperson’s physical and social surroundings and thatthe direction of influence flowed both ways: Ourattitudes are influenced by our social world, and oursocial world is influenced by our attitudes. However,these interactions may cause a conflict between ourattitude and our behavior. This conflict is referred toas cognitive dissonance. Cognitive dissonancerefers to any inconsistency that a person perceivesbetween two or more of one’s attitudes or betweenthe person’s behavior and attitudes. Festinger(1957) stated that any form of inconsistency that isuncomfortable for the person will prompt the personto reduce the dissonance (conflict). For example,suppose that Harry likes two coworkers, John andMary, but John does not like Mary (i.e.,inconsistency). If Harry becomes too uncomfortablewith the inconsistency, he may (1) try to changeJohn’s feelings about Mary, (2) change his own

feelings about either John or Mary, or (3) sever hisrelationship with either John or Mary (see CaseStudy 4-1).CASE STUDY 4-1 Scott’sDilemmaScott is a licensed physical therapist whoworks for a national rehabilitation company.The rehabilitation facility in which Scott worksis 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 sharedwith his coworkers. In addition, Scott receivedpersonal fulfillment from helping his patientsrecover from their disabilities and seeing themreturn to productive lives.Last year the health system went throughreorganization, with some new people beingbrought in and others being reassigned.Scott’s new boss, George, was transferredfrom one of the system’s Midwest facilities.Almost immediately upon taking his newposition, George began finding fault withScott’s care plans, patient interactions, and soforth. Scott began feeling as if he couldn’t doanything right. He was experiencing feelings

of anxiety, stress, and self-blame. Althoughhis previous performance evaluations hadbeen above average, Scott was shocked byhis first performance review under George’sauthority—it was an extremely low rating.Scott began trying to work harder, thinkingthat by working harder he could exceedGeorge’s expectations. Despite the long hoursand addressing George’s critiques, Georgecontinued to find fault with Scott’s work. Staffmeetings began to be a great source ofdiscomfort and stress because George wouldbelittle Scott and single him out in front of hiscolleagues.Scott began to feel alienated from his family,friends, and colleagues at work. His eatingand sleeping habits were adversely affectedas well. Scott’s activities held no joy for him,and the career that he had once loved andbeen respected in became a source of painand stress. He began to call in sick more oftenand started visualizing himself confronting andeven hurting George, which created evenmore guilt and anxiety for Scott.As time went on, George encouraged Scott’scoworkers to leave Scott alone to do his work.The perception of the coworkers became

more sympathetic to George’s point of view.Scott’s coworkers mused that perhaps Scottreally was a poor worker and that Georgeknew better because of his position as thesupervisor of the rehabilitation department.Eventually, Scott’s coworkers began todistance themselves from him, in order toprotect their own interests. They began to seeScott as an outsider, with whom it was unsafeto associate.In an effort to resolve the situation, Scottspoke to George directly, stating his feelingsand expressing an interest in how they mightimprove the situation. Rather than making thesituation better, what George perceived asScott’s insubordination served to enrageGeorge, and the personal attacks againstScott intensified. Feeling frustrated andhelpless, Scott then decided to take hisproblem to the Human Resources Department(HRD). A human resources manager listenedto Scott’s complaints and suggested that Scottreturn with documented evidence of whatScott perceived to be George’s mistreatment.In an effort to help ease the situation, the HRDmanager discussed the issue with George,which only stirred the flames of George’sanger and his negative behavior toward Scott.

As a last resort, Scott decided to go toGeorge’s boss, Rebecca. Rebecca met withGeorge to get his side of the story. Georgeportrayed Scott as an unproductive employeewith no respect for authority. The result was astrong letter of reprimand in Scott’s file forinsubordination.Discuss the cognitive dissonance reflected inScott’s Dilemma.Reproduced from case discussion: Workplace bully, by J. Pinto, M.Vecchione, and L. Howard, October 2004, presented at the 12thAnnual International Conference of the Association on EmploymentPractices and Principles, Ft. Lauderdale, FL.Other approaches that a person may use to reducethe inconsistency are as follows:Eliminating their responsibility or control overan act or decision.Denying, distorting, or selectively forgetting theinformation.Minimizing the importance of the issue,decision, or act.Selecting new information that is consonantwith an attitude or behavior.For example, why do people continue to smokecigarettes when the hazards of smoking are so well

known? Using the cognitive dissonance theory,Kassarjian and Cohen (1965) attempted to analyzehow smokers rationalize their behavior. They foundthat smokers justify their continued smoking by (1)eliminating their responsibility for their behavior (“Iam unable to stop” or “It takes too much effort tostop”); (2) denying, distorting, misperceiving, orminimizing the degree of health hazard involved(“Many smokers live a long time” or “Lots of thingsare hazardous”); and/or (3) selectively relying oninformation that reduces the inconsistency of thesmoker’s behavior (“Smoking is better thanexcessive eating or drinking” or “Smoking is betterthan being a nervous wreck”).Although the theory of cognitive dissonance helpsus understand how individuals try to make sense ofthe world they live in, it does not predict what anindividual will do to reduce or eliminate thedissonance (as reflected in the previous example ofHarry, John, and Mary ). It only relates that theindividual will be motivated to “do something” tobring attitudes and behaviors into balance.Cognitive dissonance theory has many practicalmanagerial applications for motivating employeesand is the theoretical basis for what are known asthe equity theories of motivation (Ott, 1996). Equitytheory predicts that employees will pursue abalance between their investments in work and the

rewards gained from their work such that their owninvestment/reward ratio will be the same as that ofsimilar others. Disturbance of this balance results inbehaviors that will attempt to relieve the dissonance.For example, if an employee perceives that anotheremployee is paid more for the same level ofproductivity, the first employee will be motivated toask for a raise, lower their level of productivity, orseek another job.

▶ Formation of AttitudesHow are attitudes formed? Attitude formation is aresult of learning, modeling other individuals’ actionsand attitudes, and direct experiences with peopleand situations. Attitudes influence our decisions,guide our behavior, and affect what we remember(which is not always the same as what we hear).Attitudes come in different strengths, and like mostthings that are learned or influenced throughexperience, they can be measured, and they can bechanged.Measurement of AttitudesSince the publication of Thurstone’s procedure forattitude assessment in 1929 (Thurstone & Chave,1929), employee surveys have been widely used inorganizations to obtain information about workers’attitudes toward their environments. As Fottler andcolleagues (1995, pp. 281–282) point out, “fromresponses to these surveys, management can learnhow employees view their jobs, their supervisors,their wages and benefits, their working conditions,and other aspects of their employment.” Thus,employee attitude survey responses can help healthcare managers to determine whether management

is doing the right things for retaining and motivatingemployees. For example, Lowe, Schellenberg, andShannon (2003) found that workers who rated theirwork environments as “healthy” (in terms of taskcontent, pay, work hours, career prospects,interpersonal relationships, security, etc.) reportedhigher job satisfaction, morale, and organizationalcommitment and lower absenteeism and intent toquit. Employee attitude surveys are usuallydesigned using five-point Likert-type (“stronglyagree–strongly disagree”) or frequency (“never–veryoften”) response formats. Some typical questionsare illustrated in Figure 4-2. However, as Morrel-Samuels (2002) points out, organizations need to becautious in designing employee attitude surveys toensure that problem areas are not overlooked.Morrel-Samuels provided 16 guidelines fororganizations to consider when designing anemployee attitude survey (see Exhibit 4-1).

Figure 4-2 Employee Attitude SurveyExhibit 4-1 Guidelines to Help CompaniesImprove Their Workplace SurveysContentAsk questions about observablebehavior rather than thoughts ormotives.Include some items that can beindependently verified.Measure only behaviors that have arecognized link to your company’s

performance.FormatKeep sections of the surveyunlabeled and uninterrupted bypage breaks.Design sections to contain a similarnumber of items, and questions witha similar number of words.Place questions about respondentdemographics last in employeesurveys but first in performanceappraisals.LanguageAvoid terms that have strongassociations.Change the wording in about one-third of questions so that thedesired answer is negative.Avoid merging two disconnectedtopics into one question.MeasurementCreate a response scale withnumbers at regularly spacedintervals and words only at eachend.

If possible, use a response scalethat asks respondents to estimate afrequency.Use only one response scale thatoffers an odd number of options.Avoid questions that requirerankings.AdministrationMake workplace surveysindividually anonymous anddemonstrate that they remain so.In large organizations, make thedepartment the primary unit ofanalysis for company surveys.Make sure that employees cancomplete the survey in about 20minutes.Reproduced from Getting the truth into workplace surveys, by P.Morrel-Samuels, 2002, Harvard Business Review, 80(2), pp. 111–118.Effective managers continuously survey theiremployees so they can detect problem areas andimplement the necessary changes.Changing Attitudes

How do you change someone’s attitude? To changea person’s attitude, you need to address thecognitive and emotional components. How wouldyou convince another person to start an exerciseprogram when the individual may say, “I don’t haveenough time” or “I’m just too busy”? One approachwould be to challenge the person’s behavior byproviding new information. For example, explain tothe other person how you made time in your dayand how, as a result, both your cholesterol level andyour blood pressure decreased. This is a cognitiveapproach when a person is presented with newinformation. Providing new information is onemethod for changing a person’s attitude andtherefore their behavior. Attitude transformationtakes time, effort, and determination, but it can bedone. It is important not to expect to change aperson’s attitudes quickly, as the following storyillustrates:“We can’t meet tomorrow morning, I’ve got to go to mydoctor,” 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 everhad 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. PreventiveServices Task Force. It said that there is insufficientevidence for or against routine screening withcolonoscopy. My friend is Canadian and respondedthat he does not bank on everything American. So welooked up the Canadian Task Force report, and it hadthe same result. Just to be sure, the men checkedBandolier at Oxford University in the United Kingdom,and once again we found the same result. Noprofessional health association that we looked upreported that people should have a routinecolonoscopy—after all, a colonoscopy can beextremely unpleasant—but many recommended thesimpler, cheaper, and noninvasive fecal occult bloodtest. What did my friend do? If you think that hecanceled his doctor’s appointment the next day, youare as wrong as I was. Unable to bear the evidence,he got up and left, refusing to discuss the issue anyfurther. He wanted to trust his doctor.Reproduced from Gut feelings: The intelligence of the unconscious,by G. Gigerenzer, 2007, New York: Viking Penguin.Managers need to understand that attitude changetakes time, and they should not set unrealisticexpectations for rapid change (Moore, 2003).Attitudes are formed over a lifetime through an

individual’s socialization process. An individual’ssocialization process includes their formation ofvalues and beliefs during childhood years,influenced not only by family, religion, and culturebut also by socioeconomic factors. This socializationprocess affects a person’s attitude toward work andtheir related behavior (see Case Study 4-2).CASE STUDY 4-2 WhatChanged in the HousekeepingDepartment?Betty Smith, the newly assigned manager ofthe hospital’s housekeeping department,could not understand why her employeesnever offered suggestions as to how their jobscould be performed more effectively andefficiently. Betty was of the opinion that sheshouldn’t have to tell her staff how to clean afloor or a patient’s room; they should be tellingher how they could do their jobs better.Finally, Sally, a 24-year-old recent SierraLeone immigrant who had been employed inthe hospital’s housekeeping department forthe past five years, confided in Betty duringher performance-evaluation conference, “Idon’t offer suggestions because I’m only a

housekeeper with no formal education. I don’twant to look stupid.”Betty immediately put into place a three-monthtraining program with the goal of giving heremployees the skills to recognize problemsand the self-confidence to bring them to herattention. The training program was designedto let employees know what is expected ofthem regarding performance, as well as howand where they “fit” in the overall organization.The training program helped the employeesunderstand that their contributions make adifference to the organization achieving itsgoals.After the employees had completed half of thetraining program, Betty started to hold staffmeetings on Friday afternoons to discuss anyproblems that were encountered during theweek. At the conclusion of a Friday’s staffmeeting, Betty asked, as she always did, ifanyone had an item to discuss. Betty neverreceived a reply, but she continued to ask thequestion in every staff meeting anyway.However, this Friday was different. Sallyraised her hand and related that she“overheard” a physician talking to theemergency department (ED) manager about

the delay of transferring his patients from theED to the nursing floors. Sally thought thatpart of the delay might be related to patients’rooms not being cleaned in a timely fashionafter a patient’s discharge because the unitsecretaries at the nurses’ stations did notcommunicate when the patient was beingdischarged. Housekeepers were told after thefact—after the patient was discharged andafter the ED called the nursing stationsecretaries informing them an ED patientneeded to be transferred to the unit. Becauseof their other duties, sometimes ahousekeeper could not get to the floor forcleaning for at least an hour or more. Sallyasked, “Why can’t the nursing stationsecretaries communicate with us before thepatient is discharged so we can schedule ourtime appropriately?” Betty agreed with Sally.Why couldn’t there be better communicationbetween 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 timedelay of a clean bed being made available foran ED patient transfer. Mary concurred withBetty, stating that administration had noticed

that sometimes it took up to three hours fromthe time a bed became unoccupied to the timethe bed was reported clean and available forpatient use.A team was formed that included nursemanagers, nursing supervisors, floor nurses,unit secretaries, and housekeeping staff,including Sally, to discuss the problem anddevelop a solution that was workable foreveryone. The solution* was simple, low-cost,and low-tech.First, the nursing supervisors would e-mail alist of anticipated room discharges for thefollowing day to housekeeping no later thanmidnight. The evening housekeeping staffwould retrieve the e-mail and post the list forthe morning shift so they could plan their dailyjob activities according to the anticipateddischarges. Second, two jars were placed atthe nurses’ stations—one jar was marked forclean rooms and the other marked for dirtyrooms. Third, once a patient was discharged,the nurse put a red slip of paper with the roomnumber into the dirty-room jar. Fourth, whenhousekeeping finished cleaning and preparingthe room for an incoming patient, theyremoved the red slip from the dirty-room jar

and put a green slip with the same roomnumber on it in the clean-room jar. Fifth, thegreen slip in the jar served as a visiblereminder to the unit secretary that an openbed was available and ready to be filled whenthey received the call from the ED.Mary Acton called Sally the following month tothank her for bringing her “proactive”observations to Betty’s attention. Mary relatedthat the new “communication” system hadreduced the bed turnaround time from threehours to 30 minutes!Betty related the news of the decreasedturnaround time at her next Friday staffmeeting, and she thanked Sally and everyonefor participating in developing andimplementing this new hospital procedure thathad positively impacted both patient andphysician satisfaction. When she asked ifanyone had anything else to discuss, Sallyraised her hand and said, “Barry and I noticedthat an excessive amount of paper towels arebeing used throughout the hospital, and wehave a few suggestions that may save thehospital money.” Joe interjected, “I’ve alsonoticed that the hospital is not takingadvantage of recycling its paper waste, which

could save money and reduce our workloads.”Tina related, “I have a few suggestionsregarding . . .” Betty smiled as she listened toeveryone’s suggestions andrecommendations.Discuss why Sally and the otherhousekeeping staff’s attitudes changed. Portions of the solution were reported as being implemented byUniversity Hospital of University Health System. See Blueprint at theSeams: Improving Patient Flow to Help America’s EmergencyDepartment. Available from the Robert Wood Johnson FoundationUrgent Matters Program. Reprinted with permission.Health care managers may use techniquesemployed in the counseling and conflict-resolutionfields to develop a step-by-step process forchanging employees’ attitudes when necessary (seeExhibit 4-2). The importance of attitude assessmentand change cannot be underestimated. One personwith a consistently—and vocal—bad attitude canlower the morale of an entire workgroup in anotherwise “healthy” organization. Employees whodemonstrate counterproductive work behaviors, alsoreferred to as “toxic behavior,” can seriouslydebilitate individuals, teams, and/or the organizationover the long term (Kusy & Holloway, 2009). Forexample, Rosenstein (2011) reported, based on a*

survey of more than 4500 respondents in over 100hospitals, that there was a strong perceivedcorrelation between disruptive behaviors and theoccurrence of medical error, compromised quality,adverse events, compromises in patient safety, andincreased patient mortality.Exhibit 4-2 Step-by-Step Process forChanging Attitudes in the Workplace1. Assessment of Attitudesa. Identification—Recognize commonworkplace attitude problems.b. Environment—Identify challenges inthe workplace environment.Participants are introduced tocommon examples of “attitude-challenged” workers. Group activitieshelp participants to identify and role-play how to handle different types ofattitude challenges. The goals are toassess the impact of negativeattitudes on workers, management,and patients/customers and toidentify the causes of problems.2. Adjusting Attitudesa. How listening, coaching, andproviding feedback are the tools for

attitude change.b. Role-play to practice how to usecoaching and provide feedback withstaff.c. Identify payoffs and rewards.Participants learn how to use open-ended questions, active listening,and tactful confrontation to addressattitude problems in the workplace.3. Common Management Mistakesa. How to be realistic and patient withattitude change.b. Why scolding employees does littleto stop the problem.c. How to stop the culture ofcomplaining and work to positivelyeffect attitude change.d. Group activities include examples ofcommon management mistakes andexercises to practice more realisticand positive ways to provideemployee feedback, facilitate groupdiscussion, and role-play the bestmethods for confronting negativeattitudes.4. Resolving Conflicta. The need to confront so that negativebehaviors will not continue.

b. Expectations and coping strategiesof employees to stress andmanagement directives.c. Recognizing personal conflict stylesof workers and how to deal withthem.Exercises include ways to analyzecommunications to identify employeestyles, planning the meeting, andworking collaboratively to discoverwin/win solutions.5. How to Work with Problem Behaviors andAttitudesa. Analyze the cause of the problem.b. Privately confront with a calm,nondefensive professionaldemeanor.In this session, participants role-playwith their preferred style for handlingdifficult employees. Managers andemployees exchange roles and mustreprimand or confront problembehaviors.6. The Last Resort: Employee Terminationand Legal Issuesa. Legal issues of employeeterminations.

b. Requirements, documentation, andprocedure.Exercises use case studies to workout remedial and probationarysystems and to fully documentintervention efforts prior to the needfor termination or reassignment.7. Creating a Positive Work Environmenta. Evoke a positive, collaborative teamenvironment.b. Top motivators include nonmonetaryrewards.c. Characteristics of managingmotivation in the workplace.Exercises include engaging workers in teams,providing recognition awards for employees,and changing the climate by launching careerdevelopment and advancement initiatives,leadership training, multicultural skills, andother positive incentive programs.The first step in the change process is to identify theproblem, followed by efforts to adjust attitudes,reduce conflict, and seek solutions (see Exhibit 4-3). Open communication creates environmentswhere workers feel safe to dissent and theiropinions are respected. Everyone has attitudes,

both positive and negative. To help workers realizetheir full potential requires ongoing efforts.Exhibit 4-3 Facilitating an AttitudeWorkshop for EmployeesDiscussion groups are a great way to diagnoseand treat attitude problems. Begin by statingthe guidelines for the session to alleviate anyanxiety and set a positive tone. Create asupportive atmosphere so that participants feelsafe to examine their attitudes and beliefs.The manager’s role should be as facilitatorrather than guiding a question-and-answersession. One task of the effective facilitator isactivating the group’s resources to bring out thebest in the group. For example, plan activitiesin which people interact with one another at thestart (e.g., an icebreaker type of exercise).Work with the energy of the group; use humorand laughter as well as healthy competition.These interactions build trust and help peopleto feel comfortable sharing ideas andconsidering new options.The second task of the facilitator is to activateparticipants’ internal wisdom. Ask questionsand let people discover their own answers. Youcan assist participants by keeping the dialogue

going to enable them to sort out their valuesand priorities, explore beliefs and assumptions,and feel encouraged to alter their work lives inways that they choose.The third task is to facilitate personal reflectionby asking questions to help participants test theideas that are being developed against theirown experiences. List issues, goals, problems,and solutions that come up in the groupdialogue. Write the main ideas on a board,perhaps focusing on negative attitudes andaspects of the workplace that may cause them.Ask participants to expand on these. Givepersonal examples, and ask how poor attitudesin others can make them feel.Throughout the process, the facilitator’s goal isto foster interpersonal support. Havingparticipants share ideas and experiencesinitiates the process of people supporting oneanother. Encourage team building andinterpersonal support as part of creating a workatmosphere where negative attitudes areexposed and positive attitudes flourish.At the end of each session, it is important toprovide a summary. This communicates to theparticipants that you have been activelylistening and are prepared to offer a synthesis

of the group’s observations and insights. Beginby saying, “What I heard today is . . . .” Offerparticipants a chance to compare notes withone another for feedback. You might also askparticipants to jot down ideas and feelingsabout the attitude dialogue to bring to the nextmeeting. Always provide a “take-homemessage” of commitment to change. Everyoneshould leave with at least one clear idea aboutwhat they will do next.Discussions to identify negative workplaceattitudes can be very effective. Thesediscussions lead to solutions and groupcommitment to improved morale.Modified from Kreitlow, B., & Kreitlow, D. (1997). Creative planning forthe second half of life. New York, NY: Whole Person Associates.Reprinted with permission.

▶ PerceptionPerception is closely related to attitudes. Perceptionis the process by which organisms interpret andorganize sensation to produce a meaningfulexperience of the world (Lindsay & Norman, 1977).In other words, when a person is confronted with asituation or stimuli, the person interprets the stimulias something meaningful to them on the basis ofprior experiences. However, what an individualinterprets or perceives may be substantially differentfrom reality.The perception process follows four stages:stimulation, registration, organization, andinterpretation (see Figure 4-3).

Figure 4-3 Perception Processing SystemA person’s awareness and acceptance of the stimuliplay an important role in the perception process.Receptiveness to the stimuli is highly selective andmay be limited by a person’s existing beliefs,attitudes, motivation, and personality (Assael,1995). Individuals will select the stimuli that satisfytheir immediate needs (perceptual vigilance) andmay disregard stimuli that may cause psychologicalanxiety (perceptual defense).Broadbent (1958) addressed the concept ofperceptual vigilance with his filter model. Broadbent

argued that, on the one hand, because of limitedcapacity, a person must process informationselectively; therefore, when presented withinformation from two different channels (i.e.,methods of delivery, such as visual and auditory),an individual’s perceptual system processes onlythat which they believe to be most relevant.However, perceptual defense creates an internalbarrier that limits the external stimuli passingthrough the perception process when the stimuli arenot congruent with the person’s current beliefs,attitudes, motivations, and personality. This isreferred to as selective perception. Selectiveperception occurs when an individual limits theprocessing of external stimuli by selectivelyinterpreting what they see on the basis of beliefs,experience, or attitudes (Sherif & Cantril, 1945).Broadbent’s filter theory has been updated in recentyears. A “Selection-for-Action View” suggests thatfiltering is not just a consequence of capacitylimitations but is also driven by goal-directed actions(Allport, 1987, 1993; Neumann, 1987; Van derHeijden, 1992). The concept is that any actionrequires the selection of certain aspects of theenvironment that are relevant to the action and, atthe same time, filtering other aspects that areirrelevant to the action. Therefore, when one isworking toward a goal, one will skip over information

that does not support one’s plan. Studies of thebrain have also led to new models suggesting thatthere are multiple channels of processing (Pashler,1989) and that selective perception occurs as aresult of activation of cortical maps and neuralnetworks (Rizzolatti & Craighero, 1998). In anycase, people are selective in what they perceive andtend to filter information on the basis of theircapacity to absorb new data, combined withpreconceived thoughts.

▶ Attribution TheorySince the 1950s, researchers have tried tounderstand and explain why people do what theydo. Attribution theory was first introduced by Heidler(1958) as “naive psychology” to help explain thebehaviors of others by describing ways in whichpeople make causal explanations for their actions.Heidler believed that people have two behavioralmotives: (1) the need to understand the worldaround them and (2) the need to control theirenvironment. Heidler proposed that people act onthe basis of their beliefs, whether or not thesebeliefs are valid. Weiner (1979) suggested thatindividuals justify their performance decisions bycognitively constructing their reality in terms ofinternal–external, controllable–uncontrollable, andstable–unstable factors.According to Weiner (1979), when one tries todescribe the processes of explaining events and therelating behavior, external or internal attributionscan be given. An external attribution assignscausality to an outside agent or force. An externalattribution claims that some outside force motivatedthe event. By contrast, an internal attributionassigns causality to factors within the person. An

internal attribution claims that the person wasdirectly responsible for the event. Controllabilityrefers to whether the person had the power to exertcontrol over the events of the situation. Finally,stability of the cause relates to whether the behavioris consistent over time because of the individual’svalues and beliefs or because of outside elementssuch as rules or laws that would govern a person’sbehavior in the various situations.Attribution theory is a concept from socialpsychology that examines people’s explanations forwhy things happen. It is more concerned with theindividual’s cognitive perceptions than with theunderlying reality of events (Daley, 1996). Forexample, fundamental attribution error occurs whenthe influence of external factors is underestimatedand the influence of internal factors is overestimatedin regard to making judgments about behavior. Self-serving bias is the tendency for individuals toattribute their own successes to internal factorswhile putting the blame for failures on externalfactors.When employees make attributions about anegative event that happened at work, they tend tounderemphasize internal (dispositional) factors suchas ability, motivation, or personality traits andoveremphasize (external) situational factors. Forexample, some workers are high achievers because

of their attributions. They approach rather thanavoid tasks because they are confident that successwill come from their ability and effort. These highachievers persist when the work becomes moredifficult rather than giving up because achievingtheir goals is self-rewarding and they will attributetheir success to their personal drive and efforts. Incontrast, the unmotivated (external) person willavoid or quit difficult tasks because that persontends to doubt their ability and attributes success toluck or other factors out of their control. Suchexternal individuals have little drive or enthusiasmfor work because positive outcomes are not thoughtto be related to their direct effort.Managers are often in a position in which they makecausal attributions regarding an employee’sbehavior or work pattern. Kelley’s (1967, 1973)model of attribution theory incorporates threeattributions: consensus, consistency, anddistinctiveness (see Figure 4-4).

Figure 4-4 Kelley’s Attribution Theory ModelConsensus relates to whether an employee’sperformance is the same as or different from that ofother employees. Consistency refers to whether theemployee’s behavior is the same in most situations,whereas distinctiveness asks the question, “Doesthe employee act differently in other situations?”Managers will attribute an employee’s behavior toexternal causes such as task difficulty if there ishigh consensus, low consistency, and highdistinctiveness. For example, the regional director ofan international pharmaceutical company attributesher top sales people’s inabilities to reach theirannual sales goals for a specific drug used to treatgastrointestinal conditions to recent negative media

coverage of another, similar drug’s linkage to a highnumber of patients suffering strokes (e.g., adverseeffects to the drug). By contrast, managers willattribute an employee’s behavior to internal factors,such as lack of ability, if there is low consensus,high consistency, and low distinctiveness.Mitchell, Green, and Wood (1981, p. 199) gave thefollowing example to demonstrate the precedingdiscussion: Suppose you are a physician and youhave asked a nurse to administer a medication toone of your patients. When you check back later inthe day, you find that the medication was not given.On further discussions with the nurse, thesupervisor, and other involved parties, you discoverthat (1) this nurse has failed to administer the propermedication on other occasions (low distinctiveness);(2) this nurse has had difficulty with other tasks,such as charting or patient care (high consistency);and (3) none of the other nurses have failed to carryout a physician’s order in the past 3 months (lowconsensus). The nurse has performed poorly on thistask before; the nurse has performed poorly onother tasks; and no other nurses seem to have thisdifficulty. In this scenario, the physician will mostprobably make a person attribution: The cause ofthe poor performance was some characteristic ortrait of that particular nurse (e.g., lack of effort orability).

Managers need to remember that many issuesfactor into this process (i.e., explaining events andthe relating behavior) and that organizationalhistory, personal experiences, individual tendencies(toward internal versus external views of causalityand intrinsic versus extrinsic motivations), and priorknowledge all affect perceptions of causes.Managers should avoid the “blame game” and focuson correcting workplace behavior.

▶ Social PerceptionSocial perception is how an individual “sees” othersand how others perceive an individual. This isaccomplished through various means, such asclassifying an individual on the basis of a singlecharacteristic (halo effect), evaluating a person’scharacteristics by comparison to others (contrasteffect), perceiving others in ways that reflect aperceiver’s own attitudes and beliefs (projection),judging someone on the basis of one’s perception ofthe group to which that person belongs(stereotyping), causing a person to act erroneouslyon the basis of another person’s perception(Pygmalion effect), or controlling another person’sperception of oneself (impression management).Halo EffectThe halo effect occurs when an individual forms ageneral impression about another person on thebasis of a single characteristic, such as intelligence,sociability, or appearance. The perceiver mayevaluate the other individual as being high on manytraits because of their belief that the individual ishigh in one trait. For example, if an employeeperforms a difficult accounting task well and the

manager believes that the employee is highlyintelligent, the manager may also erroneouslyperceive the employee as having competencies inother areas such as management or technology.The halo effect is applicable to individuals’perceptions of others and of organizations. Forexample, a hospital that is well known for its open-heart and cardiac programs may be perceived in thecommunity as excellent in other clinical areas, suchas obstetrics or orthopedics, whether that is true ornot.Opposite to the halo effect is the horn effect,whereby one person evaluates another as low onmany traits because of a belief that the individual islow on a trait that is assumed to be critical(Thorndike, 1920). A study on obesity conductedwith health care professionals and researchersreflects the horn effect. Study participants wereasked to complete the Implicit Association Test toassess overall implicit weight bias (associating“obese people” and “thin people” with “good” versus“bad”) and three ranges of stereotypes: lazy–motivated, smart–stupid, and valuable–worthless.The study respondents were much quicker to pair“fat” with “lazy” and other negative traits and/orstereotypes (Schwartz, Chambliss, Brownell,Blair, & Billington, 2003).

The halo/horn-effect cognitive bias is a challengethat health care managers face when they areperforming workers’ evaluations. Managers need toavoid the tendency for an employee’s positive ornegative trait to spill over into other areas of theevaluation. For example, if an employee has beenlate to work for 3 days, the manager might concludethat this person has a poor attitude and doesn’t careabout their job. However, there may be externalreasons for the employee’s lateness, such as a carbreaking down, a delay on public transportation, thebabysitter being late, or bad weather. The managerwho assumes, because of the lateness, that theemployee is a poor worker will unfairly give theemployee a negative overall evaluation.Because these types of bias can lead to poordecisions by managers, many large organizationsare allocating resources to diversity programs andsensitivity training. These training programs assistmanagers and other employees to be aware ofthese biases especially in hiring, evaluating, andpromotion decisions (Halvorson & Rock, 2015).Contrast EffectsResearch has provided evidence that perceptionsare also subject to what are termed perceptualcontrast effects. Contrast effects relate to anindividual’s evaluation of another person’s

characteristics based on (or affected by)comparisons with people who rank higher or loweron the same characteristics. For example, Wedell,Parducci, and Geiselman (1987) found that, ifcompared to a highly attractive person, a targetperson of average attractiveness is judged to beless attractive than they would have been judged ifrated on their own. When asked to contrast a targetperson with people who were more physicallyattractive, ratings of attractiveness of the targetwere more negative, and when the target personwas compared with people who were less attractive,it resulted in more positive evaluations (Thornton &Moore, 1993). In other words, the contrast effectrelates to how an individual is perceived in relationto others around them. Not only do contrast effectsapply to the perception of attractiveness, but theyhave also been shown to influence self-esteem,public self-consciousness, and social anxiety(Thornton & Moore, 1993). It stands to reason thata worker’s performance would be judged in contrastto the workers around them. However, managersneed to be aware of this contrast-effect bias wheninterviewing job candidates or evaluating a worker’sperformance.Contrast is an important principle by which we makedecisions. When we make judgments, they are notabsolute judgments. We judge an individual or

object in comparison with someone else orsomething else. By using the perceptual contrast-effects principle, one can persuade other people intheir judgments by leveraging the followingcomparisons (changingminds.org):Shortlists: Individuals are not good at selectingfrom a large group, as there are too manycontrasts to make. When faced with manycandidates for a job, we will rapidly simplify thedecision by breaking things down to a veryshort list.Pairwise Comparison: Although we can selectfrom a group of things, we compare best whenwe have only two things from which to select. Infact, one of the reasons that we do reducechoices to a shortlist is that we have fewer pairsto compare. Even then, we will break thingsdown further, comparing the top two or three,one against another.Polarizing: When we are seeking to separatetwo things, it is easier to differentiate if there isa higher contrast. We hence polarize, pushingour perceptions more toward extremes in orderto say that “this is clearly different from that”rather than “this is a bit different from that.”Living in a Black-and-White world is easier, ifless accurate, and many people choose to takeextreme views rather than living with

uncertainty. We polarize by selectivelyamplifying the aspects that will support ourposition and downplaying or ignoring those thatwill not. In this way, we create selectivedistortion. We do this in particular whenseparating ourselves (and our friends) fromother people, especially if values are involved,as we seek to ensure that we are all good andthat we can project all bad things onto the otherperson.Comparing with Prototypes and Stereotypes: Aprototype is an idealized stereotype, both ofwhich are based on polarized thinking.Sometimes the standard against which wejudge other things is a prototype that we haveconstructed. Thus, when selecting a jobcandidate, we will compare each intervieweeagainst a nonexistent prototype that has all thewanted characteristics, traits, and so on.Prototypes are often made up of all the bestparts from a wide range of experiences.Comparing with What Is Available: If twowomen are standing side by side, a man willevaluate one against the other, as the otherwoman is more immediately available than arecalled prototype would be. Women, of course,will do the same. In fact, we all tend to usewhatever comparators are most available to us

at the time of judgment. In our usual lazymental manner, we are more likely to use thecomparator that is easiest to access than to useone that may be more appropriate. Thus, givenan unattractive person and an average-lookingperson, we will judge the average person to bemore attractive than we would if we saw theaverage person alone.Comparing Against Other People: Whenevaluating ourselves, the main comparator isother people. We decide how happy, beautiful,and so on we are by comparing ourselves withothers. In particular, we tend to compareourselves to peers and people who are “likeus.” Thus, rich people compare themselves toother rich people (and often feel quite poor as aresult!). People for whom being intelligent isimportant will compare themselves to otherintelligent people. A result of this is that beingrich, powerful, clever, and so on is no predictorof happiness. We may strive for success, but ifwe change our comparators along the way, wewill not seem to have achieved that much.ProjectionWhereas contrast effects are the perception of anindividual based on comparison to others, projectionis the attribution of one’s own attitudes and beliefs

onto others. All of us are guilty of unconsciouslyprojecting our own beliefs onto others. SigmundFreud (1894/1966), along with his daughter AnnaFreud (1936/1967), suggested that projection is adefensive mechanism whereby we attribute our ownattitudes onto someone else as a defense againstour feelings of anxiety or guilt. For example, if youstrongly dislike someone, you might, instead ofacknowledging your feeling, believe that they do notlike you. Projection works by allowing theexpression of the desire or impulse but in a way thatthe ego cannot recognize, therefore reducinganxiety or guilt. Projection can mean ascribing toothers the negatives that we find inside ourselves,thereby protecting our self-esteem. For example, aperson who is rude might constantly accuse othersof being rude. Thus, the person does not have todeal with the fact that they are rude, which wouldrequire acknowledging that there is somethingwrong with them, which is generally undesirable.Projection thus makes the individual feel betterabout themselves. Who has never blamed others formaking them late to work, going off a diet, or beingin a bad mood (when it was themselves at fault)?Projection is an interesting human tendency.Projection allows one to perceive others in waysthat really reflect oneself, because, in general,

people are in favor of those who are most likethemselves.StereotypingIn 1798, printers invented a new way to permanentlyfix and reproduce visual images. This precursor tomodern photographic printing processes was calledstereotyping. Over time, the word “stereotype” cameto apply not just to visual printed images, but also tohow we fit attributes of ability, character, or behaviorto groups and/or populations in order to makegeneralizations. The term is now most often definedto mean a conventional image applied to wholegroups of people and the treatment of groupsaccording to a fixed set of generalized traits orcharacteristics.Although stereotyping can be positive because itallows us to organize a complex world, it may beconsidered negative if it leads to overly generalizedviews about groups of individuals. Researcherssuggest that stereotypes wield a strong, covertinfluence on human behavior (even among thosewho do not agree with stereotypes). Socialresearchers have revealed that it is relatively easyfor stereotypes to be activated across a wide rangeof contexts 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 isproblematic for health care professionals and healthservice organizations. The Institute of Medicine(2003) found that “racial and ethnic minorities tendto receive a lower quality of health care than non-minorities, even when access-related factors, suchas patients’ insurance status and income arecontrolled . . . and found evidence that stereotyping,biases, and uncertainty on the part of health careproviders can contribute to unequal treatment” (p.1).In addition to stereotyping racial and ethnicminorities, health care professionals have atendency to stereotype other groups, such as olderadults, homeless people, people with disabilities,and those dealing with obesity. Older adults areoften stereotyped as infirm, inflexible, weak,deficient in vision and hearing, and being unable toadvocate for themselves on health issues. Anotherexample is the homeless population. There is atendency to stereotype a person in this group as anelderly alcoholic male or perhaps a disheveled baglady. However, homelessness also affects families,children, and young people—groups that do not fitthe stereotypes. When it comes to obesity, Puhl andcolleagues (2010) have published numerous studies

documenting “harmful weight-based stereotypesthat overweight and obese individuals are lazy,weak-willed, unsuccessful, unintelligent, lack self-discipline, have poor willpower, and arenoncompliant with weight-loss treatment.”One of the most common forms of stereotypinginvolves gender and leadership. Women holdpositions at all levels in health care organizations,but only between 10% and 18% of chief executiveofficer positions are held by women (Russell,Krentz, Abouzahr, & Doyle, 2019). The influenceof gender stereotypes is one possible reason why itis sometimes difficult for people to accept women asleaders in the workplace. Traits that are oftenattached to leadership are stereotypically“masculine” qualities such as courage,persuasiveness, and assertiveness. An aggressivemale leader may be viewed as “ambitious,”compared with an assertive female leader, who maybe viewed as “pushy.” This is, in part, because theassertive female leader’s behavior violates thegender stereotype that women should be lessauthoritarian and more sensitive, gentle, andnurturing (see Exhibit 4-4).Exhibit 4-4 Gender Stereotyping

In each culture, gender roles and genderstereotypes provide specific expectations ofmale and female behavior. When thoseexpectations are violated (as in the case of awoman acting assertively), it often results in anegative label being used to describe theperson who is violating the expectation. Thiswas at issue in Price Waterhouse v. Hopkins(1989), as cited by Lord and Maher (1991).Ann Hopkins was a high-performing butmasculine-acting prospective partner at PriceWaterhouse. When she was denied apartnership at Price Waterhouse, she chargedthat gender stereotyping had played a role inthe decision (Fiske, Bersoff, Borgida, Deaux,& Heilman, 1991). At the time of her eligibilityand consideration for promotion to partner,Hopkins was the only woman among 88candidates nominated for partnership. Herclose colleagues submitted an evaluationnoting her “outstanding performance” andstrongly urged her admission to thepartnership. When she was not accepted as apartner by the promotion board, she sued.In response to the suit, Price Waterhousecountered that Ms. Hopkins had interpersonalproblems and was considered too “macho” for

the position. The person responsible forexplaining the board’s decision to Ms. Hopkinsadvised her that in order to improve herchances for partnership, she “should walk morefemininely, talk more femininely, dress morefemininely, wear make-up, have her hair styled,and wear jewelry.” Another board memberrepeatedly commented that “he could notconsider any woman seriously as a partnershipcandidate and believed that women were noteven capable of functioning as partners.” Ms.Hopkins brought her gender discriminationlawsuit all the way to the U.S. Supreme Courtand won.Lord, R. G., & Maher, K. J. (1991). Leadership and informationprocessing: Linking perceptions and performance. Boston, MA: UnwinHyman.Whether we are aware of it or not, we all usestereotypes because they help us to simplify ourworld. However, we very often do not take the timeto understand why we are perceiving groups in acertain way. We revert to our cognitive prototypesand ignore relevant information. These habits andbiases are learned and, thus, can be unlearned.Training exercises can help to sensitize individualsto issues of bias such as racism, sexism, andageism. One goal of management is to assist staff

in recognizing that stereotypes are illogical bychallenging these faulty cognitions. The need tochallenge gender stereotypes and other stereotypesin the workplace is one of the reasons so muchincreased attention has been placed on managingdiversity in organizations. It is important to be awareof how our perception of groups can influence ourbehavior, including hiring and managementpractices and interactions with workers. Stereotypesmay lead to discrimination; therefore, it is importantto discuss them and to work toward ridding theworkplace of stereotypes. Negative stereotypes canbe problematic for any organization, and propertraining can be effective in minimizing widely heldfalse beliefs (see Exhibit 4-5). Dobbin and hiscolleagues (2007) found that mandatory diversitytraining programs developed by companies to avoidliability in discrimination lawsuits were ineffective forincreasing diversity in management. However, whendiversity training was voluntary and undertaken toadvance a company’s business goals (and as partof the organization’s culture), it was associated withincreased diversity in management. According tothe study, employees don’t react well whensensitivity training is forced on them.Exhibit 4-5 Exercise to IdentifyStereotypes Within Our Organizations and

ProfessionDiscussion: Have you seen any evidence ofstereotypes in your workplace?Which of the following positions are filled moreby MEN or by WOMEN:Physician __________ Pharmacist__________ Nurse __________Computer Programmer __________ NursesAide __________ Chief of Staff __________Medical Receptionist __________ RadiologyTechnician __________Statements:Health services administrators need to be__________ to be effective.The hospital cafeteria is staffed by people whoare __________.Older people that I have worked with are__________.Pygmalion EffectThe Pygmalion effect, or self-fulfilling prophecy,describes a person’s behavior that is consistent withanother individual’s perception, whether or not it is

accurate. In other words, once an expectation ismade known by another person, an individual willhave the tendency to behave in ways that areconsistent with the expectation. This can havenegative or positive results. If a manager sets highstandards for a subordinate’s performance, thesubordinate is likely to respond accordingly withhigh performance. If a manager sets low standardsfor a subordinate’s performance because thesubordinate is viewed as lacking in ability and/ormotivation, the resulting work performance is likelyto be low. Thus, managers’ expectations directlyinfluence subordinates’ performance. In otherwords, what a manager communicates as theexpectation is what will result. Livingston (1969)stated that what was critical in the communication ofexpectations was not what the manager said asmuch as how the manager behaved. More oftenthan not, indifferent and noncommittal treatmentwas the kind of treatment that communicated lowexpectations and led to poor performance.Livingston related that managers were moreeffective at communicating low expectations to theirsubordinates than at communicating highexpectations.Closely related to the self-fulfilling prophecy is the“Galatea effect.” This effect relates to theexpectations we have for ourselves rather than the

expectations others have for us. To illustrate thisconcept, Livingston (1969) referred to “Sweeney’sMiracle.” James Sweeney was an industrialmanagement professor at Tulane University whowished to disprove the theory that a certain IQ levelwas needed to learn how to program computers.Sweeney trained a poorly educated janitor whose IQindicated that he would be unable to learn to type,much less program. The janitor not only learned toprogram, but also eventually took charge of thecomputer room along with the responsibility oftraining new employees to program and operate thecomputers. As Livingston pointed out, Sweeney’sexpectations were based on what he believed abouthis teaching ability (internal expectations), not onthe janitor’s learning capabilities. Livingston relatedthat “the high expectations of superior managers arebased primarily on what they think aboutthemselves—about their own ability to select, train,and motivate their subordinates. What the managerbelieves about himself subtly influences what hebelieves about his subordinates, what he expects ofthem, and how he treats them” (Livingston, 1969).Managers need to understand the effects of theirown self-expectations and how these expectationsinteract with the expectations they hold andcommunicate about their subordinates’performance. Managers set the tone and culture of

the workplace. By understanding the Pygmalion andGalatea effects, managers can set high but realisticperformance expectations for their subordinates. If amanager rates subordinates as “excellent,” they willcontinue their previous work behaviors. Managerscan also have workers rate their own performance.Expectations about ourselves tend to be self-sustaining.

▶ Impression Management“You never get a second chance to make a firstimpression.” This classic statement is all aboutimpression management, whereby people try toshape others’ impression of them. Impressionmanagement incorporates what we do, how we doit, what we say, and how we say it as we try toinfluence the perceptions others have of us.Individuals will try to present themselves in waysthat will lead to positive evaluations by others byhighlighting their achievements and avoiding thedisclosure of failures. This behavior is common onsocial media, where a person seeks to share onlytheir best moments and pictures. Giacalone andRosenfeld (1989) point out that impressionmanagement is inherently neither good nor bad;rather, it is a fundamental part of our social andwork lives, and we need to view it in the situations inwhich it is used. For example, consider the conceptof self-handicapping. Self-handicapping occurswhen people place obstacles in their own way sothat if they do not succeed, they can blame theobstacles, or if they are successful, they can bragabout performing successfully in spite of thesebarriers.

Schlenker and Weigold (1992) view impressionmanagement as a broad phenomenon in which wetry to influence the perceptions and behaviors ofother people by controlling the information theyreceive. They relate that people actively carry outimpression management in ways that help them toachieve their objectives and goals, both individuallyand as part of groups and organizations. This canbe done consciously and deliberately (e.g., byperfecting job-interview skills), or it may beunconscious. At times, the impression that ismanaged serves to bolster or protect our own self-image (e.g., dressing for success); at other times,we manage impressions in hopes of pleasingsignificant audiences. Sometimes impressionmanagement is truthful and accurate. At othertimes, it involves “false advertising” through the useof exaggeration, fabrication, deception, and lies(Schlenker & Weigold, 1992). Sadly, according toHireRight’s 2017 employment screening benchmarkreport, 85% of surveyed employers uncovered amisrepresentation or falsehood on a cadidate’sresume or job application. Over the years, cases offalsifying one’s professional credentials have beenreported in the popular press with negativeconsequences for the dishonest individual. Forexample, recently an Australian woman falsified herresume and faked references to obtain a high-

paying governmental job. She was sentenced toprison for “deception, dishonesty, and abuse ofpublic office” (Cheung, 2019).

▶ Employee SelectionBecause perceptions determine our behavior towardothers and can cloud our judgments of them, onearea that clearly benefits from using psychologicalprinciples has been the area of employee selection.The goals of selection are (1) to identify theknowledge, skills, abilities, and qualities necessaryto perform a job well; (2) to design tests to measureapplicants’ levels on those key job requirements; (3)to administer and score the tests; and (4) todetermine which applicants are most suitable for agiven position, ensuring that the process is accurateand fair and does not discriminate against membersof protected groups. The basis for this employeeselection process is the ability to identify keyinvariant qualities of individuals (e.g., skills,character, motivation, attitude, leadership potential,and personality) that match up well with thedemands of the position and the culture of theorganization.Psychometrics involves the measurement of humanability, potential, and attitude. This is most visiblewhen employers use tests and special interviewtechniques in employee selection. Job analysis isdesigned to identify the skills, abilities, and

attributes needed to perform well. Context-specifictests can measure applicants’ skill levels on key jobrequirements, such as the operation of hardwareand software. However, as with any tool,instruments that are used to measure human abilitycan be misused or misleading. Instruments that relyon self-report of personal information are subject tobias (such as impression management), and theinterpretation of aptitude scores is also subject tobias (such as stereotypes and halo effects).Therefore, managers who are responsible for hiringand promoting should look for many sources of datafrom which to determine the qualities that areessential to the job, such as personality (seeExhibit 4-6).Exhibit 4-6 Five-Factor Model ofPersonalityPersonality traits are the regularities that weobserve in someone’s behavior, attitudes, andexpressions. Prior research suggests thatvirtually all personality measures can bereduced or categorized under the Five-FactorModel of Personality, also known as the “Big 5.”The dimensionality of the Big 5 has been foundto be applicable across all cultures.

The Big 5 model is based on the concept thatpersonality can be described and measured onfive broad dimensions and/or traits: openness,conscientiousness, extraversion,agreeableness, and neuroticism.Dimensions/TraitsDescriptionsOpennessImaginative, innovative, open-mindedConscientiousnessCompetent, responsible,dependable, hardworking, goaloriented, self-disciplinedExtraversionAssertive, social, positive emotionsAgreeablenessTrusting, straightforward, compliant,warmhearted, generous, modestNeuroticismEmotional, insecure, self-conscious,impulsive, vulnerableData from McCrae, R. R., & John, O. P. (1992). An introduction to thefive-factor model and its application. Journal of Personality, 60, 175–215.One goal in this discussion is to help managersmake accurate and fair assessments of staffmembers or potential staff members for variouspositions in their organizations. Who should functionin positions of high contact with patients? Who isbetter at working with computers? Who is most ableto direct a unit to promote the best clinical care?

Who is best suited to manage the business office?How can we help employees who are not ready toassume a leadership role to develop the skills forleadership while still working comfortably in theircurrent subordinate positions? These are thequestions a manager or administrator must answerin making personnel decisions. To do so requiresthe manager to perceive the unchanging qualities ofa person across situations, or the key “traits” thatunderlie success in a job.Many instruments that are used to assess personneland management/leadership potential, such as theCampbell Interest and Skills Inventory, or theEnneagram of Personality, are trying to identify“constants” of personality and work style. TheCampbell Interest and Skills Inventory comparesemployee-reported interests and skills to those ofpeople who describe themselves as satisfied withtheir careers and highlights occupational areas toconsider during career exploration. Here, theinvariant is a pattern of interests and workpreferences that people carry from one job toanother. The Ennagram of Personality groupsindividuals into nine interconnected personalitytypes and helps them understand how their typerelates to other types.Another commonly used scale is the Myers-BriggsType Indicator (MBTI), an instrument for measuring

a person’s preferences using four opposing-poledimensions (extraversion/introversion,sensate/intuitive, thinking/feeling, andjudging/perceiving). On the basis of how someoneanswers a series of questions, this instrumentassigns a personality type. Each personality type issuited for specific occupations. For example,extroverts are better suited for sales positions, andintroverts do well with information technologypositions. There are many pros and cons to usingMyers-Briggs, or any instrument, as the soleselector of occupational areas based on types. Onthe positive side, these instruments pick up patterns(invariants) in self-reported behavioralcharacteristics and provide a categorization of typesthat may be useful in assessing certain qualitiesrelevant to leadership and workplace issues. Theymay also help managers identify areas wherespecific coaching or development might benefit theindividual. On the negative side, these tests tend togeneralize a person’s likely traits, which may not bean entirely accurate reflection of that individual andcan lead to incorrect stereotyping.

▶ SummaryIn this chapter, we reviewed several socialpsychology concepts that are important formanagers to understand. These are factors that caninfluence and bias our perceptions; therefore, weneed knowledge of these biases to temper andinform our perceptions. In discussing attitudes andhow to change them, we become more aware ofthose distinctly unique human qualities thatcomplicate the workplace but also make it sointeresting. Likewise, if we understand how workerssee the world, we are in a better position to facilitatea productive workplace. Today’s health caremanagers have many resources at their disposal,including a wide-ranging scientific literature onorganizational behavior, psychology, and humanresource issues in the workplace. Ideally, thischapter will encourage you to develop and use yourown skills as a social perceiver and give you someconfidence that you can foster positive attitudes. Weare always learning, improving, and building skills insocial perception. In this way, we will continue touse our understanding of human behavior to createa positive and healthy workplace.

Discussion Questions 1. Define attitudes and provide examples. 2. What is meant by cognitive dissonance? 3. What are common methods to measure aperson’s attitude? 4. List and describe ways in which attitudes canbe changed. 5. What is the difference between the haloeffect and the horn effect? 6. Define the four stages of the perceptionprocess. 7. How does attribution theory allow managersto justify workers’ behaviors? 8. Define social perception. 9. What is the difference between contrasteffect and projection?10. Is stereotyping negative or positive? Why?11. Why is stereotyping so problematic for thehealth care industry?12. What is the difference between thePygmalion effect and the Galatea effect?13. Is impression management negative orpositive? Why?14. Is employee selection an unbiased process?Why?

CASE STUDY ANDEXERCISEExercise 4-1 Gender Stereotypingin OrganizationsRole-PlayChoose a male and a female volunteer. Eachmember of the pair will argue over a situationin the workplace, such as departmentsnegotiating over which gets to purchase apiece of new medical equipment (limitedfinancial resources), deciding whether laptopsor PCs are appropriate for the nursingstations, or choosing which color to paint thehospital’s hallways.Designate one of the participants as the“influencer,” who should try to “win” theargument. Designate the other as the“influencee,” who should resist.The influencer has a fixed amount of time,perhaps 1 minute, to persuade the influencee.After you have observed the interaction, breakinto groups for discussion of the influencer

(i.e., leader), and make a list of adjectivesused to describe the influencer. For example,was the leader “bossy” or “dominating” or“assertive”?Have the male and female reverse roles with anew situation and repeat the discussion. Nowdiscuss the two leadership influencers in bothof the role-play episodes. Which one hadmore skill and fit your image of a leader?Record your responses.Break into groups again, and describe thesecond influencer with an adjective list.Continue until several male–female dyadshave role-played as influencers andinfluencees. Record the descriptive adjectives.Rate the overall leadership of each influencer.Record the responses.Discussion Questions1. Were differences in leader perceptionsdue to gender stereotypes or behavioraldifferences?2. What social invariants (constants or traits)can you identify as being important forleadership positions?3. Why are leadership perceptionsimportant? Can attributions about

leadership ability affect the behaviors offollowers? If so, how?DebriefingResearch by Butler and Geis (1990) suggeststhat in role-play exercises such as those in thepreceding activity, the female leader wasdescribed differently in terms of herpersonality traits and was more likely to be therecipient of covert gender stereotypingcompared with males.How do their findingsmatch your results?Exercise 4-2 Implicit AssociationTestAn interesting approach to uncoveringpersonal hidden biases is the ImplicitAssociation Test (IAT). IAT is a component ofProject Implicit, a collaborative research effortbetween researchers at Harvard University,the University of Virginia, and University ofWashington. IAT may be accessed atimplicit.harvard.edu/implicit/.This web-based self-assessment prompts theuser to link words with images that appear onthe computer screen. The links reveal theuser’s mental associations or automaticpreferences, which are indicative of the user’s

tendency to view one identity group morepositively over another. Millions of individualshave taken the IAT. An array of implicit biasassessments and answers to frequently askedquestions about the IAT can be found atimplicit.harvard.edu. As the websitecautions, the test sometimes provides somechallenging personal feedback!Exercise 4-3 Jung Typology Test:Personality AssessmentA 72-item web-based assessment is availableat www.humanmetrics.com. Aftercompleting the questionnaire, you will begiven a description of personality type andyour type formula according to the Carl Jungand Isabel Myers-Briggs typology. There areno right or wrong answers; the test is only foryour own self-assessment.Did the results accurately describe yourpersonality traits? Share your results with asignificant other. Does your significant otheragree with your results? (Note: Shortquestionnaires, tests, and assessments canbe unreliable in certain situations.) This web-based assessment is designed primarily tostimulate your thinking about yourself.

CASE STUDY 4-3 Only 15 Weeksto Thanksgiving!Scene I“I just hate the thought of going back to work,”Mary told her brother Tom. It was the lastnight of her vacation, which Mary thought hadbeen much too short. “It’s 15 weeks untilThanksgiving.”“I know you’re miserable,” Tom replied.“You’ve been more and more unhappy in thatjob for the past 5 years. You’re a totallydifferent person when you’re on vacation. Iknow we’ve discussed this a thousand times,but isn’t there something else you can do?”“Don’t you think I’d do something else if Icould?” Mary retorted. “I’m sorry, I knowyou’re only trying to help, but I really think I’mtrapped in this situation. With my diabetes andhigh blood pressure, I can’t afford to retireearly because I need the health insurance. Icould get Social Security at 62, but the healthcare coverage doesn’t start until 65. Asupplemental policy would be much tooexpensive, even if I could get one. I know thatas soon as I go back to work, my bloodpressure and sugar will go up from the stress.”

“Yes,” said Tom, “and you’ll start counting thedays 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! Winning the lottery!” Mary said indisgust. “That’s all I can think of!”Scene IIDan, the manager of the health informationdepartment of a large health care system inSouth Florida, sighed as he finished hiscoffee. He thought, “Mary will be back fromvacation tomorrow. I keep hoping that she’ll beless stressed out when she gets back, but italways seems to be the same. She has somuch experience, and she could be a greatrole model for the younger people at work, butI just can’t seem to get her attitude turnedaround. I’ve tried everything I can think of—special projects outside the department,adjusted work schedule, more responsibilityand authority on day-to-day stuff, advancedcomputer training—but she’s my big failure asa boss.”“Oh, I think she’s just jealous of you,” his wifeSonia replied. “You’ve really worked hard on

the old witch. I just don’t think she’s worth theeffort. Why doesn’t she just retire?”“It’s a good thing the human resources peopledidn’t hear that!” Dan laughed. “Sonia, you’rejust plain wrong about Mary. She knowseverything about the department. Without herhelp, I couldn’t have managed at all when Istarted there. I can’t believe she’s jealous ofme. She’s really been a lot of help. I just wishshe weren’t so unhappy. You know, I talked toJean about her the other day. They started inthe company together about 20 years ago.Jean said that she wasn’t sure what wasgoing on with Mary because they haven’tbeen very close lately, but she said that Maryhas always been really independent.Stubborn, even. And quite outspoken aboutthings she disagrees with. She’s usually right,but sometimes it’s tough for people to listen toher because of the way she puts things. Idon’t think she’s kidding when she says that’spart of her New England upbringing. Did youknow she got thrown out of college forobjecting to some policy? And then she forcedthem to reinstate her because they hadn’tfollowed due process?”

“Oh, so she’s always been a witch? FromSalem, perhaps?” Sonia replied. “Come on,Dan, give it a rest. You don’t need to figureMary out until tomorrow! Don’t you want towatch the Miami Dolphins beat the TampaBay Bucs? Can you imagine? They favor theBucs to win!”In Scene I, what is Mary’s attitude? Are youable to identify the three elements of anattitude in what she says?In Scene II, Dan and Sonia have very differentperceptions about Mary. Why?

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Other Suggested ReadingsAllport, G. W. (1937). Personality: A psychological interpretation.New York, NY: Holt Rinehart & Winston.Barnes-Farrell, J. L., & Ratz, J. M. (1997). Accommodation in theworkplace. Human Resource Management Review, 7, 77–107.Brief, A. P. (1998). Attitudes in and around organizations.Thousand Oaks, CA: Sage.Briggs-Myers, I., & Briggs, K. C. (1980). Myers-Briggs TypeIndicator (MBTI): Gifts differing. Palo Alto, CA: ConsultingPsychologists Press.Briggs-Myers, I., & McCaulley, M. H. (1985). Manual: A guide tothe development and use of the Myers Briggs Type Indicator.Palo Alto, CA: Consulting Psychologists Press.Campbell, D. P. (1970). Campbell Interest and Skill Survey–CISS.Upper Saddle River, NJ: Pearson Assessments, PearsonEducation. Available from www.pearsonassessments.com.Last accessed December 28, 2003.Della-Giustina, J. L., & Della-Giustina, D. E. (1989). Quality ofwork life programs and employee motivation. ProfessionalSafety, 34(5), 24.Denton, D. K., & Boyd, C. (1990). Employee complaint handlingtested techniques for human resources managers. Westport,CT: Quorum Books.Eagly, A., & Chaiken, S. (1993). Psychology of attitudes. NewYork, NY: Harcourt, Brace Jovanovich.

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research in industrial and organizational psychology (pp. 385–457). New York, NY: Elsevier Science.Van Ryn, M., & Burke, J. (2000). The effect of patient race andsocio-economic status on physicians’ perceptions of patients.Social Sciences Medicine, 50(6), 813–828.Walsh, V., & Kulikowski, J. J. (1998). Perceptual constancy: Whythings look as they do. Cambridge, UK: Cambridge UniversityPress.

CHAPTER 5WorkplaceCommunication*The greatest barrier to communication is the illusion of it in themind of the sender– William H. WhyteLEARNING OUTCOMESAfter completing this chapter, the student shouldbe able to:Describe the communication process.Understand the importance of feedback in thecommunication process.Identify various verbal and nonverbal methodsof communication.Explain the common barriers tocommunication and apply strategies toovercome these barriers.

Discuss the elements of effectivecommunication for knowledge management.Describe the various components of effectivestrategic communication.Understand the flow of intraorganizationalcommunication.Comprehend the challenges of cross-culturalcommunication.Understand the flow of communication withexternal stakeholders and the public sector.* We wish to acknowledge and thank Dr. Kristina L. Guo, who wasa contributing author of the earlier versions of this chapter, whichappeared in the previous editions of Organizational Behavior inHealth Care, Jones & Bartlett Learning.

▶ Overview“Communication is perhaps one of the greatestchallenges facing managers and leaders today”(Hicks, 2011, p. 86). Fundamental and vital to allhealth care managerial functions, communication isa means of transmitting information and makingoneself understood by others. Communication is amajor challenge for managers because they areresponsible for providing information that shouldresult in efficient and effective performance inorganizations. Every managerial function or activityinvolves some form of communication. To plan,organize, direct, or lead, a manager mustcommunicate with and through others. Managerialdecisions are effective only if they arecommunicated and understood by the people whoare responsible for enacting the decisions.Furthermore, employee motivation and satisfactiondepend on effective communication.Communication is essential to building andmaintaining relationships in the workplace.Communication is the creation or exchange ofthoughts, ideas, emotions, and understandingbetween sender(s) and receiver(s). Managers whounderstand this exchange can better analyze their

communication patterns, resulting in more effectivecommunication in the workplace.Although managers spend most of their timecommunicating (e.g., sending or receivinginformation), one cannot assume that meaningfulcommunication occurs in all exchanges (Dunn,2006). Once a message has been sent, many areinclined to believe that communication has takenplace. However, communication does not occur untilinformation and understanding have passedbetween the sender and the intended receiver. Forexample, a receiver may hear a sender but mightnot have comprehended the sender’s actualmeaning. Effective communication occurs when themessage received is the same as the one intended.Communication enables people to establish andmaintain positive interactions in the workplace. Aneffective communicator overcomes barriers toengage in more meaningful and successfulcommunication.

▶ Communication ProcessCommunication is a complex and dynamic process.Figure 5-1 illustrates the S-M-C-R model of thecommunication process. Information originates fromthe sender (S) and is encoded into a message (M)that is forwarded through a selected channel (C) tothe designated receiver (R). Messages are receivedand decoded or interpreted by the receiver.Decoding is affected by the receiver’s priorexperiences and frames of reference. Accuratedecoding of the message by the receiver is criticalto effective communication. The closer the decodedmessage gets to the intent of the sender, the moreeffective the communication. However,environmental and personal barriers can hamperthe communication process; these barriers aredescribed in a later section of this chapter. Forensuring that messages are received as intended,feedback is a necessary component of thecommunication process. The receiver createsfeedback to a message and encodes it beforetransmitting the feedback to the sender. The senderreceives and decodes the feedback. Feedback isthe destination’s reaction to a message (Certo,1992). It is an important element of communication,

since it allows for information to be shared betweenthe receiver and sender in a two-waycommunication process.Figure 5-1 The Communication Process

▶ FeedbackEffective communication takes place when asender’s message is fully understood by thereceiver. In essence, feedback is a response (i.e., asignal) from the receiver that enables the sender todetermine whether a message has been received inits intended form. The response or signal may takethe form of an oral comment, a written message, asmile, a sigh, raised eyebrows, or some otheraction. Even a lack of response by the receiver maybe interpreted as a form of feedback. Withoutfeedback, the sender cannot confirm that thereceiver has interpreted the message correctly.Feedback is a key component in the communicationprocess because it allows the sender to evaluatewhether the message was decoded as intended or acorrective action is needed to clarify the intendedmessage. For instance, a manager needs feedbackto determine the level of staff acceptance of a newpolicy requiring employees to call and verballyconfirm all patients’ appointments 48 hours inadvance. The feedback process suggests that bothsender and receiver need to adjust their outputs asrelated to the transmitted information. In theabsence of feedback, when the communication

process does not allow for sufficient feedback todevelop, or when feedback is ignored, a certainamount of feedback will occur spontaneously andwill tend to take a negative form.In one-way communication, a person sends anunidirectional message without interaction. Forexample, after reviewing a patient’s lab results, aphysician orders a medical test for the patient. Thephysician instructs the medical assistant to arrangethe appointment within the week and notify thepatient. The physician’s order is an example of one-way communication that does not provide theopportunity for the patient to pose questions directlyto the physician. Negative feedback may occur if thepatient expresses frustration or anger at thephysician for not directly explaining the necessity ofthe medical test. However, the same patient couldexpress satisfaction and appreciation toward themedical assistant who explains the purpose of themedical test based on the patient’s lab results. Inthis case, the opportunity for feedback results intwo-way communication between the patient andthe medical assistant. Two-way communication ismore accurate and information-rich when themessage is complex, although one-waycommunication is more efficient, as in the case ofthe physician’s written order.

To be effective, communication must allowopportunities for feedback. Feedback can takeseveral forms, each with a different intent. Keyton(2002) describes three different forms of feedback:descriptive, evaluative, and prescriptive.Descriptive Feedback: Feedback that identifiesor describes how a person communicates. Forinstance, Manager A invites her friend,Manager B, to attend A’s staff meeting andcomment on her form of communication. Afterthe meeting, B tells A that she was very clearand instructive as she introduced her staff tothe new computer database for managingpatient accounts. In this example, B providesdescriptive feedback of A’s communication withher staff.Evaluative Feedback: Feedback that providesan assessment of the person whocommunicates. In the preceding example, ifManager B evaluates Manager A’s form ofcommunication and concludes that A wasinstructive and helpful, which enabled A’s staffto feel comfortable when going to her foradvice, then B has provided positive evaluativefeedback of A’s interaction with her staff.Prescriptive Feedback: Feedback that providesadvice about how one should behave orcommunicate. For example, Manager A asks

Manager B what changes she could have madeto better communicate her message to herstaff. B suggests that A be friendlier and morecooperative by giving the staff specific timeswhen A is available for help with the newcomputer database. This type of advice isprescriptive feedback.In addition to forms and intent, there are also fourlevels of feedback. Feedback can focus on a groupor an individual working with specific tasks orprocedures. It can also provide information aboutrelationships within the group or individual behaviorwithin a group (Keyton, 2002).Task or Procedural Feedback: Feedback at thislevel involves issues of effectiveness andappropriateness. Specific issues that relate totask feedback include the quantity or quality ofa group’s output. For instance, are patientssatisfied with the new outpatient clinic? Did thegroup complete the project on time? Proceduralfeedback refers to whether a correct procedurewas used appropriately at the time by thegroup.Relational Feedback: Feedback that providesinformation about interpersonal dynamics withina group. This level of feedback emphasizeshow a group gets along while working together.

It is effective when combined with descriptiveand prescriptive forms of feedback.Individual Feedback: Feedback that focuses ona particular individual in a group. For example,is an individual in the group knowledgeable?Does the individual have skills that are helpfulto this group? What attitudes does theindividual have toward the group as themembers work together to accomplish theirtasks? Is the individual able to plan andorganize within a schedule that contributes tothe group’s goal attainment?Group Feedback: Feedback that focuses onhow well the group is performing. Questionslike those raised at the individual feedback levelare asked of the group. Do team members inthe group have adequate knowledge tocomplete a task? Have they developed acommunication network to facilitate theirobjectives?Feedback can take the form of questionnaires,surveys, or audio or video recordings of groupinteraction. It can also occur in activities such asmarket research, client surveys, accreditation, andemployee evaluations (Liebler & McConnell,2008). Feedback should be used to help a groupcommunicate more effectively by encouraging groupmembers to identify with the group and increase its

efficacy. Feedback should not be viewed as anegative process. O’Hair, Stewart, and Rubenstein(2006) point out that negative feedback does notimply “bad,” and positive feedback does not imply“good.” Negative feedback indicates that you shoulddo less of what you are doing or change tosomething else. Positive feedback encourages youto increase what you are doing. Thus, managersshould use feedback as a strategy to enhancegoals, awareness, and learning.Feedback, as a managerial tool, enables managersto anticipate and respond to changes. Structuredfeedback enhances managerial planning andcontrolling functions. Because of the value offeedback, managers should encourage feedbackand evaluate it systematically.The Johari WindowThe process of feedback can also be illustrated bythe Johari Window, a useful communication modelto improve understanding between individuals. Itwas created by Joe Luft and Harry Ingham in 1955(hence the name “Johari”) (Luft, 1984). The JohariWindow model has two key concepts: (1) You canbuild trust with others by disclosing informationabout yourself, and (2) with the help of feedbackfrom others, you can learn about yourself and cometo terms with personal issues.

As shown in Exhibit 5-1, windowpane 1 isconsidered the open area, in which informationabout you is known both to you and to others. Thisincludes your behavior, knowledge, skills, attitudes,and “public” history. Tubbs (2001) described thisarea the general cocktail party conversation inwhich an individual willingly shares personalinformation with others. For instance, at an officepicnic, you might reveal to your coworkers that youare a vegetarian to support your desire for ahealthier lifestyle. What is posted on social mediamay also be considered public. Windowpane 2refers to a blind area in which others knowinformation about you that you either are unaware ofor do unthinkingly. For example, your colleaguesknow that although you are a nice and caringperson, you chronically interrupt and talk overothers in conversation.Exhibit 5-1 The Johari Window

The third windowpane is the hidden area, in whichyou have likes and dislikes that you are unwilling toshare with others. This area includes your values,beliefs, fears, and past experiences that you wouldnot wish to reveal. The fourth and last windowpaneis the unknown—things that are unknown by youand are also unknown by others. This is an area ofpotential growth or self-actualization. It representsall the things that you have never tried, participatedin, or experienced.Increasing mutual understanding through feedbackand disclosure allows one to increase the open areaand reduce the blind, hidden, and unknown areas ofoneself (McShane & Von Glinow, 2003). Luft(1984) argues for increasing the open area in theJohari Window so that you and your coworkers areaware of your limitations. This is done by receivingmore feedback from others and decreasing one’sblind area (windowpane 2) and by reducing thehidden area (windowpane 3) through disclosingmore about oneself. The combination of feedbackand disclosure may also help to produce moreinformation in the unknown area (windowpane 4).The Johari Window can be used for openingchannels of communication. Open communication isimportant for improving employee morale andincreasing worker productivity. Open communicationallows supervisors and subordinates to freely

discuss organization-related issues such as goalsand conflicts. Nevertheless, Luft (1984) is cautiousabout the use of the Johari Window for all situations.He offers several guidelines for the appropriatenessof self-disclosure. He recommends that self-disclosure is a function of an ongoing relationship.The timing and extent of disclosure are critical. Acompetent communicator knows when, with whom,and how much to disclose.

▶ Communication ChannelsAnother important component of the communicationprocess is selecting an appropriate communicationchannel. This is the means by which messages aretransmitted. As Mazurenko and Hearld (2014, p. 2)note, “Individuals may have different attitudestoward [these] different communication channels,often varying as a function of different personal andcontextual factors, which can result in recipientsresponding differently to the same messagereceived via different channels.”There are two types of channels: verbal andnonverbal. Various channels of communication andthe amount of information transmitted through eachtype are illustrated in Figure 5-2.

Figure 5-2 Communication ChannelsReproduced from Information richness: A new approach tomanagerial behavior and organizational design, by R. L. Daft andR. H. Lengel, 1984, in B. Staw and L. Cummings (Eds.), Researchin organizational behavior vol. 6, pp. 191–233, Greenwich, CT: JAIPress.Verbal CommunicationVerbal communication relies on spoken or writtenwords to share information with others. Dialogue, aform of verbal communication, is a discussion orconversation between people in which participantsmay be exposed to new information. In an

organization, the process may involve a series ofmeetings of organizational members representingdifferent views on issues of mutual interest.According to Edgley and Robinson (1991), fordialogue to be successful, there are severalfundamental principles: Engage motivated people,use a facilitator and a recorder to manage theprocess, have the group develop procedures andlive by them, ensure confidentiality, and let theprocess move at its own pace. Adhering to theseprinciples will improve dialogue and result in moreeffective communication.There are different forms of verbal communication,which should be used for different situations. Face-to-face meetings are information rich, allowing foremotions to be transmitted and immediate feedbackto take place. Written communication is moreappropriate for describing details, especially thoseof a technical nature, as in the example ofmonitoring a patient’s complex medical condition.Although traditional written communication wascomparatively slow, the development of email andother forms of electronic communication such astexting has enabled written communication throughthese channels to dramatically improve efficiency(see Case Study 5-1).CASE STUDY 5-1 Are We

Getting the Message Across?James Warick, director of physical plant atSouthern Hospital, emailed Diane Curtis,director of nursing, informing her of a waterleak in Operating Room 1, which would needto be shut down for repairs early the nextmorning. Curtis forwarded the message toJoanne Messing, the operating room nursesupervisor on duty for the night shift. Messing,tired from a long night’s work, handwrote amessage to the nurse supervisor on the dayshift to switch the 8:00 A.M. operation fromRoom 1 to Room 8 and taped the messageonto the bulletin board. David Swanson, theday-shift nurse supervisor, arrived at 7:30 A.M.and found Dr. Roberts shouting that hispatient was ready for surgery but no roomswere available because Dr. Jones had alreadytaken Room 8.Discussion Questions1. What were the channels ofcommunication used by each person?2. Should a different channel ofcommunication have been used instead?3. What can be done to resolve theproblem?

4. What policies should be put in place toprevent this from occurring again?Electronic CommunicationThe use of information technology is dramaticallyaffecting how we communicate. Consider thefollowing:When Mohandas Gandhi wanted to inform the world ofinjustices committed by imperialist Great Britain towardSouth Africa and India in the 20th century, he relied onthe written word. His journals and those of hiscolleagues, as well as firsthand observations byjournalists, provided details of wrongdoing. Lookingthrough the lens of the 21st century, Gandhi’smessage traveled slowly and only to limited parts ofthe world. Fast-forward to a century later, whencitizens protesting a planned petro chemical plant nearthe Chinese city of Xiamen organized their forces byusing cell phones, text messaging, emails, and blogs.Images of the protest were virtually available to theworld in real time. In response to this negativepublicity, the Chinese government postponedconstruction of the petro chemical plant, acceding tothe protestors’ demands that an environmental impactstudy be completed. (Heraty, 2014, p. 111)The Internet is a global network of interconnectedyet independently operated computers. An intranet

is an organization’s private Internet. Especially inthe case of health care organizations, the intranethelps to protect privacy and confidentiality ofcompany records, such as patients’ medicalrecords. An extranet is an extended intranet thatenables employees to stay connected with selectedcustomers, clients, suppliers, and other partners,such as health care insurance companies andhealth care vendors. The Internet, intranets, andextranets enable employees to access, manage,and distribute information. If properly set up andmanaged effectively, these systems can enhancecommunication. On the other hand, ineffectivemanagement can hinder communication and resultin decreased productivity.Email and other forms of electronic communicationhave revolutionized the communication process,allowing for rapid communication across anydistance. Email and other forms of electronicmessaging allow information to be quickly created,changed, saved, and sent to many people at thesame time. Various scheduling apps and sharedcalendars can be used to check availability,coordinate meeting times, and send meetingreminders and alerts. Although emails, texts, andother forms of electronic messaging are convenientforms of communication, they have severalproblems and limitations. The most obvious is

information overload. Users can becomeoverwhelmed by the number of messages theyreceive on a daily basis, many of which areunnecessary to the receiver. Another problem withthese forms of communication is theirineffectiveness in communicating emotion. The toneof a message can easily be misinterpreted, causingmisunderstandings between sender and receiver.Icons known as emoticons or emojis have beendeveloped to represent emotions in email and textmessages. However, the use of emoticons or emojisis not considered professional in many settings.Email can also reduce politeness and respect forothers. Flaming is the act of sending an emotionallycharged message to others, especially beforeemotions subside. This common problem occursfrequently in forms of electronic communicationbecause the sender does not have to bear thediscomfort of having a heated discussion face toface. In a face-to-face discussion, the act ofscheduling and coordinating an in-person meetingallows a person to cool down and develop secondthoughts. Additionally, a face-to-face meeting mayallow the receiver of the heated message torespond quickly with feedback that may beuncomfortable for the sender. When you aretempted to respond with an emotionally chargedmessage, it is best to acknowledge that you have

received the message but to wait at least 24 hoursbefore crafting your response, to allow emotions tosubside. To reduce these communication problems,training in communication through electronic means,may be useful (see Table 5-1).Table 5-1 Email Etiquette1. Before pressing send on an email, consider how yourmessage would be perceived if it was forwarded to yourentire organization. Keep your audience in mind beforediscussing private matters, expressing anger, or criticizingothers. Emails last forever. There is no guarantee that yourmessages will stay private.2. Think twice before discussing confidential information byemail. If confidential patient information falls into the wrongperson’s hands, you could risk legal consequences.3. Remember to briefly introduce yourself when emailing anew person for the first time. Don’t assume the recipientalready knows who you are, or remembers you from oneinteraction.4. Be mindful of punctuation and go easy on exclamationpoints. More than one exclamation point per email maycome across as overexuberant and unprofessional.5. Reply to emails within one or two days. If your response willtake longer, reply to let the person know you are workingon an answer and will get back to them soon. Don’t leavethem waiting days, wondering whether you received theirmessage.6. Try not to send one word responses unless it is the end ofthe conversation. For example, just replying “Thanks” or“OK” could be perceived as unprofessional.

7. Avoid using text shorthand such as “u” instead of “you” or“idk” instead of “I don’t know.” Don’t use emojis in aprofessional context. The occasional : ) is ok in somecontexts, but don’t go overboard.8. Make sure your subject line is clear and direct. It shouldconcisely describe the crux of your message. Don’t bevague. Make it easy for someone with a clogged inbox tosee your message and understand it right away.9. If your message is on a new topic, start a new thread. Don’treply to an old email with a message that has nothing to dowith the previous conversation. If the topic changes, feelfree to change the subject line in your reply.10. Don’t “reply all” unless all the recipients need to know yourresponse. Avoid clogging people’s inboxes withconversations that are irrelevant to them.11. Keep your emails short and to the point. Don’t send longblocks of text that require too much time and effort todecode. If your email has multiple questions, number themso they are easier to read and respond to.12. If you find yourself typing out several long detailed emails,try calling the person instead. You’ll find that speaking overthe phone can resolve confusion and miscommunication inminutes while email correspondence might take all day.13. After discussing issues in person, send a follow up emailsummarizing what was discussed as confirmation. Thisleaves a helpful paper trail for both of you.14. Adjust your writing style to your audience. Keep youremails formal and polite when corresponding with higherups and those who tend to write formally themselves. Forother with a more informal style, you may adjust your toneto match theirs.15. Include an automatic signature with your name, title, email,and other contact information such as phone number andaddress, if applicable.

16. Managers should communicate expectations regardingemail etiquette. Don’t assume your team already knowsemail best practices. Set the standard and communicate it.17. Your emails affect your reputation. Every message yousend reflects on you, your work ethic, and your level ofprofessionalism. If your emails are rushed, full of typos,repetitive and disorganized, your colleagues will assumethat your other work is low quality as well.There are key benefits to using email or otherelectronic messaging tools. It reduces the time andcost of distributing information to employees.Furthermore, it has increased the potential for moreemployee collaboration and teamwork, increasingthe speed of organizing meetings, and collectingfeedback on documents. Another advantage ofelectronic messaging is its flexibility, especially as itcan be easily accessed on computers, tablets, andsmartphones, and watches. Senders and receiverscan now communicate in a variety of settings whilebeing mobile and are not restricted to one location.Handheld devices have contributed to the increaseddemand for access to information.Nonverbal CommunicationNonverbal communication is sharing informationwithout using words to encode messages.Mehrabian (1980) demonstrated that only 7% of anymessage is conveyed through words, 38% by the

way in which the words are said, and 55% throughnonverbal elements such as facial expressions,gestures, and posture.There are four basic forms of nonverbalcommunication: proxemics, kinesics, facial and eyebehavior, and paralanguage (Nelson & Quick,2003). Proxemics is the study of an individual’sperception of and use of space. Territorial spaceand seating arrangement are two examples. Forinstance, to encourage cooperation, coworkersworking together on a patient safety report shouldsit next to each other. To facilitate communication, amanager should seat a subordinate at a 90° angle inorder to discuss resolving staff complaints.Kinesics refers to body language, which is used toconvey meaning and messages. Pacing anddrumming fingers are signs of nervousness.Wringing the hands and rubbing the temples signalstress. Facial and eye behavior is another exampleof nonverbal communication. For example, when ahealth care manager interviews a candidate for aposition as a clinical care coordinator, the managerattaches meaning to frowns and eye contact.Avoiding eye contact tends to close communication.However, cultural and individual differencesinfluence appropriate eye contact. Moderate directeye contact communicates openness, while toomuch direct eye contact can be intimidating.

Paralanguage consists of voice quality, volume,speech rate, and pitch. Rapid and loud speech maybe taken as signs of anger or nervousness. Thecommunication process is impeded by negativenonverbal cues. For example, arriving late for aninterview with the vice president of finance, talkingvery fast, avoiding eye contact, and getting tooclose during a conversation or in a seatingarrangement for a committee meeting have negativeeffects on the communication process.To determine the most appropriate channel ofcommunication for sending messages, one needs toidentify whether verbal or nonverbal communicationshould be used. At the same time, ideal channels ofcommunications can be selected through anexamination of the information richness andsymbolic meaning of messages (Daft & Lengel,1984). Information richness refers to the volume andvariety of information that can be transmitted. Asshown in Figure 5-2, face-to-face meetings havethe highest information-carrying capability becausethe sender can use verbal and nonverbalcommunication channels and the receiver canprovide instant feedback. When a wrong channel ofcommunication is used, this wastes time and leadsto more misunderstanding. When communication isnonroutine or unclear, information-rich channels arerequired for more effective communication. For

example, suppose a gunshot victim is brought into atrauma center. Organizing the care of this patientrequires face-to-face instructions to quicklycoordinate work flow and minimize the risk ofconfusion among various care providers. However,for routine communications, less information-richchannels can be used.Choosing one communication channel over anotherlends meaning to the message; that is, there issymbolic meaning to the selection of a particularchannel of communication beyond the messagecontent. For example, when a manager tells anemployee that they must have a face-to-facemeeting, this symbolizes that the issue is important,compared with a brief email message withinstructions.In summary, one essential part of thecommunication process is selecting an idealchannel of communication. The use of differentchannels leads to differences in the amount andvariety of information transmitted. Choosing anappropriate channel of communication involvesunderstanding symbolic meanings and theinformation richness of messages.

▶ Barriers to CommunicationAs is shown in Table 5-2, several forms of barrierscan impede the communication process. Longest,Rakich, and Darr (2000) classify these barriers intotwo categories: environmental and personal.Environmental barriers are characteristic of theorganization and its environmental setting. Personalbarriers arise from the nature of individuals and theirinteractions with others. Both barriers can block,filter, or distort messages when they are sent andreceived.Table 5-2 Overcoming Barriers to CommunicationBarriers toCommunicationOvercoming Barriers toCommunicationEnvironmental Barriers1. Competition fortime and attention1. Devote adequate time and attention tolistening2. Multiple levels ofhierarchy2. Reduce the number of links or levels ofhierarchy3. Managerialphilosophy3. Change philosophy to encourage the freeflow of communication4. Power and statusrelationships4. Consciously tailor words and symbols andreinforce words with actions so that

messages are understandable5. Organizationalcomplexity5. Use multiple channels of community toreinforce complex messages6. Specificterminology6. Consciously define and tailor words andsymbols, and reinforce words with actions sothat messages are understandablePersonal Barriers 1. Frame ofreference 2. Beliefs 3. Values 4. Prejudices 5. Selectiveperception 6. Jealousy 7. Fear 8. Evaluation of thesource (sender) 9. Status quo10. Lack of empathy1. Consciously engage in efforts to becognizant of others’ frames of reference andbeliefs2. Recognize that others will engage inselective perception, jealousy, fear, andprejudices to help diminish the barriers3. Engage in empathyReproduced 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 includecompetition for attention and time between sendersand receivers. Multiple and simultaneous demandscause messages to be incorrectly decoded.Sometimes the receiver hears the message but

does not understand it. A receiver who is not payingadequate attention to the message is not reallylistening. Listening is a process that integratesphysical, emotional, and intellectual inputs into thequest for meaning and understanding. Listening iseffective only when the receiver understands thesender’s messages as intended. Thus, withoutengaging in active or mindful listening, the receiverfails to comprehend the message. Mindful listeningis a skill that managers need to develop to beeffective in the busy 24/7 world of health care.According to communication expert Rebecca Shafir(2003), the goal of mindful listening is to silence thenoise and distractions of our external environmentas well as our own thoughts so that the sender’sentire message can be heard and understood.Time is another barrier. Lack of time prevents thesender from carefully thinking through messagesand structuring them accordingly. Lack of time alsolimits the receiver’s ability to decipher messagesand determine their meaning.Other environmental barriers include theorganization’s managerial philosophy, multiplelevels of hierarchy, and power or statusrelationships between senders and receivers.Managerial philosophy can promote or inhibiteffective communication. Managers who are notinterested in or fail to promote intraorganizational

communication upward or disseminate informationdownward will create procedural and organizationalblockages. A managerial philosophy requiring thatall communication follow the chain of commandshows a lack of attention and concern towardemployees and restricts communication flow.Furthermore, when subordinates encountermanagers who fail to act, the subordinate might beunwilling to communicate upward in the futurebecause of a perception that communications arenot taken seriously.Managerial philosophy affects not onlycommunication within the organization but also theorganization’s communications with externalstakeholders. For instance, when the chiefexecutive officer (CEO) of one hospital becameaware that patients might have been exposed to adangerous infection while hospitalized, heimmediately decided to cover up the incident andcommunicated that message down to his managers.However, another hospital CEO dealt with thissituation in a very different manner. She used publicmedia as a channel of communication to encouragepatients to come forward and be tested. Thesereactions to similar events reflect differentmanagerial philosophies about communication.Multiple levels of hierarchy and complexities suchas the size and degree of activity conducted in an

organization tend to cause message distortion. Asmessages are transmitted upward or downward,they may be interpreted according to an individual’spersonal frame of reference. When multiple linksexist in the communication chain, information couldbe misinterpreted. As a result, a message sentthrough many levels is likely to be distorted or eventotally blocked. For example, the CEO of a healthcare organization asked department administratorsto relay his message of sincere congratulations andappreciation to the staff for their hard work towardobtain their institutional reaccreditation from TheJoint Commission. This message was transmitteddownward through several layers in the organizationand was received in a more nonchalant mannerthan was originally intended. In another scenario, areport generated by the management informationsystem analyst was given to his supervisor, whowent on vacation and left it on his desk withoutgiving it to the vice president, who had requested ita week earlier. In this case, the message did notreach its destination.Power or status relationships can also affecttransmission of a message. An inharmonioussupervisor–subordinate relationship can interferewith the flow and content of information. Moreover,a staff member’s previous experiences in theworkplace may prevent open communication

because of fear of negative sanctions. For instance,a poor supervisor–subordinate relationship inhibitsthe subordinate from reporting that the project is notgoing as planned. A subordinate who is fearful ofthe manager’s power and status might preventeffective communication from taking place. Gardeziand colleagues (2009) observed silence as a formof communication in the operating room. They foundthat silence was often used by nurses because of alack of understanding, fear of asking questions, andintimidation. They also found that silence was usedin the operating room to communicate disrespect orpower. Consider the following example from theirstudy (p. 1397):This communication event takes place over a 45minute period. The staff surgeon keeps asking thescrub nurse for ‘burning forceps’, but often he hasn’thanded them back to her. Instead he’s placed them ona rubber mat on the patient’s chest. To retrieve themand hand them to the surgeon when he next needsthem, the scrub nurse has to step down off her stool,reach around the surgical resident who is standing toher right, come back up on to the stool, and hand themacross the patient’s abdomen to the surgeon. Thesurgeon notices this and says, ‘Just tell me it’s up’ andthen ‘We’ll try to remember to pass it back to you’. Thishappens multiple times, however, with the scrub nursestepping down and reaching and the surgeon

repeating, ‘Just tell me it’s up!’ The scrub nurse lookssort of bewildered. Once she very quietly says, ‘Up,’but the next time she reaches for it instead. There isno strong emotion in the surgeon’s tone as he repeatsthe instruction over and over.Another environmental barrier that may lead tomiscommunication is the use of specific terminologythat is unfamiliar to the receiver or messages thatare especially complex. Managers and clinical staffmembers in health care organizations use medicalterminology, which may be unfamiliar to externalstakeholders. Communication between individualswho use different terminology can be unproductivesimply because people attach different meanings tothe same words. Thus, misunderstandings canoccur as a result of unfamiliar terminology.Personal BarriersPersonal barriers arise because of an individual’sframe of reference or beliefs and values. Thesebarriers are based on one’s socioeconomicbackground and prior experiences, and they shapehow messages are encoded and decoded. One mayalso consciously or unconsciously engage inselective perception or be influenced by fear orjealousy. For example, some cultures believe in“don’t speak unless spoken to” or “never questionelders” (Longest et al., 2000). These beliefs inhibit

communication. Others accept all communication atface value without filtering out erroneousinformation. Still others provide self-promotioninformation, intentionally transmitting and distortingmessages for personal gain. Unless one has hadthe same experiences as another individual, it canbe difficult to completely understand the otherindividual’s message. In addition to frame ofreference, one’s beliefs, values, and prejudices canalter and block messages. Preconceived opinionsand prejudices are formed on the basis of varyingpersonalities and backgrounds. Selective perceptionis a tendency to retain positive parts of the messageand filter out negative parts.Two additional personal barriers are status quo andevaluating the source (or the sender) to determinewhether the receiver should retain or filter outmessages. For instance, a manager always ignorescomplaints from Melissa, the medical receptionist,because Melissa tends to exaggerate issues andevents. However, one must be careful to evaluateand distinguish exaggerations from legitimatemessages. Status quo is when individuals prefer thepresent situation. They intentionally filter outinformation that is unpleasant. For example, amanager does not tell staff and patients that theirfavorite physician, Dr. Ames, has decided to leavethe practice. To prevent patients from switching to

another physician, the manager postpones thecommunication to retain status quo.A final personal barrier is lack of empathy—in otherwords, insensitivity to the emotional states ofsenders and receivers. When a physician shouts forhis assistants to hurry with preparing clean roomsbecause 50 patients are in the waiting room, hisassistants should empathize with the physician andunderstand that he is under stress and pressure tosee his patients, who are complaining that theyhave been waiting for up to 3 hours. At the sametime, the physician should empathize with hisassistants because the office is understaffed as aresult of one of the three assistants calling in sick.

▶ Overcoming Barriers toImprove CommunicationRecognizing that environmental and personalbarriers exist is the first step to effectivecommunication. By becoming cognizant of theirexistence, one can consciously minimize theirimpact. However, positive actions are needed toovercome these barriers (see Table 5-1).Longest et al. (2000) provide us with severalguidelines for overcoming barriers:1. Environmental barriers are reduced ifreceivers and senders ensure that attentionis given to their messages and that adequatetime is devoted to listening to what is beingcommunicated.2. A management philosophy that encouragesthe free flow of communication isconstructive.3. Reducing the number of links (levels in theorganizational hierarchy or steps between thesender in the health care organization andthe receiver, who is an external stakeholder)diminishes opportunities for distortion.

4. The power or status barrier can be removedby consciously tailoring words and symbolsso that messages are understandable;reinforcing words with actions significantlyimproves communication among differentpower or status levels.5. Using multiple channels to reinforce complexmessages decreases the likelihood ofmisunderstanding.Personal barriers to effective communication arereduced when senders and receivers makeconscious efforts to understand each other’s valuesand beliefs. One must recognize that people engagein selective perception and are prone to jealousyand fear. Having empathy for the individuals towhom messages are directed is the best way toimprove communication.Communicating effectively in a complex, multisitehealth care system is challenging. Barriers may bedifficult to overcome. Porter (1985) offers severalapproaches for achieving effective linkages amongbusiness units in a diversified corporation andsuggests ways in which managers can overcomesome of these barriers:1. Use techniques that extend beyondtraditional organizational lines to facilitatecommunication. For instance, the use of

diagonal communication that flows throughtask forces or committees enhancescommunication throughout the organization.2. Use management processes that are cross-organizational rather than being confined tofunctional or department procedures.Implementing management processes in theareas of planning, controlling, and managinginformation systems facilitatescommunication.3. Use human resources policies andprocedures (job training and job rotation) toenhance cooperation among members inorganizations.4. Use management processes to resolveconflicts in an equitable manner to produceeffective communication.

▶ Effective Communicationfor KnowledgeManagementCommunication plays an important role inknowledge management. Employees are theorganization’s brain cells, and communicationrepresents the nervous system that carriesinformation and shared meaning to vital parts of theorganizational body. Effective communication bringsknowledge into the organization and disseminates itto employees who require that information. Agarwal,Sands, and Schneider (2010) attempted to quantifythe economic waste associated with communicationinefficiencies in hospital settings at a national level.They found that U.S. hospitals waste more than $12billion annually as a result of communicationinefficiency among care providers.Effective communication minimizes the “silos ofknowledge” problem that undermines anorganization’s potential and, in turn, allowsemployees to make more informed decisions aboutcorporate actions. Effective communication is one ofthe most critical goals of organizations (Spillan,Mino, & Rowles, 2002). Research suggests that aneffective manager is one who spends considerable

time on staffing, motivating, and reinforcing activities(Luthans, Welsh, & Taylor, 1988).Shortell (1991) identified multiple key elements toeffective communication in a model developed forphysicians and hospital administrators to improvetheir communication abilities to disseminateknowledge within the organization. The following listsummarizes these key elements:An effective communicator must have a desireto communicate, which is influenced both byone’s personal values and the expectation thatthe communication will be received in ameaningful way.An effective communicator must have anunderstanding of how others learn, whichincludes consideration of differences in howothers perceive and process information (e.g.,analytic versus intuitive, abstract versusconcrete, verbal versus written).The receiver of the message should be cued asto the purpose of the message, that is, whetherthe message is intended to provide information,to elicit a response or reaction, or to arrive at adecision.The content, importance, and complexity of themessage should be considered in determiningthe manner in which the message iscommunicated.

The credibility of the sender affects how themessage will be received.The time frame associated with the content ofthe message (long versus short) needs to beconsidered in choosing the manner in which themessage is communicated. More precise cuesare needed with shorter time frames (seeFigure 5-3).Figure 5-3 Interrelationships of Effective Knowledge-ManagementCommunicationReproduced from Shortell, S. M. (1991). Effective hospital-physician relationship. Ann Arbor, MI: Health Administration Press.A formula to evaluate an individual’s effectiveness incommunicating to others can be calculated asshown in Exhibit 5-2. The index of communication

effectiveness (ICE) is a percentage of the reactionto the intended message over the total number ofmessages sent. If managers find that their ICE islow over time, they should evaluate theircommunication processes to identify ways to makeimprovements (Certo, 1992). Research suggeststhat to improve health care organizationalcommunication and cohesion, exchanges betweenemployees and leaders should involve leaders’direct support and encouragement of employees’constructive expressions of dissatisfaction andinnovative ideas (Sobo & Sadler, 2002) (see CaseStudy 5-2).Exhibit 5-2 An Index of CommunicationEffectivenessReproduced from Modern management: Quality, ethics, and theglobal environment (5th ed., p. 395), by S. C. Certo, 1992, Boston,MA: Allyn and Bacon.CASE STUDY 5-2 WhatShould We Do Now?Jenny Taylor, receptionist at CaringPhysicians Clinic, was responsible for calling

patients to remind them of their appointments.Dr. Ann Ryan, medical director of the clinic,found Jenny to be hardworking and pleasantto the patients. One morning, Dr. Ryan arrivedand found Jenny crying in the supply room.When she questioned Jenny, Jenny sobbedthat for the past 3 months she had keptforgetting to order supplies. Jenny had beenborrowing supplies from the pediatrics officenext door. Now they were unwilling to lend hermore. Jenny said that she had called thesupply center once and had faxed a list ofsupplies over but had not followed through.This morning, Jenny had called the supplycenter again and had found that they were outof business. Jenny told her immediatesupervisor, Barbara Lakes, patient carecoordinator for the clinic. Lakes fired Jenny forincompetence. In the meantime, patients werewaiting, and there were no clean sheets,gloves, or gowns.Discussion Questions1. What was the beginning of the problem?2. What should Jenny have done?3. Using the elements of effectivecommunication, discuss what Dr. Ryanand Barbara Lakes should do now.

Strategic CommunicationStrategic communication is an intentional process ofpresenting ideas in a clear, concise, and persuasiveway. A manager must make an intentional effort tomaster communication skills and use themstrategically, that is, consistently according to theorganization’s values, mission, and strategy. Toplan strategic communication, managers mustdevelop a methodology for thinking through andeffectively communicating with superiors, staff, andpeers. Sperry and Whiteman (2003) provide us witha strategic communication plan that consists of fivecomponents:1. Outcome: The specific result that anindividual wants to achieve.2. Context: The organizatioanal importance ofthe communication.3. Messages: The key information that staffmembers need to know.4. Tactical Reinforcement: Tactics or methodsused to reinforce the message.5. Feedback: The way the message is receivedand its impact on the individual, team, unit, ororganization.Strategic communication requires forethought aboutthe purpose and outcome of the message.

Managers must be able to link the needs of the staffto the organization’s mission and deadlines.

▶ Flows ofIntraorganizationalCommunicationCommunication can flow upward, downward,horizontally, and diagonally within organizations.Upward communication occurs between supervisorsand subordinates. Downward communicationprimarily involves passing on information fromsupervisors to subordinates. Horizontal flow is frommanager to manager or from coworker to coworker.Diagonal flow occurs between different levels ofdifferent departments. Longest et al. (2000)provides us with several forms of intraorganizationalcommunication for health care organizations, asdescribed in the following paragraphs.Upward FlowThe purpose of upward communication flow is toprovide managers with information to makedecisions, identify problem areas, collect data forperformance assessments, determine staff morale,and reveal employees’ thoughts and feelings aboutthe organization. Upward flow becomes especiallyimportant with increased organizational complexity.For example, as Adelman (2012, p. 133) noted, the

Institute of Medicine’s 2004 report titled KeepingPatients Safe: Transforming the Work Environmentof Nurses related that “a lack of critical upwardfeedback in the hospital setting has adverse effectson direct patient care and health outcomes.”Therefore, managers must rely on effective upwardcommunication and encourage it as an integral partof the organizational culture. Upwardcommunication flow helps employees meet theirpersonal needs by allowing those in positions oflesser authority to express opinions and perceptionsto those in positions of higher authority. As a result,the employees make contributions to theorganization, and participate in the decision-makingprocess. Adelman (2012) found that award-winninghigh-performance hospitals’ leaders have four keyareas that promote effective upwardcommunication:1. Establishing a culture of excellence—inwhich employees feel comfortable voicingtheir concerns for improvement.2. Creating employee voice opportunity—through leaders’ visibility and approachabilityand 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 ofsafety (i.e., trust) that allows employees totake interpersonal risks with regard tocommunicating improvement ideas to theleaders of the organization.The hierarchical structure (chain of command) is themain channel for upward communications in healthcare organizations. To increase the effectiveness ofupward communication, Luthans (1984)recommends the use of grievance procedures,open-door policies, counseling, employeequestionnaires, exit interviews, participativedecision-making techniques, and the use of anombudsperson.Grievance Procedure: The grievance procedureallows employees to make an appeal upwardbeyond their immediate supervisor. It protectsindividuals from arbitrary action by their directsupervisor and encourages communicationabout complaints.Open-Door Policy: The supervisor’s door isalways open to subordinates. It is an invitationfor subordinates to come in and talk to thesupervisor about problems that trouble them, toseek advice, or to share information.

Counseling, Questionnaires, and ExitInterviews: The department of humanresources in a health care organization canfacilitate subordinate-initiated communicationby conducting confidential counseling,administering attitude questionnaires, andholding exit interviews for those leaving theorganization. Information gained from theseforms of communication can be used to makeimprovements.Participative Decision-Making Techniques:Through the use of informal involvement ofsubordinates or formal participation programssuch as quality-improvement teams, union–management committees, and suggestionboxes, participative techniques can improveemployee performance and satisfaction.Because employees can participate in thedecision-making process, they feel that theycan make valuable contributions to theorganization.Ombudsperson: The use of an ombudspersonprovides an outlet for persons who feel theyhave been treated unfairly.In upward communication, subordinates can providetwo types of information to supervisors: (1) personalinformation about ideas, attitudes, and performanceand (2) technical information to provide feedback.

Managers who encourage feedback enhance theupward flow of communication.Downward FlowDownward communication involves passinginformation from supervisors to subordinates. Thisincludes verbal and nonverbal communication, suchas instructions for completing tasks, as well as one-to-one communications. Downward communicationsinclude meeting with employees, written memos,newsletters, bulletin boards, procedural manuals,and clinical and administration information systems.Horizontal FlowRelying only on upward and downwardcommunication is inadequate for effectiveorganizational performance. In complex health careorganizations, horizontal flow, or lateralcommunication, must also occur. The purpose oflateral communication is the sharing of informationamong peers at similar levels to keep organizationalstaff informed of all current practices, policies, andprocedures (Spillan et al., 2002). For example,coordinating the continuum of patient care requirescommunication among multiple units. Committees,task forces, and cross-functional project teams areall useful forms of horizontal communication.

Diagonal FlowThe least-used channel of communication in healthcare organizations is diagonal flow, although it isgrowing in importance. Although diagonal flow doesnot follow the typical hierarchical chain of command,it is especially useful in health care for efficientcommunication and coordination of patient care. Forexample, diagonal communication occurs when thedirector of nursing asks the data analyst in themedical records department to generate a monthlyreport for all patients in the intensive care unit (seeCase Study 5-3).CASE STUDY 5-3Communication FlowsSara Lang, a charge nurse at Sunny NursingHome, has worked under the same president,Lisa Davis, for 5 years. In fact, the two havebecome good friends. They frequentlysocialize after hours. Rick Walters, director ofnursing, is a capable person who has beenworking there for 3 years. Four nurses (Anna,Barbara, Charles, and Dan) report directly toSara.Anna, one of the nurses, was having personaldifficulties. She asked Sara whether she couldchange her work schedule from the usual 8-

hour shift of four days with three consecutivedays off to 16-hour shifts for two days and fiveconsecutive days off. Sara thought that wasnot a problem and told Anna that she wouldenter that information into the computerizedscheduling system and that she would tell LisaDavis of the change, since they were gettingtogether for a drink after work.Barbara overheard the conversation betweenSara and Anna, and she immediately went tosee Rick Walters to complain that Anna wasgetting preferential treatment and he wantedthe same schedule. Rick, who always wantedto make sure that the nursing staff were happyand got along, approved Barbara’s change inschedule. He made this change through thecomputerized schedule and did not tellanyone else. Barbara, who is good friendswith Charles, told him of the new schedule.Charles, who works closely with the chief ofstaff, Dr. Goodman, told Dr. Goodman of thechange in Barbara’s schedule and asked Dr.Goodman to change his. Dr. Goodmanthought it was a good idea and emailedCharles’s new schedule to his assistant,Susan Stevens, to enter it into the schedulingsystem.

On the next Monday morning, changes wereimplemented to Anna’s, Barbara’s, andCharles’ schedules. No one had discussedthese changes with anyone else. When theschedule was printed out and posted, itshowed that Anna, Barbara, and Charles wereall off for five days that week, from Monday toFriday, and all three began work on Saturday.In the meantime, the only nurse left workingwas Dan.Discussion Questions1. What are the different forms ofcommunication flow taking place in thisscenario?2. What changes should have beenimplemented?3. What should be done now?

▶ Communication NetworksFlows of communication can be combined intopatterns called communication networks. Thesenetworks are interconnected by communicationchannels. A communication network is theinteraction pattern between and among groupmembers. A network creates structure for the groupbecause it controls who can and should talk towhom (Keyton, 2002). Groups generally developtwo types of communication networks: centralizedand decentralized (Figure 5-4).

Figure 5-4 Two Types of Communication Networks: Centralizedand DecentralizedDecentralized networks allow each group memberto talk to every other group member withoutrestrictions. An open, all-channel, or decentralizednetwork is best used for group discussions, decisionmaking, and problem solving. The all-channelnetwork 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 muchinformation or excessively complex communicationmay occur (Keyton, 2002). When communicationoverload is produced, messages may conflict withone another and result in confusion ordisagreement. To reduce communication overload,a facilitator should be used to monitor groupdiscussions.A centralized network restricts the number ofindividuals in the communication chain. In a groupsetting in which a dominant leader takes over groupdiscussions by controlling the number of messagesand amount of information being passed, groupmembers do not interact except through the leader.Such a network can create communicationunderload, in which too few or too simple messages

are transmitted. In this type of network, groupmembers feel isolated from group discussions andgenerally feel dissatisfied. In the chain network,communication occurs upward and downward andfollows line authority relationships. An example is astaff nurse who reports to the charge nurse, whoreports to the director of nursing, who reports to thevice president for clinical services, who finallyreports to the CEO of a large hospital. This networkdelineates the chain of command and shows clearlines of authority.Other types of centralized networks include the Y-pattern, the wheel pattern, and the circle network.The Y-pattern is similar to the chain network, with itshierarchical structure, except that it shows twoemployees at the same level who then follow thechain. An example is of two medical assistants inthe organ transplant division who report to theclinical administrator for the division, who reports tothe clinical administrator for the department ofsurgery, who reports to the vice president of clinicalservices, who finally reports to the CEO of thehospital.The wheel pattern shows four subordinatesreporting to one supervisor. Subordinates do notinteract, and all communications are channeledthrough the manager at the center of the wheel.This pattern is rare in health care organizations and

systems, although elements of it can be found in theexample in which four vice presidents report to apresident if the vice presidents have little interactionwith one another. Even though this network patternis not routinely used, it may be used when urgencyor secrecy is required. For example, the presidentwith an organizational emergency mightcommunicate with the vice presidents in a wheelpattern because time does not permit using othermodes. Similarly, if secrecy is important, such aswhen investigating possible embezzlement, thepresident might require that all relevantcommunication with the vice presidents be keptconfidential. The wheel pattern works well whenthere is pressure for time, secrecy, and accuracy.The circle pattern allows communicators in thenetwork to communicate directly only with twoothers. Because each person communicates withanother in the network, there is no central authorityor leader. The circle network works well when thereare open channels of communication among allparties. However, it can slow down thecommunication process to enable everyone accessto information.There is no one type of communication network thatis right for all situations. Different forms can beapplied under varying circumstances. To beeffective, health care managers must be able to

select the appropriate flows of communication forspecific situations. Identifying the bestcommunication network for the situation is critical tosuccessful communication. Health problems rangefrom simple to complex, and simple problems canbe easily resolved by using simple networks. Forexample, scheduling patient appointments for Dr.Davis can be easily accomplished through thesuperior–subordinate chain network. However,complex problems require many levels of decisionmaking. For instance, whether Horizons Hospitalshould merge with its major competitor to gain moremarket share at the risk of making a major capitalinvestment can be accomplished through the all-channel network, which is more useful and effectivefor tackling complex problems. Hellriegel andSlocum (2004) compared the five communicationnetworks using four assessment criteria. Figure 5-5shows the specific criteria used in making aselection among the different types of networks.

Figure 5-5 Effects of Five Communication NetworksReproduced from Hellriegel, D., & Slocum, J. W. (2004).Organizational behavior (10th ed.). Mason, OH: South-Western.1. Degree of Centralization: Degree ofcentralization is the extent to which teammembers have access to morecommunication than others. In the case ofthe wheel network, because communicationflows from and to only one member, this isthe most centralized network. By contrast,the all-channel network provides everyone inthe network with the same opportunity for

communication; thus, it is the leastcentralized network.2. Leadership Predictability: Leadershippredictability is the ability to anticipate whichmember of the communication network islikely to emerge as the leader. In the case ofthe Y-pattern and the wheel pattern, the mostcentrally positioned individual is the mostlikely person.3. Average Group Satisfaction: Average groupsatisfaction reflects the level of satisfaction ofmembers in the communication network. Inthe wheel network, average membersatisfaction is the lowest in comparison withother networks, since the most centrallypositioned person plays the most crucialroles and leaves less important decision-making responsibilities for the people aroundthe wheel.4. Range of Individual Member Satisfaction:The range of an individual’s satisfactionwithin the communication network has aninverse relationship with the average groupsatisfaction. Again, in the wheel, althoughaverage member satisfaction is low, therange of individual member satisfaction ishigh, because they are highly dependent onthe individual in the middle. In the case of the

all-channel network, average groupsatisfaction is high because there is greaterparticipation by all members of thecommunication network, but individualsatisfaction tends to be low.

▶ Informal CommunicationIn addition to formal communication flows andnetworks within health care organizations, there areinformal communication flows, which have their ownnetworks. Employees have always relied on theoldest communication channel: the grapevine. Thegrapevine is an unstructured and informal networkthat is founded on social relationships rather thanorganizational charts or job descriptions. Accordingto some estimates, 75% of employees typicallyreceive news from the grapevine before they hearabout it through formal channels (McShane & VonGlinow, 2003).Early research identified several unique features ofthe grapevine. One feature of note is that ittransmits information rapidly in all directions(Newstrom & Davis, 1993). Figure 5-6 illustratesfour common patterns that the grapevine can take.

Figure 5-6 Grapevine NetworksThe typical pattern of a grapevine is a cluster chain,whereby a few people actively transmit rumors tomany others. The grapevine works through informalsocial networks, so it is more active for employeeswho have similar backgrounds and are able tocommunicate easily. Many rumors seem to have atleast a little bit of truth, possibly because rumors aretransmitted through information-rich communicationchannels and employees are motivated tocommunicate effectively. Nevertheless, thegrapevine distorts information by deleting finedetails and exaggerating parts of the message.In this era of information technology, email, texting,other forms of electronic messaging and socialmedia have replaced the traditional watercooler siteof grapevine gossip. Instead, networks haveexpanded as employees communicate with oneanother inside and outside of the organizationinstantly through computer-aided communication.Furthermore, public websites such as Yelp andsocial media such as Twitter and Instagram havebecome virtual watercoolers for posting anonymouscomments about specific companies for all to view.This technology extends gossip to anyone, not justemployees connected to the social networks. Amanager’s responsibility is to utilize the informal

network selectively to benefit the organization’sgoals (see Case Study 5-4).CASE STUDY 5-4 Did YouHear the Latest?Sally Reeds, a medical secretary for thedepartment of neurology at Western HeightsHospital in Colorado, checked her phone lastnight and found a post on Facebook from herfriend and coworker Justin Zeels, a socialworker in the same hospital. Justin wrote thatDr. Sites, medical director of neurology, hadbeen found under a bench outside theemergency department. The hospital securityofficers had allegedly reported that Dr. Siteswas completely intoxicated, and he had beenrushed home. Sally spiced up the tale andimmediately posted it. This morning, Sallylooked up and noticed Dr. Sites seeing hispatients as if nothing had happened. Sheconfronted him and asked him how he couldpossibly face everyone after what happenedlast night. Dr. Sites looked confused until ascreenshot of Zeels’s post was shown to Dr.Sites by another staff member. After readingit, Dr. Sites became livid and fired Justin forspreading such a malicious rumor. Meanwhile,

Maria Hummingshire, another medicalsecretary, who saw the entire incident in theoffice, took a video, and texted it to herfriends.Discussion Questions1. What did Sally do wrong?2. What should Justin have done?3. What should the organization do toprevent the spread of gossip through thegrapevine?

▶ Cross-CulturalCommunicationIncreasing information technology, globalization,and cultural diversity present a number ofcommunication opportunities and challenges fororganizations. Organizational personnel must besensitive and competent in cross-culturalcommunication. While ethnic and racial diversityenriches the environment, it can also causecommunication barriers that impede efficient andeffective service delivery. Communication difficultiesarise from differences in cultural values, languages,and points of view. For instance, in the health careindustry, one major barrier is language, becausenumerous languages may be encountered amongstaff and patients. As of 2017, more than 65 millionpeople in the United States speak a language otherthan English at home. That is almost 22% of thetotal population! In the country’s five largest cities,this percentage rises to nearly half the city’spopulation (Zeigler & Camarota, 2018). Becauselanguage is the most obvious cross-cultural barrier,words can be easily misunderstood in verbalcommunication (Dutton, 1998). Although theEnglish language is relied on as the common

business language, English words may havedifferent meanings in different cultures.Voice intonation varies by country. For instance, inJapan, communicating softly is an expression ofpoliteness, whereas in the Middle East, the louderthe voice, the more one is believed to be sincere(Mead, 1993). To achieve effective communication,health care professionals can apply severalstrategies to reduce communication barriers.Thiederman (1996) provides us with several verbaland nonverbal techniques to improve cross-culturalcommunication:Write down in simple English the issues thathave been agreed upon in order to obtainfeedback on accuracy.Repeat a message when there is doubt.Watch for nonverbal signs of a lack ofunderstanding.Listen carefully to an entire message,especially when the speaker’s accent isdifferent from one’s own.Create a relaxed atmosphere so that tension isreduced to increase the flow of communication.Phrase questions in different ways to make iteasier for the receiver to understand.Opportunities for working with individuals fromdifferent cultures have increased dramatically. As

U.S. industries branch into world markets throughthe interconnectedness of the Internet, email, socialmedia, live chat, voice messaging, andsmartphones, organizations and individuals are ableto conduct business without ever meeting face toface. To be effective in cross-culturalcommunication, several guidelines are important.Understand your own identity. To developsensitivity to other cultures, you must firstunderstand your own culture and identity. Yourpersonal identity encompasses who you areand who you want to be. That is, you chooseyour lifestyle, goals, occupation or profession,and friends. The choices that you make and thegoals you pursue may be affected by racial,cultural, gender, and social class factors.Enhance personal and social interactions.Globalization has increased our opportunities toassociate and develop close interactions withindividuals who are different from us. Theconscious decisions that we make to becomemore accommodating, flexible, and tolerant ofothers will broaden our views of the world andenrich our perspectives. Our relationships withpeople of different cultures help us to learnmore about the world and to break stereotypes.These interactions also enable us to develop

new skills for communicating with others and tolearn from them.Solve misunderstandings, miscommunications,and mistrust. Take the time and make the effortto study, understand, and appreciate individualsof different cultures. Through open, honest, andpositive communication, this will resolvemisunderstandings, miscommunications, andmistrust.Enhance and enrich the quality of the workenvironment. Recognizing and respectingethnic and cultural diversity through more opencommunication are the first steps towardvaluing diversity and enriching the quality of thework environment (Hybels & Weaver, 2007).

▶ Communicating withExternal StakeholdersIn health care organizations, managers must becompetent communicators because they spendmost of their time and energy communicating withlarge numbers of external stakeholders, individuals,groups, and organizations that are interested in thehealth care organization’s actions and decisions. Acompetent communicator is an individual who hasthe ability to identify appropriate communicationpatterns in a given situation and to achieve goals byapplying that knowledge. Competentcommunicators quickly learn the meaning thatlisteners take from certain words and symbols, andthey know which communication channel is mostappropriate in a particular situation. Moreover,competent communicators use this knowledge tocommunicate in ways that achieve personal, team,and organizational objectives. A manager with highcommunication competence would be better thanothers at determining whether an email, telephonecall, or personal visit would be the best way toconvey a message to an employee.To competently communicate with externalstakeholders, organizations and their managers are

responsible for assessing the environment to gaininformation in order to make strategic decisions.Managers must utilize their roles as liaisons andmonitors to scan the environment for opportunitiesand minimize threats. Furthermore, managers mustutilize their strategist role to formulate andimplement policies that are consistent with theirorganization’s strategic goals and plans (Guo,2003). Exhibit 5-3 shows steps for analyzingstakeholders to increase the acquisition of usefulinformation.Exhibit 5-3 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 instakeholders’ views and positions)5. Assess their importance (assess theimplications of stakeholders’ views andpositions)

6. Diffuse information (diffuse stakeholderinformation to those who need it)First, scanning the macroenvironment and themicroenvironment results in information aboutstakeholders. Figure 5-7 illustrates the diversity ofstakeholders for a community hospital.

Figure 5-7 External Stakeholders

Relationships between the organization and itsexternal stakeholders are complex and affectcommunication, since the organization is a dynamic,open system operating in a turbulent externalenvironment. The size and variety of externalstakeholders make communication complex,especially because stakeholders attempt toinfluence the decision making of organizations.Fottler, Blair, Whitehead, Laus, and Savage (1989)examined communication between a large hospitaland its stakeholders and found differentrelationships. While some relationships are positive,others are neutral or negative. Positive relationshipswith external stakeholders are easier to manage,and communication tends to be more effective thanis the case in negative relationships.In the stakeholder analysis, important issues andstakeholders are identified through theenvironmental scan. Next, monitoring the activitiesof stakeholders is crucial. Managers must be able totake the views of stakeholders and use thatinformation to incorporate trends into their decision-making process.Finally, managers must evaluate the value of theinformation, take the information gathered, andtransmit it to those who need the information.

Another way to describe communication withexternal stakeholders is known as boundaryspanning. Boundary spanning, or externalcommunication links, provides opportunities fororganizational learning in areas such as strategicplanning or marketing (Johnson & Chang, 2000).Communicating with all external stakeholders isessential; however, each stakeholder may beviewed for its unique position and benefits to theorganization. For instance, in interactions with thepublic sector, health care organizations are affectedby public policies. Government is a majorstakeholder because of its legislative and regulatorypowers and because it is one of the largestpurchasers of health services. For example, issuessuch as access to care, cost containment, andquality concerns have driven federal governmentdebate, reforms, and involvement in health care.Therefore, health care organizations cannot beinsulated from public policies and must makestrategic responses to reflect the needs of the publicsector. A health care organization has a specialrelationship with the geographical community wherethe organization is located. Meeting the particularneeds of the community is a primary goal of healthcare organizations.For effective communication to take place, bothparties must form realistic expectations. Health care

organizations have six areas of responsibility towardtheir communities (Longest et al., 2000):1. Engaging in the core, health-enhancingactivities in the community.2. Providing economic benefits to thecommunity.3. Offering unique benefits or a niche to thecommunity.4. Pursuing philanthropic activities in a broadand generous manner.5. Being in full compliance with legalrequirements.6. Meeting ethical and fiduciary obligations.

▶ SummaryCommunication in the workplace is critical forestablishing and maintaining high-quality workingrelationships in organizations. Communication is thecreation or exchange of thoughts, ideas, emotions,and understanding between sender(s) andreceiver(s). Feedback is information that individualsreceive about their behavior. Feedback can be usedto promote more effective communication. TheJohari Window is a model to improve an individual’scommunication skills through identifying one’scapabilities and limitations. The channels ofcommunication are the means by which messagesare transmitted. Verbal communication relies onspoken or written words to share information withothers. Computer-aided communication, such asemail, has greatly enhanced the communicationprocess. Especially in health care, other forms oftechnology (such as high-speed, high-definitionimages; telemedicine; and wireless, handheld digitalelectronic medical records) can be used to bridgecommunication gaps between clinicians andadministrators. Nonverbal communication is thesharing of information without using words toencode messages. This includes proxemics,

kinesics, facial and eye behavior, andparalanguage.There are two types of barriers to communication:environmental and personal. Barriers can beovercome by conscious efforts to devote time andattention to communication, reduce hierarchicallevels, tailor words and symbols, reinforce wordswith action, use multiple channels ofcommunication, and understand one another’sframe of reference and beliefs.Key elements of effective communication includethe desire to communicate, understanding howothers learn, the intent, the content, the sender’scredibility, and the time frame. Strategiccommunication is an intentional process ofpresenting ideas in a clear, concise, and persuasiveway. Five components of strategic communicationare outcome, context, messages, tacticalreinforcement, and feedback.Intraorganizational communication flows upward,downward, horizontally, and diagonally. Variousflows of communication can be combined to formcommunication networks, such as the chain, Y-pattern, wheel, circle, and all-channel. Certainnetworks may work better than others, dependingon the situation. A manager’s role is to determinethe best network to use for simple or complex

communications. Informal communication resultsfrom interpersonal relationships developed in theworkplace. Although informal networks can beuseful, they can also be misused.Cross-cultural communication can be challenging.Communication difficulties arise from differences incultural values, languages, and points of view.Organizational personnel must be sensitive andcompetent in cross-cultural communication. Severaltechniques and guidelines for improving cross-cultural communication are provided.Health care organizations must managerelationships with large numbers of externalstakeholders: individuals, groups, and organizationsthat are interested in the organization’s actions anddecisions. Effective communication with externalstakeholders involves environmental assessmentsto enable managers to identify and make strategicdecisions for their organizations.

Discussion Questions 1. What are the various components of thecommunication process? 2. What are the three forms and four levels offeedback? 3. What is the Johari Window? How is it used incommunication? 4. What is verbal communication? Give anexample. 5. What are the different types of nonverbalcommunication? 6. What are the appropriate uses of verbal andnonverbal communication channels? 7. What are the two types of barriers to effectivecommunication? 8. What methods are available to overcomethese barriers? 9. What are the elements of effectivecommunication?10. What are the five components of a strategiccommunication plan?11. What are the different forms ofintraorganizational flows of communication?12. What are the various networks available forformal and informal communication?13. Why is cross-cultural communicationimportant to today’s health servicesorganizations?

14. What competencies are needed by managersfor communicating with externalstakeholders?

CASE STUDIESCase Study 5-5 “Now We Can FinallyTalk”Comfort Zone is a 60-bed, for-profitintermediate-care facility in northernCalifornia. The rehabilitative departmentmanager, Jamie Richards, has been workingat Comfort Zone for only 6 months. She holdsmonthly staff meetings as well as additionalindividual meetings with staff members toaddress specific patient-related issues. Onmost days, she eats lunch in a quiet corner ofthe cafeteria so that she can catch up on herpaperwork at the same time.Catherine Williams, one of her staff members,who has been working at the facility for morethan 25 years, spotted her in the cafeteria oneday and sat down uninvited. Catherine hasnever attended any of the monthly meetingsand always has an excuse for not attending.Catherine said, “I’ve been waiting to tell youthis ever since you began working here, but Iwanted you to get adjusted first. Now we canfinally talk. I have been here for a long time

and have seen all kinds of comings andgoings.”Catherine proceeded to tell Jamie aboutmembers of her staff who were constantlytardy or absent. She also told Jamie about thethings the staff members had been doingbehind her back, such as using the Internet forpersonal matters, going shopping during lunchhour and coming back late, and going homeearly without permission. Catherineconcluded, “At your monthly meetings, thestaff show up to tell you that everything’s justfine, when I know differently. I’m too busyworking to attend these meetings. If you wantmy opinion, I would fire them all since they areincompetent.”Discussion Questions1. How should Jamie deal with theinformation that Catherine provided?2. What do you think of Jamie’s methods ofcommunicating with her staff?3. Do you think that Jamie should use adifferent form of communication withCatherine?Case Study 5-6 It’s Not My Job

In the medical unit of the NortheasternMedical Center, Leah Hernandez is aninsurance claims specialist who works withone nurse, one certified nursing assistant, andone medical assistant/receptionist. Thephysician and the administrator are located ina separate building of the medical center. Theadministrator, Dan Jules, spends 3 hours aday in the clinic, from 9:00 to 10:30 everymorning and from 2:00 to 3:30 everyafternoon. He never varies the times that he isin the clinic.One morning at 9:00 A.M., Dan was in theclinic with nurse Kate Williams, addressing theconcerns of the patient in room 2, when thephone rang. A second phone line rang a fewseconds later and then a third. The nursingassistant was in room 1 with the physician,and the medical assistant/receptionist was inroom 3 with another patient. The only staffmember available to answer the phone wasLeah, who was holding on the line with aninsurance company. She yelled, “Anybody?Somebody, pick up the phone already! It’sdriving me crazy!” Everyone in the clinic,including the patients, heard her shouting.Kate rolled her eyes and told Dan that it waslike this every day. Dan excused himself and

rushed into the reception area to pick up thephone. Later on, Dan asked Leah why shecouldn’t pick up the phone. Leah answered,“It’s not my job. I was busy with the insurancecompany.”Discussion Questions1. What should Dan do to address theproblem?2. Should Dan meet with Leah individuallyor communicate with all staff members?3. Because Dan works in a differentbuilding, who should have communicatedthis ongoing problem to Dan?

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PART IIUnderstandingIndividual BehaviorsIn Motivation and Personality (1954), AbrahamMaslow asked, “What conditions of work, what kindsof work, what kinds of management, and what kindsof reward or pay will help motivate humans?” In PartII, we answer Maslow’s questions with threechapters dedicated to the discussion of motivation.In Chapter 6, we describe and explain four contenttheories of motivation: (1) Maslow’s Hierarchy ofNeeds, (2) Alderfer’s ERG Theory, (3) Herzberg’sTwo-Factor Theory, and (4) McClelland’s Three-Needs Theory. These theories attempt to explainwhat motivates employees, and each theorycontains some parts of the others.In Chapter 7, we examine five process theories ofmotivation: (1) Expectancy Theory, (2) EquityTheory, (3) Satisfaction–Performance Theory, (4)Goal-Setting Theory, and (5) Reinforcement Theory.Although Reinforcement Theory is not usually

included with process theories of motivation, it doesassist managers with understanding whatreinforcements control an individual’s behavior.Process theories contain some components of thecontent theories and vice versa.In Chapter 8, we examine attribution theory. Thediscussion of attribution theory and its relevance inthe workplace provides managers with a betterunderstanding of the highly cognitive andpsychological mechanisms that influenceindividuals’ motivation levels.

CHAPTER 6Content Theories ofMotivationLEARNING OUTCOMESAfter completing this chapter, the student shouldbe able to understand:The definition of motivation.The difference between content theories andprocess theories of motivation.Maslow’s Hierarchy of Needs Theory andcriticisms of the theory.Alderfer’s ERG Theory.Herzberg’s Two-Factor Theory and how itrelates to job design.Hackman and Oldham’s Job CharacteristicsModel.McClelland’s Three-Needs Theory.

▶ OverviewWe will begin by defining motivation before weexplore two groups of motivation theories: contenttheories and process theories. Motivation isdescribed as the conscious or unconscious reasonor reasons that one has for acting in a particularway and one’s general desire or willingness to dosomething. (see Figure 6-1). Motivation is thepsychological process through which unsatisfiedneeds or wants lead to desires that are the basis forgoals or incentives. The purpose of an individual’sbehavior is to satisfy needs or wants. In this context,a need is anything a person requires or desires. Awant is the conscious recognition of a need. Thepresence of an unsatisfied need or want creates aninternal tension, from which an individual seeksrelief.Figure 6-1 Process of MotivationIn organizational behavior, the concept of motivationhas been researched over many years. Through thisresearch, we have identified and categorized

motivation theories into two groups: content andprocess.Content theories of motivation (also referred to asneeds theories) explain the specific factors thatmotivate people. The content approach focuses onthe assumption that individuals are motivated by thedesire to satisfy their inner needs. Content theoriesanswer the question “What drives behavior?”Content theories help managers to understand whatarouses, energizes, or initiates employee behavior.Process theories of motivation (also referred to ascognitive theories) focus on the cognitive processesunderlying an individual’s level of motivation. Thisapproach provides a description and an analysis ofhow behavior is energized, directed, sustained, andstopped. Process theories help to explain how anemployee’s behavior is initiated, redirected, andhalted.Employee motivation has a direct impact on a healthservices organization’s performance; therefore,managers need to understand what motivatesemployees. By understanding what motivates them,managers can assist employees in reaching theirfullest potential. There are some factors themanager can control, such as extrinsic factors (e.g.,salary, working conditions, interpersonalrelationships). For the motivating factors that are

intrinsic to the employee (e.g., need for recognition,achievement), managers can be influential byproviding a work environment that allows employeesthe opportunity to satisfy their personal needs and,simultaneously, the organization’s goals.Motivating staff is not about hanging posters withcute sayings in the office. Motivating is somethingmanagers do by establishing an organizationalstructure and environment that provide theopportunity for employees to satisfy both theirintrinsic and extrinsic needs. Remember, motivationis an individual’s voluntary drive to satisfy a need orwant!

▶ Maslow’s Hierarchy ofNeeds TheoryThe most popular and widely cited humanmotivation theorist is Abraham Maslow. Maslow(1954) is considered the father of humanisticpsychology. Briefly, humanistic psychologyincorporates aspects of both behavioral psychologyand psychoanalytic psychology. Behavioristsbelieve that human behavior is controlled byexternal environmental factors, whereaspsychoanalytic psychology is based on the idea thathuman behavior is controlled by internalunconscious forces. Early in his career, Maslowconcluded that human behavior is controlled notonly by internal factors or only by external factors(e.g., needs) but by both. He also proposed thatsome factors have precedence over others. Fromthis concept, Maslow created his five-tier Hierarchyof Needs (see Figure 6-2).

Figure 6-2 Maslow’s Hierarchy of NeedsReproduced from Maslow, A. H. (1954). Motivation andpersonality. New York, NY: Harper & Row.According to Maslow, humans have five levels ofneeds and are driven to fulfill these needs. Themost basic needs are physiological, such as theneed for air, water, and food. After the basicphysiological needs have been achieved, anindividual moves toward satisfying safety andsecurity needs. At this lower level of the hierarchy,individuals are interested in having a home in a safeneighborhood, job security, a retirement plan, andhealth/medical insurance. Because employees areconcerned about satisfying these external (extrinsic)

needs, these motivators need to be addressed byemployers, such as by providing employees with anadequate benefits package. The next three levels inMaslow’s Hierarchy of Needs Theory are somewhatless tangible and more psychological. The third levelin the hierarchy is a desire to be loved, to belong,and to be approved of by others. Humans have adrive to feel needed and loved. In the workplace,employees seek a sense of community andbelonging. To achieve this, they seek the approvaland acceptance of their peers and supervisors.Managers, by helping staff feel connected to theorganization and its mission, can provide this senseof belonging and community. After an individual’sphysiological, safety, and belonging needs aresatisfied, the next tier in the hierarchy is self-esteem. Maslow noted two versions of esteemneeds: a lower one (external) and a higher one(internal). External esteem is satisfied by achievingthe respect of other people, social and professionalstatus, recognition, and appreciation. The higherform of esteem, internal esteem, involves the needfor self-respect, a feeling of confidence,achievement, and autonomy. Individuals want to becompetent in what they do, and self-esteemincreases when one receives attention andrecognition from others for one’s accomplishments.Therefore, careful use of praise and of positive

feedback to staff members is an important means ofmotivating them. A word of praise orencouragement for a job well done or other forms ofpositive feedback go a long way toward motivatingstaff to perform. Managers should also provideemployees with opportunities to demonstrate theircompetence. Encouraging staff participation incontinuing education and other professionaldevelopment activities and providing opportunitiesfor challenging and meaningful work are effectivemotivators. These opportunities allow employees toachieve feelings of self-esteem andaccomplishment.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, an inner tensionis created within the individual that must be relieved(see Case Study 6-1). However, if these needshave been satisfied, they cease to motivate theindividual, who moves to the next level in thehierarchy. Maslow believed that individuals mustsatisfy their lower-level needs, at least to anacceptable state, before they can be motivated toachieve the higher levels in the hierarchy.CASE STUDY 6-1 Poor Cindy,What Should She Do?

Cindy has been employed by Memorial HealthSystem for the past 25 years, working her wayup the organization’s hierarchy. She startedworking for the organization as a medicalcoder after obtaining her bachelor’s degree.After 10 years, Cindy returned to school toearn a master’s degree in health servicesadministration so that she could qualify formanagement positions. After many years ofhard work, she became the system’s directorof compliance. However, she has recentlybeen hearing rumors that the organization isnot doing well because of the national healthreform changes and that layoffs may beannounced in the near future. This is causingCindy stress and worry. Memorial is the onlyorganization she has worked for! She hastried to stay focused, but it is extremelydifficult for her to do so, especially after shetalked with Harry last week.Harry and Cindy went to graduate schooltogether and have kept in touch over theyears since Harry moved to another state towork for a larger health care system. Lastweek, Harry told Cindy that he had been laidoff 3 months earlier and had not been able tosecure even an interview with other provider

organizations because of the uncertainty inthe marketplace due to the reform changes.Knowing about Harry’s experience furtherstressed Cindy as she thought about how shecould be in the same situation soon. She triedto get reassurance from her boss about herjob security, but he just seemed to give herthe runaround. Because of her preoccupationwith her job security, Cindy’s quality of workbegan slipping, and she became forgetful ofproject deadlines. She now spends most ofher time worrying and has had to call in sick afew times over the past 4 weeks because shehad stomach cramps and headaches.Discuss Cindy’s situation using Maslow’sHierarchy of Needs.The highest level of need is an individual’s desire tobecome all that they can be. Although Maslow useda variety of terms to refer to this level, it is mostcommonly referred to as self-actualization. Self-actualization is the desire to become more of whatone is and everything that one is capable ofbecoming. It is referred to as a “being need” (B-need) because it is motivating without there being adeficiency, as with the D-needs. In Maslow’s view,self-actualization is not an endpoint; rather, it is an

ongoing process that involves many growth choicesthat entail risk and require courage (O’Connor &Yballe, 2007). In addition to describing what ismeant by self-actualization in his theory, Maslow(1970) identified key characteristics of a self-actualized person:Acceptance and Realism: Self-actualizedpeople have realistic perceptions ofthemselves, others, and the world around them.They easily accept themselves and others asthey are.Problem-Centering: Self-actualized individualsare concerned with solving problems outside ofthemselves. They often dedicate themselves toa larger purpose in life based on ethics or asense of personal responsibility.Spontaneity: Self-actualized people arespontaneous, natural, and open in theirbehavior and thoughts. However, they caneasily conform to conventional rules andexpectations when situations demand suchbehavior.Autonomy and Solitude: Although they acceptand enjoy other people, self-actualizedindividuals have a strong need for privacy andindependence. They focus on their ownpotential and development rather than on theopinions of others.

Continued Freshness of Appreciation: Self-actualized people continue to appreciate thesimple pleasures of life with awe and wonder.Peak Experiences: Self-actualized peoplecommonly have peak experiences, or momentsof intense ecstasy, wonder, and awe duringwhich their sense of self is lost or transcended.The self-actualized person may feeltransformed and strengthened by these peakexperiences.Although progress to self-actualization is ofteninterrupted by failure to meet lower-level needs as aresult of situations such as illness (lack ofphysiological well-being), loss of a job (lack ofsecurity), or divorce (lack of sense of being loved),individuals can learn that satisfying basic needsbecomes an integrated, consciously managedaspect of a whole life and is not compulsive ordominating of all other concerns. As O’Connor andYballe (2007, p. 749) point out, “a paradigm shifttakes place. An individual becomes a person whohas needs, not a needy person.”Managers need to ask themselves, “How can Imotivate my employees?” When answering thisquestion, managers need to be conscious of the factthat not all employees are driven by the sameneeds, nor is any employee driven by only one needat a time. For example, right now as you read this

book, you may have several needs operatingsimultaneously—curiosity, a need for newknowledge, thirst, and so forth. Managers need torecognize the needs of each employee, individually.Managers who simultaneously address eachemployee’s lower level of needs will benefit fromworkers who are motivated to achieve the higherlevels of Maslow’s Hierarchy of Needs (see Figure6-3).

Figure 6-3 How Managers Can Satisfy Employees’ Needs atDifferent Levels of Maslow’s Hierarchy of NeedsAlthough Maslow introduced his Hierarchy of NeedsTheory more than 60 years ago, there have beenonly a limited number of studies that support histheory, and those that have been published havereported mixed findings (Alderfer, 1972). In fact,some research contradicts Maslow’s specificordering of needs. For example, Huizinga, as citedby Griffin (1991), attempted to validate the theory inthe workplace. Because of its scope and differentcultural setting, Huizinga’s study is one of the moreambitious attempts to verify the principles of thehierarchy. Huizinga surveyed over 600 managersdrawn from five industries in the Netherlands. Hissample included people from production, personnel,research and development, finance, and topmanagement. They ranged in age from 20 to 65years, and their educational backgrounds extendedfrom the Dutch equivalent of grade school touniversity graduates. Huizinga found that no matterhow many ways he analyzed the data, there wassimply no evidence that workers had a singledominant need, much less that the need diminishedin strength when gratified (Griffin, 1991, p. 131).Maslow’s needs theory also had difficulty explainingindividuals such as Mother Teresa, who neglected

her lower-level needs in pursuit of her spiritualcalling to serve the poor in India. Maslow himselfused the example of a starving artist pursuing hiscreativity needs (e.g., self-actualization) whileignoring physiological needs. Despite the gap inempirical research to support Maslow’s Hierarchy ofNeeds Theory, it remains “popular with managersbecause (1) its core elements are simple to present,(2) it accords with the values held by manymanagers, and (3) it draws a parallel betweenorganizational hierarchies and needs hierarchies”(Dolea & Adams, 2005, p. 5).

▶ Alderfer’s ERG TheoryTo address the criticisms of Maslow’s Hierarchy ofNeeds, in the late 1960s, Clayton Alderfer (1972)introduced an alternative needs hierarchy, referredto as the ERG Theory. Alderfer’s hierarchy relatesto three identified categories of needs: existence,relatedness, and growth (see Table 6-1).Table 6-1 Alderfer’s ERG TheoryLevel ofNeedDefinitionPropertiesGrowthDrives a personto make creativeor productiveeffects onthemselves andthe environment.Satisfied through a person usingtheir capabilities fully (anddeveloping additional ones) inproblem solving; creates a greatersense of wholeness and fullnessas a human being.RelatednessInvolvesrelationships withsignificant otherpeople.Satisfied by mutually sharingthoughts and feelings; acceptance,confirmation, understanding, andinfluence are elements of therelatedness process.ExistenceIncludes all ofthe various formsof psychologicaland materialWhen resources are limited andmust be divided among people,one person’s gain is another’s loss.

desires.Existence refers to an individual’s concern withbasic material and physiological requirementssuch as food, water, pay, fringe benefits, andworking conditions.Relatedness refers to the need for developingand sustaining interpersonal relationships suchas those with family, friends, supervisors,coworkers, subordinates, and other significantgroups.Growth refers to an individual’s intrinsic need tobe creative and to make useful and productivecontributions, including personal developmentwith opportunities for personal growth.When compared with Maslow’s Hierarchy of Needs,Alderfer’s ERG Theory differs on three points. First,the ERG Theory allows for an individual to seeksatisfaction of higher-level needs before lower-levelneeds have been satisfied. In other words, the ERGTheory does not require a person to satisfy a lower-level need for a higher-level need to become thedriver of the person’s behavior. Although the ERGTheory retains the concept of a needs hierarchy, itdoes not require a strict ordering, as in Maslow’stheory.Second, the ERG Theory accounts for differences inneed preferences between cultures; therefore, the

order of needs can be different for different people.This flexibility allows the ERG Theory to account fora wider range of observed behaviors. For example,it can explain Mother Teresa’s behavior of placingspiritual needs above existence needs.Third, and perhaps the most important aspect of theERG Theory, is the frustration–regression principle.The frustration–regression principle explains thatwhen a barrier prevents an individual from satisfyinga higher-level need, the person may “regress” to alower-level need to achieve feelings of satisfaction.For example, a person wants existence-relatedobjects when their relatedness needs are notsatisfied; a person wants relationships withsignificant others when growth needs are not beingmet.Managers must recognize that an employee mayhave multiple needs to satisfy simultaneously, andfocusing exclusively on one need will not effectivelymotivate an employee. In addition, the frustration–regression principle affects workplace motivation.For example, if growth opportunities are notprovided, employees might regress to relatednessneeds and socialize more with coworkers, or theymight look to other types of organizations forsatisfaction of this need—for example, a union. Ifthe work environment does not satisfy anemployee’s need for social interaction, the

employee might feel an increased desire for moremoney or better working conditions. If a manager isable to recognize these conditions, steps can betaken to satisfy the employee’s frustrated needsuntil the employee is able to pursue growth again(see Case Study 6-2).CASE STUDY 6-2 I Get bywith a Little Help from My FriendsJennifer Smith, RN, has worked at St. Joe’sMedical Center for the past 5 years as anoperating room nurse. She enjoys her workand the interaction it provides with patients,physicians, and especially her coworkers. Infact, she has developed strong friendshipswith many of her coworkers. They eat lunchtogether almost every day, they have monthlydinner parties at one another’s homes, andthey frequently go on vacations together.Helen Jones, the director of surgical services,has remarked about the cohesiveness of thegroup and how well they work together,creating a well-functioning team. However,during the past year, Jennifer has madefrequent remarks to her coworkers that shefeels that her nursing career is at a stalemateand she is getting bored with doing the same

thing every day. She has been questioningwhy she went back to school to earn her MSNdegree when Helen has never given her anopportunity to apply what she learned.Jennifer has started to think about looking fora new position at a different hospital thatwould give her opportunities to growprofessionally. Jennifer’s coworkersempathize with her, and when a vacancy wasposted on the hospital’s job bulletin board foran assistant clinical manager position in herdepartment, they encouraged her to apply.After reviewing the job description, Jenniferagreed that with her clinical experience andgraduate degree, she was the perfectcandidate for the job. She submitted herapplication, fully confident that Helen wouldoffer her the position. Jennifer was veryexcited and looked forward to the challengesshe would face when promoted.However, when Helen informed Jennifer thatanother staff member with more managementexperience had been offered the position,Jennifer could not disguise herdisappointment. She wondered what sheshould do now. Should she quit and seek anew position at a different hospital? But whatabout her friends at St. Joe’s?

Jennifer’s coworkers knew how upset she wasand made special efforts to ease herdisappointment by scheduling more outingstogether. They told her that other opportunitieswould come and that, with a little moreexperience, she would be promoted. Beingwith her coworkers was like group therapy forJennifer.After a few weeks, Jennifer returned to thelevel of enjoyment she had obtained from herwork before this episode. In addition, Helenapproached Jennifer to discuss her enrollingin a mentorship program that the hospital hadrecently established. The mentorship program,similar to an internship, would provide clinicalstaff members with hands-on managementexperience. Jennifer did not hesitate; sheenrolled in the program the following week.Jennifer was confident that she would beready when the next opportunity presenteditself.Discuss how Jennifer displayed thefrustration–regression principle of Alderfer’sERG Theory.

▶ Herzberg’s Two-FactorTheoryFrederick Herzberg developed his Two-FactorTheory, also known as the Motivation–HygieneTheory, from a study designed to test the conceptthat people have two sets of needs: (1) avoidance ofunpleasantness and (2) personal growth. InHerzberg’s original study (1959), 200 engineers andaccountants were asked about events they hadexperienced at work that had resulted in either amarked improvement in job satisfaction or a markedreduction in job dissatisfaction. From Herzberg’sresearch (1966), five factors stood out as strongdeterminers of job satisfaction (i.e., motivatorfactors) and are related to job content: (1)achievement, (2) recognition, (3) work itself, (4)responsibility, and (5) advancement. Thedeterminants of job dissatisfaction (i.e., hygienefactors) that are related to job context were found tobe (1) company policies, (2) administrative policies,(3) supervision, (4) salary, (5) interpersonalrelations, and (6) working conditions. It is importantto note that Herzberg used the term “hygiene” todescribe factors that are necessary to avoid

dissatisfaction but that by themselves do not providesatisfaction or motivation (see Exhibit 6-1).Herzberg’s research findings are significant tomanagers because the factors involved in producingjob satisfaction are separate and distinct from thefactors that lead to job dissatisfaction. As Exhibit 6-1 illustrates, these two factors are not opposites ofeach other. As Herzberg pointed out, the opposite ofjob satisfaction is not job dissatisfaction but ratherno job satisfaction. Similarly, the opposite of jobdissatisfaction is no job dissatisfaction, notsatisfaction with one’s job.In a practical sense, this means that dissatisfiers,referred to as hygiene factors, support and maintainthe structure of the job (job context), while satisfiers,referred to as motivators, assist employees inincreasing their motivation to do their work (jobcontent). Unfortunately, Timmreck’s (2001) study of99 health services middle managers found that onlya minority actually believed in and used motivatorsto stimulate subordinates’ behavior.Exhibit 6-1 Job SatisfactionJob Satisfaction No Job Satisfaction

Motivators/Satisfiers(Intrinsic–Job Content)AchievementRecognitionWork ItselfResponsibilityAdvancementNo Job Dissatisfaction JobDissatisfactionHygiene Factors/Dissatisfiers(Extrinsic–Job Context)CompanyPoliciesAdministrativePoliciesSupervisionSalaryInterpersonalRelationsWorkingConditionsOne of the criticisms of Herzberg’s Two-FactorTheory is that a factor may be a motivator for oneperson but cause job dissatisfaction for another. For

example, increased responsibility may be welcomedby one employee but avoided by another. Anothercriticism has been Herzberg’s placement of salaryor pay in the dissatisfier category, which has causedsome peopleto believe that Herzberg did not valuemoney as a motivator. However, what Herzbergmeant was that if pay did not meet expectations,employees were dissatisfied, but if pay metemployees’ expectations, salary was not a need toachieve satisfaction. This view is reiterated in DanielPink’s (2011) book Drive: The Surprising TruthAbout What Motivates Us. Pink refers to anemployee’s salary as a “baseline reward.” If thisbaseline reward is not adequate, then employeeswill focus on the inadequacy of their remuneration,which will lead to anxiety about their financialcircumstances, resulting in very little motivation.Herzberg believed that the absence of good hygienefactors, including money, would lead todissatisfaction and thus potentially block anyattempt to motivate the worker (see Exhibit 6-2).Exhibit 6-2 Stop Demotivating, BeforeYou Start MotivatingWhen people think about motivatingemployees, they’re usually thinking about waysto reward them. What carrots can be offered toget employees to work harder; what can we

dangle in front of them to encourage them totake the actions we desire? There are entirebooks written on ways to reward ouremployees, and multimillion-dollar consultingengagements built on those books. Theyinclude issues big and small, like money, pay-for-performance plans, flexible shifts, thank-younotes, gift cards, extra days off, promotions,educational opportunities, public recognition,and private pats on the back.Although rewarding employees is important, itmisses a hugely important point. If someone ishitting your foot with a hammer, you can’t stopthe pain with a backrub. This is an odd bit offolk wisdom, but here’s the lesson. In one ofour recent studies, 76% of employees said thatin the past 12 months, their managers haddone things that made them want to quit. And89% of employees said that their organizationhad done something that made them want toquit.Every day, employees face variousdemotivators, things that cause them to losetheir passion for their jobs and even causethem to consider quitting. And before we cantry to “motivate” them, we’ve got to stop“demotivating” them. To make this concept a

little easier, instead of talking aboutdemotivators and motivators, we’re going totalk about Shoves and Tugs. Shoves are thoseissues that cause people to lose their passion,enthusiasm, and even consider quitting. Tugsare those issues that get people excited, ignitetheir passion, and make them committed tostaying with an organization or boss.This tends to be a radical concept for mostleaders, so let’s walk through an example.Pat is a nurse at a major teaching hospital.She’s worked there for 8 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 evenpublish. Her major Tug is doing intellectuallychallenging work with really smart people. Buttwo weeks ago, the hospital instituted flexiblework schedules and changed all the shifts. Thisis causing Pat serious difficulty because shehad timed her kids’ schedules around her oldshift start/end times, and this change disruptseverything. For Pat, this scheduling change is aShove.Now, here’s the radical part. Before Pat’smanager can address her Tugs, they will haveto fix her Shoves. When you see Pat’s issues

described separately as Shoves and Tugs, itbecomes pretty clear that she’s going to bemuch less excited about the opportunity topublish as long as her schedule is causing herproblems. But because most leaders don’tinitially separate Shoves and Tugs into twodistinct issues, the typical leader will ignore thescheduling issue and just try to give Pat moreresearch work. Or try to buy her compliancewith money.Shoves are often focused on basic issues likeworking conditions, schedules, compensation,an acceptable relationship with the boss, andso on. Tugs often encompass higher-orderissues like enjoying the work, careeradvancement, working with interesting people,organizational culture, and so on.If we had only asked Pat what excited herabout her job, what really made her love thishospital, we’d have gotten an answer aboutdoing intellectually stimulating work. And if wehad only asked Pat what could make her lifesufficiently miserable to cause her resignation,we’d have gotten an answer about herschedule and her outside-of-work obligations.It’s only when we ask about both issues that weget the complete picture.

When you’re working with low performers,when you’re working terrible hours, or you’vegot a terrible working environment, you couldbe so frustrated that you feel like you’re beingShoved out the door. You could feel sofrustrated that you no longer notice all of theother good things about your job that Tug atyou to stay—the autonomy, the ability to havecontrol over an entire process, the ability towork on innovative projects and teams. If yourorganization is like the organizations in ourstudies, as much as 35% of your workforcecould feel this way. And these people are hugeretention risks.On the other hand, you could have a workingenvironment that is free from Shoves, but alsolacking in any significant Tugs. You’re not beingShoved out the door by frustration, but neitherare you being Tugged to remain at thecompany. And once again, if yours is anythinglike the organizations in our studies, as muchas 50% of your workforce could feel this way.The good news is that these people probablyaren’t spending their days on Monster.comactively applying for jobs. The bad news is thatif the economy changes, or one of yourcompetitors makes a play for them, or they just

happen across another opportunity, they willleave.To get someone really truly committed to yourorganization, you must first eliminate anyShoves and fulfill at least some Tugs. Inessence, you’ve got to meet their basic needsand afford some opportunity to address theirhigher-order needs.Reproduced from Murphy, M. (2008). Stop Demotivating, Before YouStart Motivating. Leadership IQ. Retrieved fromhttps://www.leadershipiq.com/stop-demotivating-before-you-start-motivatingDent (2002) relates that when Herzberg firstpresented his work, it was very controversial in theacademic community but very popular in industrybecause it helped to answer employers’ questionsas to why the level of an employee’s productivitydoes not equate to the compensation received.In the late 1950s, the U.S. economy wasexperiencing a tremendous upswing. The issue ofmotivation was critical for retaining good people,who often had several other opportunities. Theprimary advice coming from industrial psychologistswas to motivate through compensation packages.As a result, employers were paying higher andhigher salaries but felt that they were not getting

higher levels of performance in return. Herzberg’swork validated what the employers were feeling.Herzberg suggested that higher performance levelswould come not from higher salaries but from givingemployees the opportunity to create and affect theirown environments (Dent, 2002, p. 276).Although managers need to provide employees witha reasonable salary, a degree of job security, andsafe and comfortable working conditions (hygienefactors), focusing on these matters will notcontribute to an employee’s motivation orperformance improvement (Sashkin, 1996).Herzberg promoted the concept that if the work onedoes is significant, it will ultimately lead tosatisfaction with the work itself. In other words,employees will be motivated to do work that theyperceive to be significant (see Case Study 6-3).CASE STUDY 6-3 Why Don’t IJust Quit?Robin Williams sat at her desk, going throughher mail, and asked herself the same questionshe had asked herself a hundred timesbefore: “Why don’t I just quit?” Robin thought,“I don’t need this job. I have enough money inmy savings account to last a year, and withmy degree and experience, I could go

anywhere.” Robin graduated from one of thetop schools in the country with a Master ofSocial Work (MSW) and has been a socialworker for the Alpine Medical Center for thepast 4 years. Although she loves herinteractions with her clients and the ability andfreedom to help them through the system,thus enabling them to satisfy their social andmedical needs, she is unhappy with therequired 60-hour work week for a salary farless than what her friends who graduated withan AS/Nursing degree are earning. In addition,Robin believes that her boss is trying to sether up to be fired just because she told himthat he was an incompetent administrator.“Well, he is,” thought Robin. He hadn’t beenable to find the money in the departmentbudget to purchase a new computer that shedesperately needed to help her clients. Tomake matters worse, her coworkers, who “livein their own worlds,” never extended thecourtesy of asking her to join them for lunch.“Not that I would go with them,” Robin thought.“They are just as useless as the director—anddidn’t they forget that yesterday was mybirthday?”As she thought the issues over in her mind,she opened a thank-you letter from a client

she helped last month. He just wanted to tellher how much he appreciated her helpthrough his illness and to say that without herassistance, he would not have known all thecommunity services available to him so thathe could remain at home versus beingadmitted into a nursing home.Robin smiled and put the card aside. She wasstill trying to figure out why she didn’t quit herjob. She wished she knew the answer.Using Herzberg’s Two-Factor Theory, discusswhy Robin has not resigned from her position.To build on this concept, jobs should be designedwith special attention for opportunities relating toachievement, responsibility, meaningfulness, andrecognition. Pink (2011) relates that organizationsneed to focus on individuals’ intrinsic needs forautonomy (providing employees with the controlover some or all of their work), mastery (allowingemployees to become better at something thatmatters to them), and purpose (fulfilling employees’natural desire to contribute to a cause greater andmore enduring than themselves).According to Herzberg, motivation comes from jobcontent. Therefore, it is important for managers to

consider the nature of the jobs that they ask theiremployees to do. Herzberg’s approach can besummarized as follows: “If you want people to do agood job for you, then you must give them a goodjob to do.” As Sethi and Stubbing (2019, p. 1)explain, “[P]eople want to do good work, in twoways: (1) they want intrinsically rewardingexperiences, and (2) they want to make acontribution that fits their values.” Managers need tobe concerned with job-design characteristics,including job enrichment. Job enrichment is thevertical expansion or loading of the job as opposedto a horizontal expansion (job enlargement) (seeTable 6-2). In other words, vertical loading isproviding employees more responsible tasks inorder to develop their skills.Table 6-2 Herzberg’s Principles of Vertical Job LoadingPrincipleMotivatorsInvolvedRemoving some controls while retainingaccountabilityResponsibility andpersonalachievementIncreasing the accountability of individuals forown workResponsibility andrecognitionGiving a person a complete natural unit ofwork (module, division, area, and so on)Responsibility,achievement, andrecognition

Granting additional authority to an employeein their activity; job freedomResponsibility,achievement, andrecognitionMaking periodic reports directly available tothe worker themselves rather than to thesupervisorInternal recognitionIntroducing new and more difficult tasks notpreviously handledGrowth and learningAssigning individuals specific or specializedtasks, enabling them to become expertsResponsibility,growth, andachievementReproduced from Herzberg, F. (1983). One more time: How do youmotivate employees? Harvard Business Review, 81(1), 93.

▶ Job DesignJob-design research in the past three decades hasgenerated many insights into the relationshipbetween job characteristics and job satisfaction. Thewell-known and widely researched JobCharacteristics Model was developed by Hackmanand Oldham (1976, 1980) (see Figure 6-4).

Figure 6-4 The Job Characteristics Model of Work MotivationReproduced from Hackman, J. R., & Oldham, G. R. (1980). Workredesign (p. 90). Reading, MA: Addison-Wesley.Hackman and Oldham (1980) listed five coremotivational job characteristics:

Skill Variety: The degree to which a job requiresa variety of different activities in carrying out thework, involving the use of a number of differentskills and talents of the person.Task Identity: The degree to which a jobrequires completion of a whole and identifiablepiece of work—that is, doing a job frombeginning to end with a visible outcome.Task Significance: The degree to which the jobhas a substantial impact on the lives of otherpeople, whether those people are in theimmediate organization or in the world at large.Autonomy: The degree to which the jobprovides substantial freedom, independence,and discretion to the individual in schedulingthe work and in determining the procedures tobe used in carrying it out.Feedback: The degree to which the workactivities required by the job provide theindividual with direct and clear informationabout the effectiveness of his or herperformance (pp. 78–80).As reflected in Figure 6-4, each core jobcharacteristic or combination of factors leads tocritical psychological states for an employee.Hackman and Oldham (1980) relate that thecombination of skill variety, task identity, and tasksignificance leads to the psychological state of

experienced meaningfulness, in which the workerperceives that the job is significant. Autonomy leadsto the psychological state of experiencedresponsibility for outcomes (i.e., the employee feelsindividual responsibility for the work), and feedbackleads to the psychological state of knowledge of theactual results of work activities. These criticalpsychological states lead to an employee’s highlevels of internal motivation, growth, job satisfaction,and work effectiveness (quality and quantity).Using the moderators in the Job CharacteristicsModel, Hackman and Oldham (1980, pp. 82–88)attempted to explain why some employees “take off”on jobs that are high in motivating potential andothers are “turned off.” The first moderator isknowledge and skills. If people have sufficientknowledge and skills to perform their job well, theywill experience positive feelings as a result of theirwork activities. However, people who are notcompetent to perform their tasks well will experienceunhappiness and frustration at work.The second moderator is growth-needs strength.Some people have strong needs for personalaccomplishment, for learning, and for developingthemselves beyond where they currently are. Thesepeople are said to have strong “growth needs.”Other people have less strong needs for growth orpersonal accomplishment. Therefore, individuals

with high growth needs respond positively to theopportunities provided by enriched work. However,individuals with low growth needs might notrecognize the existence of enriching opportunities,might not value them, or might find them threateningand complain about being pushed or stretched toofar at work.The third moderator is satisfaction with the workcontext. Employees who are relatively satisfied withtheir job context (pay, job security, coworkers, etc.)will respond more positively to enriched andchallenging jobs than will employees who aredissatisfied with their job context.Managers need to pay close attention to themoderators. If an employee is fully competent tocarry out the work required by a complex andchallenging task, has strong needs for personalgrowth, and is well satisfied with the work context,then the manager should expect the employee toexhibit high personal satisfaction and high workmotivation and performance. If an employee lacksany of these moderators, the opposite results arelikely to occur.To assist managers in designing jobs that willincrease motivation for employees, Hackman andOldham (1975) developed the Job DiagnosticSurvey (JDS). The JDS measures the degree to

which the various job characteristics are included inthe job. The job characteristics can then be alteredto enrich the job and increase its motivationalpotential (Lunenburg, 2011). The JDS generates asummary score reflecting the overall motivatingpotential of a job in terms of the core job dimensions(Hackman & Oldham, 1975). The motivatingpotential score (MPS) is calculated as follows:The core job characteristics of skill variety, taskidentity, and task significance are combined,whereas the job characteristics of autonomy andfeedback stand alone. Because of the additive andmultiplicative relationships of the job characteristicsin the MPS formula, one or more of skill variety, taskidentity, and task significance could be missing ormeasured as zero, and the employee could stillexperience the work as meaningful. However, ifeither autonomy or feedback were missing, the jobwould 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 job redesign for bank tellers increasedboth job performance and job satisfaction, with

positive effects lasting up to 4 years. Grant and hiscolleagues’ work supports the idea that careful jobredesign that increases performance andsatisfaction is an important factor not only foremployees but also for organizations. Grant’sresearch was conducted at a large bank wheremanagers, using a research survey, found that banktellers were very dissatisfied with their jobs, statingthat they were “just glorified clerks”—micromanagedwith boring jobs and no decision-makingresponsibilities. The bank managers decided toredesign the teller jobs. New tasks were added toprovide variety requiring a broad range of skills. Thetellers were also given more autonomy in their rolesas well as decision-making responsibilities. Jobsatisfaction increased, and when a survey wasadministered 6 months later, it showed that thetellers not only were more satisfied with their rolesbut also were more committed to the organization(Grant et al., 2010).

▶ McClelland’s Three-NeedsTheoryDavid McClelland (1985) experimented withindividuals’ responses to pictures of various groupsof people gathered together. On the basis of theparticipants’ responses, McClelland identified threetypes of motivational needs: achievement, power,and affiliation.Achievement (n-Ach) is described as the needto excel or succeed. In general, high achieverstend to seek moderately challenging tasks, takepersonal responsibility for their performance,and require feedback to confirm theirsuccesses.Power (n-Pow) is described as an individual’sneed to influence others. This can be positiveor negative, as we will discuss later.Affiliation (n-Aff) is described as an individual’sneed to be liked and approved of by others. Assuch, n-Aff people have a strong need forinterpersonal relationships.McClelland (1985) believed that most people have acombination of these motivational needs, with someexhibiting a stronger tendency to one particular

motivational need (e.g., a high power need versus ahigh achievement need). This tendency affects aperson’s behavior and management style. Forexample, McClelland suggested that a highaffiliation need weakens a manager’s objectivity anddecision-making capability because of themanager’s need to be liked by their subordinates,colleagues, and supervisors. Although individualswith high power needs are attracted to leadershiproles, they might not have the required flexibility andhuman relations skills necessary to be effective.McClelland argues that individuals with strongachievement needs make the best leaders, althoughthey can have a tendency to demand too much oftheir staff in the belief that they are all similarly andhighly focused on achievement (i.e., results driven).One interesting aspect of McClelland’s theory is thatindividuals can learn or acquire a need forachievement by being associated with success andfailure in the past (and the effect that accompaniessuccess and failure).AchievementA significant part of McClelland’s research focusedon the achievement motivational need (n-Ach).Through his research, McClelland concluded thatwhile most people do not possess a strong n-Achmotivation, those who do have it display a

consistent behavior of moderate risk-taking. Tosupport his theory, McClelland (1985) performed thenow famous ring-toss experiment.Participants played a ring-toss game in which thesubjects determined how close or far away theywould stand from the peg. One group of participantsstood very close to the peg to ensure that theywould never miss. Another group stood so far awaythat if they actually did place the ring on the peg, itwas because of chance, not ability. The third groupcalculated their distance from the peg. They didn’tstand so far away as to make the task impossible,nor did they stand so close as to make it too easy. Ifthey missed the first toss, they would move closer; ifthey made the toss, they would take a step back forthe next toss. McClelland referred to the third groupas moderate risk-takers—individuals who desired achallenge but whose success was based on theirabilities, not chance, as with the second group.McClelland (1961) relates that n-Ach people havevarious attributes. First, n-Ach individuals are nothigh risk-takers as compared to a gambler who hasno control over the outcomes. High achievers aremoderate risk-takers. Achievement-motivatedindividuals set difficult goals, but these are goalsthat they believe to be achievable through theirefforts and abilities. High achievers work harder andmore efficiently when the task is challenging and

requires creativity, such as designing new systemsor just a better way of doing things. Second, n-Achindividuals view goal achievement as their rewardand require feedback that is quantifiable and factual.They view more money and/or higher profits as themeasurement or feedback of their success. Jobsecurity is not an important issue for n-Ach people.They prefer occupations that allow them theflexibility and the opportunity to set their own goals,such as in sales, business, or entrepreneurial roles.Although high achievers can work in groups, theyreceive their satisfaction by knowing that theyinitiated an action that contributed to the group’ssuccess.McClelland (1961) believed that n-Ach individualsare the ones who make things happen and getresults in an organization. They are successful inobtaining the resources, including employee buy-in,to achieve organizational goals. However, highachievers may be viewed as demanding of staff andinsensitive to the needs of others because of theirresults-driven attitude.PowerMcClelland (1985) relates that a high need forpower may be expressed as personalized power orsocialized power. Individuals with a high need forpersonalized power tend to display impulsive

aggressive actions, to abuse alcohol, and to collectprestige “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 forpersonalized power demand personal loyalty fromstaff, not loyalty to the organization. Yukl (2001)points out that when a high personalized powerleader leaves an organization, the result is usuallychaos, loss of direction, and low morale.Socialized power need is associated with effectiveleadership. These leaders direct their power in waysthat benefit others and the organization rather thanfor their own personal gain. As McClelland (1985)and Yukl (2001) relate, these leaders are interestedin seeking power because it is through power thatthey can influence other people to accomplish tasks.They empower others who use that power to enactand further the leader’s vision for the organization.AffiliationIndividuals with a high need for affiliation seek to bewith and interact with others. McClelland (1985)relates that they are concerned with establishing,maintaining, or restoring positive relationships withothers. High affiliation individuals want to pleaseothers and engage in more dialogue with others.Individuals are very important to n-Aff people. Theyprefer friends over experts when working in groups

(n-Ach individuals prefer experts over friends asworking partners) and prefer feedback on how wellthe group is getting along rather than how well theyare performing on the task. They avoid conflict andcriticism and have a fear of rejection by others.Therefore, individuals with a high need for affiliationdo not make good managers (see Case Study 6-4).CASE STUDY 6-4 The OfficeManager’s DilemmaWhen Karen Lewis was promoted to officemanager for Dr. Green’s orthopedic practice,she was thrilled. She had worked for Dr.Green for almost 6 years and considered theoffice her home away from home and hercoworkers as her extended family. Karen wasthe office organizer for picnics, Friday nightget-togethers, and holiday parties. She alwaysmade sure that staff members’ birthdays andanniversaries were recognized andcelebrated. She was very concerned aboutwhether everyone was happy, and she wasalways available to help other coworkers withany problems.In addition, Karen was competent in all areasof the office operations. Although originallyhired as an X-ray technician, she had

performed, at one time or another, the dutiesof all the positions within the practice. She hadcovered the receptionist, medical records, andbilling staff members’ positions when theywere on vacation or ill or when there was anunfilled vacancy. Not only was sheresponsible for running the X-ray area of thepractice, but over the years, she had alsoassumed the responsibilities for orderingsupplies and scheduling surgeries.Karen thought that making the transition tooffice manager would be easy, and the firstfew months went well. But in her fourth month,other staff members came to her complainingabout Suzie, the new appointment-schedulingclerk. Karen was surprised to hear that Suziewas not doing her job well and that her errorswere affecting the entire office operations.Suzie was scheduling patients to come to theoffice when Dr. Green was at the hospitalperforming surgery and during staff members’lunch periods. She was also overscheduling,causing patients to wait for hours. Karen toldthe other office staff members that she woulddiscuss the matter with Suzie as soon aspossible.

However, Karen found it very difficult toschedule a meeting with Suzie to discuss theproblems. Every time Karen approachedSuzie about the subject, she found that herstomach tightened and she began to sweat.The best she could do was to ask Suzie, “Howis everything going?” Suzie replied,“Everything is great. I love working in such awarm and friendly office.”A week later, some of the staff membersapproached Karen again and asked whethershe had spoken with Suzie because theproblems were getting worse. Karen lied andsaid that last week was so busy that she didnot get an opportunity but that she would talkwith Suzie this week. Again, Karen found itdifficult to discuss the matter with Suzie. Shedidn’t want to hurt Suzie’s feelings becauseSuzie thought she was doing a good job.However, if she didn’t speak with Suzie soon,Karen knew Dr. Green would start to questionwhether she was capable of handling theduties of the office manager position. Shecouldn’t bear to think that she let Dr. Greendown and that he might be displeased withher work. In addition, there were rumorscirculating through the office grapevine that ifthe “appointment-scheduling” problem was not

fixed soon, a few staff members were thinkingabout quitting because the mistakes hadcaused their workload to increase 20%.Karen decided that she would discuss thematter with Suzie the following day. Karenasked Suzie to come in 10 minutes beforeoffice hours started so that they could have achat. Karen had a restless night’s sleep.When she awoke, she noticed that she haddeveloped a rash over her entire body. Shehad no choice; she called the answeringservice to tell Dr. Green and the staff that shewas too ill to come to work.Using McClelland’s Three-Needs Theory,discuss whether Dr. Green made the rightdecision in promoting Karen Lewis to officemanager. Why or why not?

▶ SummaryWhen the content theories of motivation arecompared, there are notable similarities (see Table6-3). The theories describe an individual’s variousneeds in similar terms. Herzberg’s hygiene factorsparallel Maslow’s physiological, security, andbelongingness needs and Alderfer’s existence andrelatedness needs. Maslow’s self-esteem and self-actualization needs are similar to Herzberg’smotivators and Alderfer’s growth requirement.McClelland’s achievement is closely related toHerzberg’s motivators, and his power and affiliationcan be related to Alderfer’s relatedness needsbecause of an individual’s need to influence (power)or satisfy a need for warm feelings (affiliation)(Alderfer, 1972). It is clear that Maslow’s Hierarchyof Needs Theory has had a great influence on thestudy of organizational behavior and continues to doso even after 60 years (Latham & Pinder, 2005).Table 6-3 Comparisons of Content Theories of Motivation

Discussion Questions 1. Define motivation. 2. Connect the five tiers of Maslow’s Hierarchyof Needs to the workplace. 3. Discuss how Alderfer’s ERG Theory satisfiedthe criticisms of Maslow’s Hierarchy ofNeeds. 4. Explain Herzberg’s Two-Factor Theory as itrelates to job design. 5. Explain the various components of Hackmanand Oldham’s Job Characteristics Model. 6. Discuss McClelland’s Three-Needs Theoryas it relates to a manager’s success in theworkplace. 7. Discuss the relationship between the variouscontent theories of motivation.

CASE STUDIES ANDEXERCISESCase Study 6-5 All in a Day’s WorkSarah Goodman, senior manager of networkdevelopment for Holy Managed CareCompany, looked over her calendar for theday and sighed deeply. It seemed as if therewould be no time at all to work on the projectshe’d been putting off for most of the week.Circumstances seemed to be such that shesimply didn’t have any control over her owntime anymore.Well, first things first, she determined. At 9:00she was due at a meeting of senior managerswho were involved in trying to devise astrategy for counteracting a threatenedunionization drive by the company’snonexempt employees. As Sarah thoughtabout the people working for her, she beganto wonder exactly what they wanted. They hada pleasant working space, good benefitspackage, and secure employment. She heardthe laughter and chatter drifting into her officeas people came into work 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 6 monthsSarah’s office was scheduled to be moved toa new industrial park on the west side of town.The plans she’d seen so far had all kinds ofgreat perks for employees: on-site day-carecenter, fitness center, ample parking, greatfacilities for training. The company wascertainly spending a lot of money on this newsite. Sarah hoped it would help increaseproductivity; it certainly would make theemployees happier and make recruitmenteasier.She’d have to hurry to her lunch meeting withthe adviser for the MHA program at SaintThomas University. Sarah had decided as apart of her New Year’s resolution that she wasfinally going to begin her graduate degree.She felt she was simply stagnating in her joband, after looking around at positions in hercompany that looked interesting, she realizedshe needed a graduate degree if she weregoing to progress. The only problem was thatshe wasn’t sure how enthusiastic Richard, herhusband, would be about the whole idea. And

her mother certainly wouldn’t be happy! Thehints about grandchildren had become anoutright discussion over the holidays.Discuss the various motivation theoriesreflected in this case study.Reproduced from Pidge Diehl, EdD.Case Study 6-6 Develop a MotivationPlanJane Couch is the director of nursing for a400-bed nonprofit hospital in the Southwest.Susan Smith joined the hospital as a staffnurse 3 years ago after relocating from theNortheast. She is 30 years old and has been astaff nurse since graduating from a 2-yearcollege nursing program 10 years ago. She ismarried to a lawyer, and they have twochildren, aged 6 and 8.The hospital’s inpatient census has beenextremely high because of another hospital’sclosing. The tension on the nursing floors hasincreased because of pressures to dischargepatients early, lack of professional staff, andan upcoming accreditation visit from The JointCommission. Because of time restraints, Janewas unable to complete the staff ’s annualperformance evaluations. However, all nurses

received a 5% pay increase. With thisincrease, the hospital staff is now the highestpaid of all the hospitals in the region. Janebelieves that the higher pay compensates thenursing staff for their increased workload andrelated stress levels.Until recently, Jane had been pleased withSusan’s performance. Susan haddemonstrated a willingness to work hard andhad made very few, if any, patient-care errors.However, over the past 3 months, Jane hasnoticed that Susan is not performing at herusual productivity level and appears to arguefrequently with the treating physicians andother nurses about the patients’ treatmentplans. Jane often hears Susan complainingthat “no one listens to me,” “no one wants tohear my opinion,” and “they don’t pay meenough to do this job.”Susan was once a highly motivated,productive member of the nursing staff. Janeunderstands that everyone is experiencingmore stress than usual because of theincreased workload, but what can be done tomotivate Susan to return to her priorperformance?

Within the principles of the content theories ofMaslow, Herzberg, and Alderfer, explain toJane why Susan is behaving the way she hasover the past 3 months.Case Study 6-7 Employees’Motivation NeedsAlthough cash bonuses can improve physicianexecutive job performance, money isn’t toohelpful when it comes to improving jobsatisfaction, a recent survey found.According to the survey of physicianexecutives, personal growth, personaldevelopment, life/work balance, effectivecommunications, and personal relationshipsare the true keys to improving satisfaction.The informal survey questioned 104 physicianleaders and included CEOs, vice presidents ofmedical affairs, medical directors, departmentchairs, and consultants. It examined bothindividual and organizational views of jobsatisfaction. When asked to describesuccessful methods of improving jobsatisfaction for their staff:46% of respondents describedimproving communications andpersonal relationships.

9% mentioned improving leadershipquality.Only 3% of respondents stated thatbonuses successfully could be used toimprove satisfaction at the staff level.When it comes to dealing with staff, “listen tothem and treat them with respect,” one surveyrespondent said. “Give them credit for theirhelp and ideas whenever there is anopportunity, especially in front of my bosses orin a large group. Ask them what they need todo their job better and then try to give it tothem. If we can’t give it to them, be honestand ask for other suggestions.” Anotherparticipant said more money is certainly notthe answer. “Added pay for addedresponsibility does not work if they really didnot want the responsibility in the first place.”Using Herzberg’s Two-Factor Theory, explainthe informal survey’s results regardingemployees’ motivation needs.Reproduced from Matheny, G. L. (2008). Money not key tohappiness, survey finds. Physician Executive, 34(6), 14–15.Case Study 6-8 We Only Wanted toScare Management into Making Changes!

A small group of nurses at a large communityhospital were unhappy about their workenvironment and met daily during lunch todiscuss the situation. A recent change in thehospital’s senior management was causing ahigh level of uncertainty and anxiety amongthe nursing staff. The nurses felt overworked.They were being asked to forgo their breaktimes, work overtime, and take extra on-callwork because of the hospital’s hiring freeze(which included nursing positions) and thehigh daily occupancy rate with sicker patients.Their wages and benefits had been stagnant,with no salary increases for the past 2 years,and the cost of living in their community hadincreased by 10% during this period. They feltthat they were falling behind economically. Infact, a few nurses complained that they couldno longer afford to send their children toprivate schools.The nurses saw the situation as managementrequiring them to do more work with fewerresources and with no appreciation orrecognition of their efforts. In addition,because of recent layoffs of support staff, thenurses were losing precious time caring fortheir patients each day as they hunted forneeded medications and supplies. The nurses

felt that these “hunting and gathering”activities threatened patient safety becausethey took the nurses away from the bedside.The nurses also were tired of the physicians’verbal abuse and disruptive behaviors.Whenever the nurses approachedmanagement about these matters, theyperceived their concerns as falling on deafears, since no changes were ever made.Feeling that they had no other choice, thenurses contacted a labor union. The laborunion began an organizing effort in thehospital shortly thereafter, waging anaggressive campaign over a 6-week period.There was tremendous peer pressure, assome of the well-respected members of thenursing staff became active leaders forunionization, although they had not beenamong the initial group of nurses who had firstcontacted the union. The election was held,and the union was voted in by two-thirds of thenursing staff. In the weeks that followed, theoriginal group of nurses remarked that theywere surprised by the union’s victory; they hadonly wanted to scare management intomaking changes to their work environment.

1. Using Maslow’s Hierarchy of Needs,diagram the nurses’ issues within eachlevel.2. Explain why the nurses were motivated tocontact the labor union using Herzberg’sTwo-Factor Theory.Exercise 6-1 Job SurveyIntroductionObjective: To learn how job design affectsperformance.Time: About 25 minutes.Instructions: Take the survey below. Once youhave completed it, total your scores. Compareyour final score with others in the class anddiscuss the following questions:Normally, persons who are in a positionof leadership will have scores that arehigher than their workers’. Why is this?If your employees were to take thissurvey today, what do you think theiraverage scores would be?Discuss Hackman and Oldham’s fivedimensions and how they help tomotivate a job holder. Ask for a fewexamples of how a job could be

redesigned under each of the fivedimensions.Job Design QuestionnaireDirections: Listed below are some statementsabout your job. For each statement, write inyour response based on how much you agreeor disagree with it.StronglyDisagreeSlightlyDisagreeDisagreeUndecidedSlightlyAgreeAgreeStronglyAgree(1)(2)(3)(4)(5)(6)(7)My job:Provides much variety. __________Allows me the opportunity to completethe work I start. __________Is one that may affect a lot of otherpeople by how well the work isperformed. __________Lets me be left on my own to do myown work. __________Provides feedback on how well I amperforming as I am working.__________Provides me with a variety of work.__________

Is arranged so that I have a chance todo the job from beginning to end.__________Is relatively significant in theorganization. __________Provides the opportunity forindependent thought and action.__________Provides me with the opportunity to findout how well I am doing. __________Gives me the opportunity to do anumber of different things. __________Is arranged so that I may see projectsthrough to their completion.__________Is very significant in the broaderscheme of things. __________Gives me considerable opportunity forindependence and freedom in how I domy work.__________Provides me with the feeling that Iknow whether I am performing well orpoorly. __________SummaryScoring for Job DesignQuestionnaire

The survey is designed to analyze fivedimensions of the job:Skill Variety: Total the scores forquestions 1, 6, 11 __________Task Identity: Total the scores forquestions 2, 7, 12 __________Task Significance: Total the scores forquestions 3, 8, 13 __________Autonomy: Total the scores forquestions 4, 9, 14 __________Feedback About Results: Total thescores for questions 5, 10, 15__________The lower scoring dimensions (normally,anything below 15) should be investigated tosee whether the job environment can beimproved.About the SurveyHackman and Oldham’s Five Dimensions ofMotivating PotentialSkill Variety: The degree to which a jobrequires a variety of challenging skillsand abilities.Task Identity: The degree to which ajob requires completion of a whole andidentifiable piece of work.

Task Significance: The degree to whichthe job has a perceivable impact on thelives of others, either within theorganization or in the world at large.Autonomy: The degree to which the jobgives the worker freedom andindependence in scheduling work anddetermining how the work will becarried out.Feedback: The degree to which theworker gets information about theeffectiveness of his or her efforts, eitherdirectly from the work itself or fromothers.©Donald Clark, created March 18, 2000, last update August28, 2010. Available atwww.nwlink.com/~donclark/leader/jobsurvey.html.Exercise 6-2The Healthy People 2020 initiative hasidentified social determinants of health thatare important nonclinical elements affectingthe health of individuals. Often, these socialdeterminants can influence whether or notpatients will take good care of their bodies,engage in healthy lifestyles, seek preventivecare, or address more pressing health

concerns before they progress. Often,navigating the complex system of hospitalsand insurance takes significant motivation andinitiative on the part of the patient. As healthcare institutions are facing new pressures tocare for the health of their populations insteadof just handling acute cases that come into thehospital, it is important for administrators tounderstand what motivates members of thecommunity to take care of their health.Discuss how each of the elements belowrelates to Maslow’s Hierarchy of Needs andhow barriers in these areas might affect one’smotivation to engage in a healthy lifestyle.Economic StabilityEmploymentFood InsecurityHousing InstabilityPovertyEducationEarly Childhood Education andDevelopmentEnrollment in Higher EducationHigh School GraduationLanguage and LiteracySocial and Community ContextCivic Participation

DiscriminationIncarcerationSocial CohesionHealth and Health CareAccess to Health CareAccess to Primary CareHealth LiteracyNeighborhood and Built EnvironmentAccess to Foods That SupportHealthy Eating PatternsCrime and ViolenceEnvironmental ConditionsQuality of HousingMore information available athttps://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health

ReferencesAlderfer, C. (1972). Existence, relatedness, and growth. NewYork, NY: Free Press.Dent, E. B. (2002). The messy history of OB&D: How threestrands came to be 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 deSociologie et de Démographie Médicales, 45(1), 135–161.Grant, A. M., Fried, Y., & Juillerat, T. (2010). Work matters: Jobdesign in classic and contemporary perspectives. In S. Zedeck(Ed.), APA handbook of industrial and organizationalpsychology (Vol. 1, pp. 417–453). Washington, DC: AmericanPsychological 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 jobdiagnostic survey. Journal of Applied Psychology, 60(2), 159–170.Hackman, J. R., & Oldham, G. R. (1976). Motivation through thedesign of work: Test of a theory. Organizational Behavior andHuman Performance, 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:The World Publishing Company.Herzberg, F., Mausner, B., & Snyderman, B. (1959). Themotivation to work. New York, NY: John Wiley & Sons.Latham, G. P., & Pinder, C. C. (2005). Work motivation theory andresearch at the dawn of the twenty-first century. AnnualReview of Psychology, 56(4), 85–516.Lunenburg, F. C. (2011). Motivating by enriching jobs to makethem more interesting and challenging. International Journal ofManagement, 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.). NewYork, NY: Harper & Row.McClelland, D. C. (1961). The achieving society. New York, NY:The Free Press.McClelland, D. C. (1985). Human motivation. Glenwood, IL: Scott-Foresman.O’Connor, D., & Yballe, L. (2007). Maslow revisited: Constructinga road map of human nature. Journal of ManagementEducation, 31(6), 738–756.Pink, D. H. (2011). Drive: The surprising truth about whatmotivates us. New York, NY: Riverhead Books/PenguinGroup.Sashkin, M. (1996). The MbM questionnaire: Managing bymotivation (3rd ed.). Amherst, MA: Human ResourceDevelopment Press.

Sethi, B., & Stubbings, C. (2019). Good work. Strategy+Business,94, 1–13. Available from https://www.strategy-business.com/feature/Good-Work?gko=89684Timmreck, T. C. (2001). Managing motivation and developing jobsatisfaction in the health care work environment. Health CareManager, 20(1), 42–58.Yukl, G. A. (2001). Leadership in organizations (5th ed.). UpperSaddle River, NJ: Pearson Education.

Other Suggested ReadingsCampbell, 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 7Process Theories ofMotivationLEARNING OUTCOMESAfter completing this chapter, the student shouldbe able to understand:The various components of ExpectancyTheory and how they affect an individual’slevel of motivation.Equity Theory and the methods to resolveinequity tension.The significance of the Satisfaction–Performance Theory.Goal-Setting Theory and the steps necessaryfor successful implementation.Reinforcement Theory and the four types ofreinforcement.

▶ OverviewUnderstanding individuals and what motivates themis a conundrum for health care managers, especiallysince we need to manage such diverse groups ofemployees. These employees are diverse not onlyin culture, race, and gender, but also in their varyinglevels of education. On a daily basis, we need tomanage not only secretarial staff who might haveminimal education, but also highly skilled individualssuch as nurses, physicians, and other licensedhealth care professionals. Process theories canassist us in predicting employees’ behavior so thatwe may influence their behavior, if necessary.In this chapter, we examine five theories ofmotivation: (1) Expectancy Theory, (2) EquityTheory, (3) Satisfaction–Performance Theory, (4)Goal-Setting Theory, and (5) Reinforcement Theory.

▶ Expectancy TheoryOne widely cited theory of motivation is VictorVroom’s (1964) Expectancy Theory (also referredto as the VIE Theory). Expectancy Theory suggeststhat for any given situation, the level of a person’smotivation (“force” in Vroom’s conceptualization)with respect to performance depends on (1) thedesire for a certain outcome, (2) the perception thatindividual job performance is related to obtaining thedesired outcome, and (3) the perceived probabilitythat individual effort will lead to the requiredperformance. The theory may be expressed as M =V × I × E (see Figure 7-1).Figure 7-1 Vroom’s Expectancy Theory (VIE)Vroom (1964) explains that the force that drives aperson to perform depends on three factors:

valence, instrumentality, and expectancy.Valence is the strength of an individual’s want orneed for, or dislike of, a particular outcome. Anoutcome has a positive valence when the personprefers attaining the outcome to not attaining it, avalence of zero when the person is indifferent toattaining or not attaining the outcome, and anegative valence when the person prefers notattaining the outcome to attaining it. Thus, valencecan have a wide range of both positive and negativevalues. The strength of a person’s desire for, oraversion to, an outcome is based on the intrinsicproperties of an outcome that are valued or not (asecond-level outcome in Vroom’s conceptualization)and/or on the anticipated satisfaction ordissatisfaction associated with other outcomes thatare related to any given outcome (a first-leveloutcome in Vroom’s conceptualization). Forexample, some workers may value an opportunityfor promotion or advancement because of theirneed for achievement. For these individuals, oneoutcome, advancement, is positively related to orinstrumental with respect to achieving anotheroutcome—achievement. Others might not want thepromotion because it would require an additionaltime commitment and therefore would reduce timeavailable to spend with family or friends. For theseindividuals, one outcome, advancement, is

negatively related to or instrumental with respect toanother outcome: need for affiliation.Instrumentality is an individual’s perception that theirperformance is related to other outcomes, eitherpositively or negatively. It is an outcome–outcomeassociation. In other words, an individual willperform in a certain manner because they believethat behavior will be rewarded with something thathas value to the person. For example, an individualmight believe that producing both high-quality andhigh-quantity work will result in recognition (e.g.,praise) or a promotion from the person’s supervisor.Expectancy is an individual’s perception that theireffort will positively influence their performance. It isan action–outcome association. It can be defined asa momentary belief concerning the likelihood that aparticular act (effort) will be followed by a particularoutcome (performance). Expectancies can bedescribed in terms of their strength. Maximalstrength is indicated by subjective certainty that theact will be followed by the outcome, while minimal(or zero) strength is indicated by subjective certaintythat the act will not be followed by the outcome. Forexample, an individual might perceive that if theywork overtime, the management report will becompleted by the deadline (maximal strength).However, if the employee perceives the deadline tobe unrealistic and not obtainable because of the

time required to complete the report, the expectancystrength is minimal.Newsom (1990) summarized Expectancy Theorywith what he termed the “Nine Cs”:1. Challenge: Does the individual have to workhard to perform the job well? Managers needto review an employee’s job design. Is the jobroutine and unchallenging? Does itincorporate Herzberg’s Two-Factor Theorymotivators?2. Criteria: Does the individual know thedifference between good and poorperformance? Managers need to effectivelycommunicate to an employee theresponsibilities and/or requirements of thetask and how the employee will be measuredas to its successful completion. A managershould not assume that an employee knowsthe criteria for performing satisfactorily. Inaddition, managers need to provide feedbackso that an employee is aware of what theyare doing right and what needs to beimproved.3. Compensation: Do the outcomes associatedwith good performance reward the individual?Nadler and Lawler (1983) discussed themixed message an organization sends to

employees when employees are rewardedfor seniority rather than performance. Whatthe organization gets is behavior orientedtoward safe, secure employment rather thanefforts directed at performing well.4. Capability: Does the individual have theability to perform the job well? Employeeswho lack the necessary skills, knowledge,and experience to perform a task well willbecome frustrated and are likely to avoidfuture growth opportunities.5. Confidence: Does the individual believe thatthey can perform the job well? Employeesneed to believe that they can perform a taskwell. An employee might have the knowledgeand skill but might not see themselves ashaving the ability to perform the task well.This may be based on past experiences offailure.6. Credibility: Does the individual believe thatmanagement will deliver on promises?Managers must deliver what they promised.7. Consistency: Does the individual believe thatall workers receive similar preferredoutcomes for good performance and similarless-preferred outcomes for poorperformance? Managers need to treat all

employees equally on the basis of objectivecriteria.8. Cost: What does it cost an individual in timeand effort to perform well?9. Communication: Does managementcommunicate well and consistently with theindividual in order to affect the other eightCs? Managers need to set clear goals andprovide the right rewards for different people(see Figure 7-2).

Figure 7-2 Application of Expectancy Theory Using Newsom’sNine CsFor managers, Expectancy Theory is very usefulbecause it helps them to understand a worker’sbehavior. An employee’s lack of motivation may becaused by indifference toward, or desire to avoid,the existing outcomes. Expectancy Theory is basedon the assumption that individuals calculate thecosts and benefits in choosing among alternativebehavioral actions. For example, if an employeewants to move up the corporate ladder, then apromotion has a high valence for that employee. Ifthe employee believes that high performance willresult in excellent evaluation ratings, then theemployee has a high expectancy. However, if theemployee believes that the organization will notpromote from within, then the employee has lowinstrumentality and will not be motivated to performtheir job at a high level. So the important questionfor managers to ask is, “What rewards (outcomes)do my employees value?” (see Case Study 7-1).CASE STUDY 7-1 JaneWants to Be an RNJane Smith is a 21-year-old single mother oftwo children, ages 3 and 4 years. She lives ina small apartment and depends on her mother

to help care for her family. Jane is savingmoney to send her children to preschool in thefall. The preschool is located across the streetfrom her mother’s house and two blocks fromthe nursing home where Jane works as aLPN. She works a straight day shift with anobligation to work every third weekend. Agrant has been obtained from a nationalhealth agency that will provide for full tuitionfor Jane and others like her to go to school tobecome an RN. The only drawback to thisopportunity is that classes will begin in the fall(it is now June), which means that to takeadvantage of this opportunity, Jane mustattend classes on a full-time basis during theday and still continue to work in her current jobbut on the evening shift. The program isscheduled to last one full year. The nursinghome administrators have stated in a blanketpolicy that they will allow shift changes toemployees who pursue this opportunity. Janewants to accept the opportunity to pursue hereducation.Using Vroom’s Expectancy Model, explainJane’s motivation to pursue her education.Gyurko, C. G. (2011). A synthesis of Vroom’s model with other socialtheories: An application to nursing education. Nursing Education

▶ Equity TheoryIn his Equity Theory, J. Stacy Adams (1963, 1965)proposed that a person evaluates their outcomesand inputs by comparing them with those of others.Adams’s theory is based in the social-exchangetheories that center on two assumptions. The firstassumption is that there is a similarity between theprocess through which individuals evaluate theirsocial relationships and economic transactions inthe market. Social relationships can be viewed asexchange processes in which individuals makecontributions (investments) for which they expectcertain outcomes (Mowday, 1983). The secondassumption concerns the process through whichindividuals decide whether a particular exchange issatisfactory. If there is relative equality between theoutcomes and contributions of all parties to anexchange, satisfaction is likely to result from theinteraction (Mowday, 1983). If an inequality isperceived, then dissatisfaction occurs, triggering aninternal tension within one or more of theindividuals. For example, a hardworking, dedicatedemployee believes that they are paid a fair salary,given their experience and education, until theybecome aware that other departmental staff

members with the same level of seniority andeducation are paid higher salaries. This newinformation could cause the employee to becomeunmotivated, thus lowering their level of productivity.The two major components in Equity Theory areinputs and outcomes. Inputs are defined as thethings that a person contributes to an exchange. Inthe workplace, an employee’s inputs are typicallyexperience, education, efforts, skills, and abilities.Outcomes are those things that result from theexchange, such as salary, bonuses, promotions,and recognition. Adams states that equity existswhen the ratio of a person’s outcomes to inputs isequal to the ratio of other people’s outcomes andinputs (see Figure 7-3).Figure 7-3 Adams’s Equity TheoryAdams’ theory has several important aspects. First,the determination of whether inequity exists isbased on the individual’s perceptions of input and

outcomes, which may or may not be reality. Second,inequity will not exist if the person has high inputsand low outputs, as long as the other person has asimilar ratio. Third, inequity exists when a person iseither underpaid or overpaid. For example, ifemployees perceive that they areovercompensated, they may increase their level ofproductivity. If employees perceive that they areundercompensated, they may either decrease theirlevel of productivity or attempt to obtain additionalcompensation.Adams (1965) proposed that when an individualperceives an inequity, (1) it creates tension withinthe person, (2) the tension is proportional to thedegree of inequity, (3) the tension created within theindividual motivates them to relieve it, and (4) thestrength of the motivation to reduce the tension isproportional to the perceived inequity. Adams statesthat several cognitive and behavioral mechanismsare available to individuals to reduce thepsychological discomfort (i.e., inequity tension)associated with the perceived inequity. He refers tothese cognitive and behavioral mechanisms asmethods of inequity resolution. The six methodsdescribed by Adams are as follows:1. Altering Inputs: Reduce productivity, takelonger break times, and use sick days forpersonal activities.

2. Altering Outcomes: Try to obtain an increasein pay, a bonus, or a new job title or resort totaking supplies from the company forpersonal use (i.e., stealing).3. Cognitively Distorting Inputs or Outcomes(Self): Describe how much harder he or sheis working.4. Leaving the Field: Transfer to anotherdepartment or quit the organization.5. Distorting the Inputs or Outcomes of theComparison Other: Describe the otherperson’s job as routine and unchallenging.6. Changing the Comparison Other: Findsomeone in the organization more likehimself or herself—another high-performingworker.Equity Theory does not predict which method theindividual will select. The behavior chosen by theindividual depends on the situation with the goal ofmaximum utility (see Case Study 7-2). According toMowday (1983), the easiest method is trying todistort the other’s inputs and outcomes. Leaving theorganization will be considered only in extremecases. Managers need to be aware of howemployees perceive inequities in the workenvironment because individuals will respond tofeelings of inequity in various ways. For instance, ingeneral, the level of demotivation displayed by the

person will be proportional to the perceived inequitywith others. However, for some employees, theslightest indication of negative inequity betweenthemselves and others may cause a high level ofdisappointment and a feeling of injustice, resulting indemotivation or hostile behavior toward others.Other employees may lower their level ofproductivity and become disruptive in the workplace,expressing negative attitudes toward managementand/or their peers. Others may request additionalcompensation or more benefits to adjust their outputupward or seek a new position that provides forhigher levels of outputs. In conclusion, ifsubordinates perceive that they are not being dealtwith fairly, it is difficult, if not impossible, to motivatethem.CASE STUDY 7-2 I Don’tKnow What to DoKatie was disgusted with the situation she wasin at work. She was seriously thinking aboutapplying for the open RN position in thehospital’s ambulatory surgery center just toget away from Beth. Katie has been employedat Good Point Hospital for 10 years. Shestarted in the housekeeping department butknew she wanted more. So she took

advantage of the hospital’s tuitionreimbursement program and returned toschool to earn her nursing degree. Katie didn’tcare that she was 39 years old when she wentback school and that it took her 3 long yearsto earn her associate of science degree. Itwas worth the time and effort, although it wasstressful working full time during the day in thehousekeeping department while going toschool, especially with three small children athome. But Katie’s husband Mike supportedher, taking care of the children and householdchores at night and on weekends so that shecould attend class or study at the library. Shefelt very blessed that she could set anexample for her children by being the firstperson in her family to earn a college degree.It has been 4 years since Katie became anRN, and she has enjoyed working in thehospital’s intensive care unit (ICU)—until Bethjoined the ICU nursing staff last year.Mike could see that she was very upset.When he asked her what was bothering her,Katie said,“Beth has been working at GoodPoint Hospital for 2 years and in the ICU forthe past year. I am now convinced that shehas absolutely no work ethic. Maybe it’s partof her being in this new generation—her 24th

birthday is next month. She spends half of hershift on the phone or texting with her friends.She calls in sick almost every other Mondayor Friday when she is not scheduled for theweekend shift. She’s always complainingabout how busy she is and how can thehospital’s administration think she can get allher work done in a 12-hour shift! Beth’sworkload is similar to mine. In fact, I havemore responsibility than she does, but Ialways seem to get my work done. Becauseshe never finishes her jobs, it causes morework for me. For example, Beth is always thefirst one off the floor at the end of our shift andnever completes her patients’ medical charts,so the nurses from the incoming shift have toask me to bring them up to date on herpatients before they start their shift. I don’tmind helping them out, but it usually takes atleast 30 minutes, and since the hospital frozeovertime, I don’t get paid to cover for Beth’slaziness! Today she started whining thatbecause I have seniority, I get first pick forvacation time and holidays. I tried to lightenthe mood by saying that when I’m gone, shewill have the seniority. I had to remind her thatI’ve done my share of holiday shifts, andeveryone has to work their way up the ladder.

I’ve spoken to Terry, our manager, about Bethon numerous occasions, but I feel I’m wastingmy time. He says he’ll talk to Beth, but henever does. I think he’s overwhelmed trying tomanage the ICU along with the other twodepartments that were recently assigned tohim. I just don’t know what to do since I’m notBeth’s supervisor. Beth has this attitude of ‘Idon’t want to work, but pay me anyway.’ I’mso frustrated with the situation, I’m ready toleave the ICU!”Using Adams’s Equity Theory, discuss Katie’smotivation to quit the ICU.

▶ Satisfaction–PerformanceTheoryOne of the major criticisms of Expectancy Theory isthat it does not take into account the relationshipbetween employee performance and jobsatisfaction. Therefore, Lyman Porter and EdwardLawler (1968a) extended Expectancy Theory andincorporated Equity Theory into a model to reflectthe relationship of an employee’s performance tojob satisfaction. Job satisfaction is related to bothabsenteeism and turnover. This is of great concernto organizations because turnover and absenteeismhave a direct influence on an entity’s effectiveness(Lawler, 1983). As Lawler points out,Absenteeism is very costly because it interruptsscheduling, creates a need for overstaffing, increasescosts; turnover is expensive because of the manycosts incurred in recruiting and training replacementemployees. Because satisfaction is manageable andinfluences absenteeism and turnover, organizationscan control them. By keeping satisfaction high andspecifically by seeing that the best employees are themost satisfied, organizations can retain thoseemployees they need the most. (p. 87)

Interestingly, prior to Porter and Lawler (1968a), nomotivational model had directly dealt with therelationship between satisfaction and performance(Luthans, 2002). The Porter and Lawler modeldoes not predict who is satisfied; it simply gives theconditions that lead to employees experiencingfeelings of satisfaction or dissatisfaction (Lawler,1983). The researchers believe that performanceleads to satisfaction rather than satisfaction leadingto improved performance.The Porter and Lawler model reflects the idea thatsatisfaction results from performance itself, therewards for performance, and the perceivedequitability of those rewards (see Figure 7-4).

Figure 7-4 Porter–Lawler Satisfaction–Performance ModelPorter and Lawler (1968a) stated that jobsatisfaction is generated when an employeereceives rewards for their performance. Theserewards can be intrinsic (e.g., sense ofaccomplishment) or extrinsic (e.g., bonus). Anemployee’s degree of satisfaction will beproportionate to the amount of rewards they believethey are receiving.An important aspect of Porter and Lawler’s theory isthe fact that the amount of the reward an employeereceives may be unrelated to how well they have

performed (e.g., pay increases based on seniority orlabor union agreements). For employees whoserewards are tied to factors that are beyond theircontrol versus receiving rewards based on how wellthey perform, there will be little or no correlationbetween satisfaction and job performance.However, if an employee holds a position (e.g.,manager) in which rewards are received on thebasis of the quality and quantity of the employee’sperformance, there would be a correlation betweensatisfaction and performance. Porter and Lawler’s(1968a, b) research confirmed this hypothesis. Theresearchers found that managers who are rankedhigh by their supervisors report significantly greatersatisfaction than do the low-ranked managers. Moreimportant is that, although the best-performingmanagers did not report receiving any greaterextrinsic rewards (e.g., pay and security) ascompared to their counterparts, they did reportreceiving greater intrinsic rewards (e.g., expressedautonomy and the ability to obtain self-realization inthe job). Therefore, the question is, “Does theorganization actively and visibly give rewardsdirectly in proportion to the quality of jobperformance for all of its employees?” If the answeris yes, then high satisfaction should be more closelyrelated to higher performance if the employeesvalue the rewards distributed.

The Satisfaction–Performance Model tells us twothings. First, if an individual is attracted by the valueof the reward, if they perceive that a higher degreeof effort on their part will lead to those rewards, andif the employee has the necessary abilities andaccurate role perceptions, then higher performancewill result. Second, if the intrinsic and extrinsicrewards an employee receives for higherperformance are perceived as equitable, thensatisfaction will result—satisfaction being thedifference between perceived equity and actualrewards.Job satisfaction is a complex and multifacetedconcept. It is circumstantial and subjective for eachemployee and situation being assessed.

▶ Goal-Setting TheoryIn the 1960s and 1970s, Gary Latham and EdwinLocke (1983) performed a number of laboratory andfield research studies that determined thatparticipants who were given specific, challenginggoals outperformed those who were given vaguegoals such as “Do your best.” For example, in a1974–1975 study, Latham found that unionizedtruck drivers increased the number of logs loadedonto their trucks from 60% to 90% of the legalallowable weight as a result of setting goals. Theysaved the company $250,000 in 9 months. In 1982,another group of unionized drivers saved $2.7million in 18 weeks by adhering to assigned goals ofincreasing their daily trips to the mill (Locke &Latham, 2002, p. 711). On the basis of theirstudies, Latham and Locke developed a goal-settingmodel. Although goal setting is a simple concept, itrequires careful planning and forethought on thepart of the manager (see Figure 7-5). A goal is theaim of an action or task that a person consciouslydesires to achieve or obtain (Locke & Latham,2002, 2006). Goal setting involves the consciousprocess of establishing levels of performance inorder to obtain desirable outcomes.

Figure 7-5 Latham and Locke’s Goal-Setting ModelReproduced from Latham, G. P., & Locke, E. A. (1979). Goalsetting—A motivational technique that works. OrganizationalDynamics, 8(2), 68.Latham and Locke suggest that there are threesteps to be followed in successful goal setting: (1)setting the goal, (2) obtaining commitment to thegoal, and (3) providing support elements.

1. Setting the Goal: The goal that is set shouldhave two main characteristics. First, it shouldbe specific, rather than vague, andmeasurable. For example, a goal statementsuch as “Increase elective outpatientsurgeries by 5% within the next 6 months” isspecific, with a time limit for goalaccomplishment. Second, the goal should bechallenging yet reachable. Difficult goals leadto better performance. However, two pointsneed to be made. For employees with lowself-confidence or ability, goals should be setat a level that is easy and attainable. Foremployees with high self-confidence andability, goals should be made difficult butattainable. In either case, if employeesperceive the goals as unattainable, they willnot accept them and performance will notimprove. In fact, the employees willexperience dissatisfaction and frustration.Managers need to be conscious that settingunattainable goals may cause employees toview management with suspicion anddistrust.Latham and Locke stated that there are fivepossible methods, in addition to anemployee’s confidence and ability levels, thatmanagers may use to determine goals for an

employee. First, the manager could use time-and-motion studies to set an appropriate goallevel. A second option, which would probablybe more readily accepted, would be settingfuture goal levels on the basis of the averagepast performance of the employee. However,if the employee’s past performance wasunacceptably low, upward adjustments wouldneed to be made. A third option would allowfor the supervisor and subordinate to jointlyset the goal. This participative approach hasthe advantages of being readily acceptableby both parties and promotes role clarity. Thefourth method may be determined by externalsources. This is very common in the healthcare industry; because third partiesdetermine reimbursements, the goal is todeliver service at the lowest possible costwithout reducing quality. The fifth method isdetermining individual goals that correspondto the long-term goals of the health servicesorganization as determined by theorganization’s board of trustees.2. Obtaining Commitment to the Goal: If goalsetting is to be successful, the managerneeds to ensure that subordinates will acceptand remain committed to the goals.Appropriate pay (i.e., rewards) with the

manager’s supportiveness is usuallysufficient for goal acceptance andcommitment by the employee. Employeesreceive a feeling of satisfaction for reachingchallenging, fair goals, which tends toreinforce acceptance of future goals.Generally, employees resist goals for tworeasons. First, they might perceivethemselves as being incapable of reachingthe goals. To overcome this resistance,managers need to provide training to improveemployees’ skills and knowledge, therebyincreasing their self-confidence that the goalcan be achieved. Second, employees mightnot see any relationship between theirpersonal benefits (i.e., feeling ofaccomplishment or external rewards) andattaining the goals. Managers may use aparticipative approach so that employeeshave a feeling of control over the situation.Reward systems must be in place to directlycompensate employees for reaching theagreed-upon goals.3. Providing Support Elements: Managers mustensure that employees have adequateresources (e.g., financial, equipment, time,assistance) to reach their goals. Furthermore,company policies and procedures must not

create barriers to employees’ goalattainment. Employees need to trust thatmanagers are supporting, not undermining,their efforts. For example, perhaps thecompany’s goal is to have employees trainedin new safety protocols. However, themanager’s bonus depends upon theorganization’s financial performance, not theemployee’s implementation of the safetyprocedures. Therefore, the manager mightnot be motivated to allow employees to stoptheir daily tasks to complete the training(Fusion, n.d.).Managers need to provide employees with an actionplan of agreed-upon goals and rewards so thatthere is no ambiguity in the process. In addition,feedback is essential. Employees must have accessto information as to the status in their goalattainment. Finally, Latham and Locke point out thatgoal setting is not a solution for problems due topoor management or for poor compensation ofemployees.

▶ Reinforcement TheoryReinforcement Theory is based primarily on thework of B. F. Skinner (1953), who experimentedwith the theories of operant conditioning. Skinner’sresearch found that an individual’s behavior couldbe redirected through the use of reinforcement.Reinforcement Theory suggests that an employee’sbehavior will be repeated if it is associated withpositive rewards and will not be repeated if it isassociated with negative consequences. AlthoughReinforcement Theory is not a motivation theory (atleast not in the context we have been discussing), itdoes help managers to understand and influence,when necessary, behavioral change by thereinforcements they use. Reinforcement is abehavioristic approach, which argues thatreinforcement conditions behavior (Robbins, 2003).Since reinforcement is an important means ofunderstanding what controls an individual’sbehavior, it is included in motivation discussions(see Figure 7-6) (Robbins, 2003; Tosi & Mero,2003).

Figure 7-6 Reinforcement Theory and Types of ReinforcementsThere are four types of reinforcement: positive,negative, punishment, and extinction.Positive reinforcement occurs when a desirableoutcome is associated with a behavior. Desirableoutcomes can be simple and symbolic, such aswords of praise, a certificate of accomplishment, ora month’s use of the parking space directly outsidethe hospital’s main entrance. To fully appreciate itseffect, managers should use positive reinforcementonly when an employee displays the desiredbehavior. For example, the director of nursing has

attempted to reduce the turnover time (i.e., timerequired to set up an operating room [OR] aftereach surgical procedure) of the hospital’s ORs toimprove the efficiency of the department. The ORnurses formed a task group, and after many monthsand careful planning with full cooperation of thephysicians and support staff, the daily turnover timedecreased by 15% within a 6-month period. Thedecrease in OR turnover time allowed for oneadditional case to be scheduled per day. Thedirector of nursing recognized the team’saccomplishment by publishing it in the healthsystem’s newsletter and hosting a thank-you lunchfor the department.Negative reinforcement occurs when an unpleasanteffect is eliminated or avoided, which, like positivereinforcement, encourages repeated positivebehavior. In our OR example, the nurse responsiblefor ordering surgical supplies, by working with thehospital’s technology department, designed aninventory system using bar codes that alert herwhen supplies are at a reordering level. With theuse of technology, the system automaticallytransmits a message that an order must be placedto the purchasing department. By designing andimplementing the new inventory ordering system,the nurse has eliminated her need to work overtimecounting inventory and has eliminated the negative

consequences (e.g., unhappy patients andphysicians, lost revenues) that occur when asurgery case has to be canceled and rescheduledbecause the hospital did not have the necessarysupplies on hand.Punishment can come in two forms: negativeconsequences and positive consequences, bothundesirable. A negative consequence is anundesirable response to an employee’s behaviorthat is intended to stop the behavior from beingrepeated. For example, an OR nurse who isresponsible for ordering supplies was reprimandedby the department’s manager when she failed toplace an order for a required surgical instrument,causing an OR case to be canceled. (Thisreprimand motivated the OR nurse to design aninventory system so that the situation would notoccur again.) A positive consequence occurs whensomething desirable is removed from the employee.For example, when the OR nurse failed to order thenecessary surgical instrument, the department’smanager required them to update the inventorysupply list within 24 hours, which meant that theyhad to work on their scheduled day off and canceltheir trip to Disney World.Extinction is defined as the removal of anestablished reinforcement (positive or negative) thatwas previously used to reinforce an employee’s

behavior. This removal may weaken an employee’sfuture behavior. For example, one hospital’s ORdepartment had a policy that if the room chargenurse’s surgical cases started and ended on time(measured on a weekly basis), they would receive a$50 certificate to a local restaurant. When there wasa change in the hospital’s senior management, thispositive reinforcement was abruptly eliminated andthe following message was issued: “It is your job tomake sure the OR is run efficiently, which includeshaving the cases start and end on time. Therefore,we are eliminating the previously awarded giftcertificate. If you have any questions regarding thisnew policy, please contact your manager.”Managers need to be careful about theadministration of punishment reinforcements.Unless it is done carefully and appropriately, theeffects can cause long-term consequences for theorganization. Punishment can cause employeeresentment, hostility, and turnover. Managersshould punish only undesirable behavior and bevery clear as to what constituted the undesirablebehavior when discussing the situation with theemployee; give reprimands or discipline actions assoon as possible after the behavior has occurred;administer punishment in private; and, whenpossible, combine negative and positivereinforcements.

Reinforcement schedules refer to the timing andfrequency with which the consequences areassociated with behavior. The scheduling of thereinforcement is important because the frequencywill determine the time it takes to learn a newbehavior (Tosi & Mero, 2003). Reinforcementschedules can be continuous, fixed interval, variableinterval, fixed ratio, or variable ratio.A continuous reinforcement schedule requiresthe specific employee’s behavior to bereinforced each time it occurs (e.g., the chiefexecutive officer rewards all employees everytime the hospital passes its Joint Commissionaccreditation). Research suggests thatcontinuous reinforcement is the fastest way toestablish new behaviors or to eliminateundesired behaviors.In a fixed-interval reinforcement schedule, thereinforcement is administered at predeterminedperiods (e.g., annual performance appraisals,weekly paycheck). A fixed-intervalreinforcement schedule does not appear to bea particularly strong way to elicit desiredbehavior, and behavior learned in this way maybe subject to rapid extinction.A variable-interval reinforcement scheduleallows reinforcements to be administered atirregular intervals (e.g., special recognition for

successful performance, promotions to higher-level positions). This reinforcement scheduleappears to elicit desired behavioral change thatis resistant to extinction.A fixed-ratio reinforcement schedule requiresthe reinforcement to be administered after apredetermined number of behaviors haveoccurred (e.g., sales commission based on anumber of units sold). Fixed-ratio reinforcementschedules can produce high rates of responsesthat continue as long as the reinforcement hasvalue to the employee.A variable-ratio reinforcement schedule isevident when the number of behaviorsnecessary for reinforcement varies (e.g.,bonuses or special awards that are appliedafter varying numbers of desired behaviorsoccur). Variable-ratio reinforcement schedulesappear to produce desired behavioral changethat is consistent and very resistant toextinction. (Tosi & Mero, 2003).Consider the following scenario:A hospital CEO is discussing his facility’sexperiences at trying to effectively manage theordering and tracking of supplies in the hospital’sOR department.

“We started looking at some product lineassessments. As an example, a couple of years agowe met with two different groups ofophthalmologists to look at their costs on a case-by-case basis. We then compared what they used andmight use, and determined the areas in which wemight be able to standardize products andequipment… We had the ophthalmologists workwith vendors and use a case supply cap, and wesaved some money that way. Recently though,we’ve noticed that some of the ophthalmologists aredrifting back to their old routines again, so I thinkthis is something that you can’t just do once andexpect it to manage itself.”What reinforcement schedule would you advise theCEO to use in the future? Why?Reprinted with permission from Healthcare Financial ManagementAssociation’s Executive Roundtable Series, July 2004, Improving ORthroughput: Real world successes and challenges.

▶ SummaryIn this chapter, we discussed various processtheories of motivation. These motivation theorieshelp health care managers to predict employeebehavior. Managers can then effectively influencethat behavior, achieving organizational successthrough increased job satisfaction.

Discussion Questions 1. Discuss the various components ofExpectancy Theory. 2. Explain Newsom’s Nine Cs. 3. Discuss the two components of EquityTheory. 4. Explain the methods of inequity resolution. 5. Discuss the significance of the Satisfaction–Performance Theory. 6. Explain how the Satisfaction–PerformanceTheory relates to Expectancy Theory andEquity Theory. 7. Discuss the three components of the Goal-Setting Theory. 8. Explain how goals can be determined underthe Goal-Setting Theory. 9. Explain management’s responsibilities underthe Goal-Setting Theory.10. Explain why we include ReinforcementTheory in motivation discussions.11. Discuss the types of reinforcements that areavailable to managers for changing anemployee’s behavior.12. Discuss the various reinforcement schedulesand why their timing and frequency areimportant.

CASE STUDIESCase Study 7-3 What Can Joe DoAbout Betty?Just before quitting time, Joe, the hospital’shealth information department manager,watched his three new trainees struggling withthe complicated electronic medical recordssoftware they had to learn to use to do theirjobs. Across the room, Betty, who was anexpert with the software, was preparing toleave for the day, her tasks done ahead oftime as usual. Also as usual, she gathered upher belongings and left without saying good-bye to any of her coworkers. “There goes theanswer to my problem,” thought Joe, “if only Iknew how to reach her.” With her expertiseand experience in using the system, Bettywould seem to be an ideal coach for the newemployees. However, she had begged offfrom taking on training duties when Joe hadasked 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 herselfat her own job.Joe was stunned by her refusal. He enjoyedhelping his coworkers and thought that it waswhy he had advanced to department managerlast year instead of Betty, who had moreseniority and experience with the companythan he did. Since her work was excellent, Joehesitated to make it an “either you do what Iwant or you’re in trouble” situation; hebelieved that employees worked best at whatthey wanted to work at. But his problem stillremained: There was no money in the trainingbudget, and there were no other employeesas skilled with the system as Betty was. Wasthere an approach he hadn’t thought of that hecould use to convince her to help?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 onepromoted to department manager last year,not him. I’m the one with seniority and thenecessary experience. In fact, I was the onewho trained Joe when he first joined thehospital! Just because he has a master’s inhealth information management and I shouldnot have been the determining factor, but

obviously senior management thought sowhen they selected him over me. I could careless what happens from this point forward. Ionly have five more years until I can retire withmy full pension. As long as my work continuesto be excellent, there is no way Joe can upsetmy plans. Not that he could, since he hardlyunderstands the complexity of the software weuse. It requires a person with a lot oftechnology knowledge and experience.”Using Vroom’s Expectancy Theory (VIE),explain Betty’s lack of motivation.Case Study 7-4 How Much Longer CanAlice Continue Working for MGMHealthcare?Alice has been a business/finance trainer forMGM Healthcare Consulting Group’s clientsfor 3 years. Until recently, she enjoyed her jobresponsibilities and coworkers, and althoughshe would like to earn more money, shebelieves that her salary is fair compensationfor her duties, experience, and education.Alice’s first career choice was to be a teacher,so she especially likes the ability to teachothers about her second passion: thebusiness side of health care. She has anMHSA degree, certification as a health care

finance professional through HFMA, and alean Six Sigma Green Belt. Alice has beenrecognized by her director for her excellentwork each year.As a trainer, Alice needs to travel extensively8 months of the year to clients’ facilitiesthroughout the United States. During thisperiod, Alice works 12-hour days, 6 days aweek. During her nontraveling months, Alice isin the office preparing new training manualsand conducting educational webinars forexisting and potential clients. During thisperiod, she works three and half days a weekbut collects a full paycheck. Alice has beenfine with this schedule because she enjoyswhat she does and she feels that, in the end, itall balances out. Also, although she has neverrequested time off during the traveling months,her director has said that she would cover forAlice if the need arose.Just as Alice’s latest traveling period began,she found out that her mother will needsurgery next month, which will require a 2-dayhospital stay and complete bed rest for aweek. Alice’s father is available to help withthe situation, but Alice and her mother arevery close, and Alice wants to be there to take

care of her mother while she is recuperating.Alice tells her director immediately about herfamily situation, but her director refuses toaccommodate her request, telling Alice thatbecause the office is short staffed, there is noone to cover her clients’ training requirementsduring that week. Alice becomes frustratedand angry because she has never asked fortime off during her traveling period, and nowshe will not be able to help her mother.Another issue that has frustrated Alice fromthe beginning is how her directormicromanages her and other coworkers whenthey are in the office during the nontravelingperiod. All changes to the training manuals,the content of the educational webinars—essentially everything—has to be approved bythe director before it can be finalized. This hascaused deadlines to be missed, resulting inclient complaints. Alice feels that this affectsher reputation with existing clients in additionto affecting the bonus money she would havereceived for signing up new clients toparticipate in the educational webinars. Shehas also felt frustrated with the lack of growthopportunities within the consulting company.The organization is small, so after working forthe company for 3 years, she has already

reached the top position and pay scale belowthe director level.Although Alice enjoys working with her clientsand coworkers, she has become dissatisfiedwith her job and no longer feels committed todoing whatever it takes to get the job done.She is starting to resent having to give up herweekends for 8 months of the year, herdirector’s delays that cause her to lose bonusmoney, and the lack of growth opportunities.She doesn’t know how much longer she cancontinue working for MGM HealthcareConsulting Group.Using Porter–Lawler’s Satisfaction–Performance Theory, discuss Alice’s jobdissatisfaction and lack of motivation.Case Study 7-5 Problems in thePurchasing DepartmentEmployees in the purchasing department of alarge hospital were suffering from lack ofmotivation. On the day shift, there had alwaysbeen a few employees who were lessproductive than others. The other employeeswould have to pick up the slack to ensure thatall supplies for the hospital were ordered on atimely basis. This would cause the

departmental staff who were performing theirjobs properly to become frustrated and angrybecause the other employees were not beingheld accountable for their low levels ofproductivity. There was clearly a disconnectbetween what was expected of all employeesand what was actually being done.Jack and Chris consistently worked hard andconsistently exceeded the requirements oftheir jobs. They made sure that all dailyrequests for supplies were ordered so thatthere was not backlog to deal with at thebeginning of each shift. However, they startedto notice that Page and Betty were spendingmore time doing things other than theirassigned jobs in the purchasing department.Jack and Chris became less motivated towork as hard because they felt that they werepicking up the slack for undeservingcoworkers. The overperformance levels for thedepartment began to fall. Backlogs started toincrease, as did complaints from the otherfunctional units of the hospital when requestedsupplies were not received in a timely fashion.Some surgical cases had to be canceled andrescheduled because the proper supplieswere not available for the surgeons.

Something had to be done!Using the Goal-Setting Theory, create a plan that will motivateall the departmental staff to work to their fullpotential and perform more efficiently.Case Study 7-6 How to MotivatePhysicians to Improve ComplianceA hospital, located within a highly competitivemarket, is concerned over a decline in itsperformance on national quality indicators.Although many members of the medical staffare cooperative and compliant with therequired documentation, a group of physiciansdon’t seem to understand the importance ofthese measures. When either the hospitaladministration or members of the medical staffleadership confront these physicians, theyoften state they will try harder to be compliant,but ultimately don’t change their behavior.Others simply choose to ignore letters sent tothem or any attempts to discuss theirnoncompliance. Frustrated by the lack ofcooperation by these physicians, the hospitaland medical staff leadership decide to gettough on enforcement. They design a tieredresponse system. Physicians who do not meetthe documentation requirements will be sent awarning letter. Failure to improve or respond

will result in temporary loss of privileges.Continued lack of compliance will lead to lossof privileges.Will this punitive system work to motivatephysicians to improve compliance? If not, whynot? Develop recommendations as to how tomotivate these physicians to improve theircompliance.Reproduced from Tarantino, D. P. (2008). If you want tomotivate physicians, you have to understand and fulfill whatdrives human behavior. Physician Executive, 34(5), 84–85.Case Study 7-7 All in a Day’s WorkSarah Goodman, senior manager of networkdevelopment for the Holy Managed CareCompany, has just returned from a lunchmeeting with the adviser for the MHSA(Master’s of Health Services Administration)program at State University, and now she isback on the job attending more meetings. At1:30 p.m. she has a meeting to discuss payissues. The Human Resources Departmenthas evaluated the salary picture for the entireorganization and is concerned that women arenot being paid as well as men. They wantinput on a strategy to bring the pay issue intoline so as to avoid a gender discrimination

charge. Personally, Sarah wondered if she gotpaid as well as Dave, her counterpart inTampa. Certainly she has been there as longand worked about twice as hard as he seemsto! He does seem to benefit from the “good oldboy network,” however.At 3:00 there is a performance appraisalSarah had scheduled with her assistant Maria.Sarah wasn’t sure what to do about Maria. Herwork was terrific from the standpoint ofaccuracy and amount. As long as she got apat on the back pretty frequently, Maria wasan ideal employee in a lot of ways. Sarahknew that Maria would be prepared for theinterview, including her goals for the next sixmonths. The problem was that Sarah reallywanted to get Maria more involved with othersin the department. If she wasn’t able to getMaria ready to assume her position, howcould Sarah ever hope to be promoted?Productive as she was, Maria just wasn’t a“people person.”Then at 4:00, there is another performanceappraisal scheduled. This one was going to bedifficult. Janine was a fairly new employee andSarah loved the work she produced, but shedidn’t think she’d ever seen a more uptight

person! She seemed to need to be told ateach step what to do next and worriedconstantly about breaking the rules. Sarahhad begun to think Janine had even inventedsome new rules! Last week, for example,Sarah had asked Janine to stay a little late tofinish a project. She didn’t discover until thenext day that Janine had been late picking upher baby from the babysitter. Certainlyovertime wasn’t required, and Sarah felt badabout causing the problem. She could haveasked someone else to do the work, butthought it might be a way of encouragingJanine to “get out of the box” a little.By the time the meetings were over, Sarahfigured she’d just have time to return herphone calls and scan the mail before it wastime to go home. She’d promised Richardsomething special for dinner, mostly becauseshe was planning to tell him about graduateschool. The traffic would be awful, and sheneeded to stop by the store on the way. “Ohwell! It’s all in a day’s work,” she thought.Discuss the various motivation theoriesreflected in this case study.Reprinted with permission from Pidge Diehl, EdD.

Case Study 7-8 Why Aren’t MyEmployees Motivated?Roger Harris is the founder and managingpartner of a large health managementconsulting firm that specializes in strategicplanning for hospitals. The firm has sixpartners, including Roger, and 20 professionalstaff members (all with graduate degrees inhealth administration). The staff, which isevenly divided between males and females,consists of single and married individualsbetween 25 and 35 years of age. Of the 10married staff members, two of their spouseswork outside the home. All the marriedindividuals have families of at least twochildren, and all the children are under 10years old.The philosophy of the firm is to serve theneeds of its clients and have fun serving thoseneeds, all while making a profit. Because ofthe tight labor market, the firm’s salaries for itsprofessional staff are well above the marketrate in order to attract and retain the besttalent. In addition, each employee has aprivate office, breakfast served daily, freeweekly car washes, and their dry cleaningdelivered to the office. The firm also offers thestaff home computers if they prefer to work at

home on weekends during the firm’s busytime, which usually runs from October to May.During the busy period, staff members arerequired to work approximately 55–60 hoursper week. They receive 2 weeks of vacationannually, in addition to 1 week for continuingprofessional education and 1 week forpersonal time, which is utilized by 100% of thestaff. Roger was concerned because,although the partners’ billable hours (i.e.,hourly rates charged to clients for servicesrendered) had increased 12% over the past 2years, the staff’s billable hours had decreasedby 14%. In addition, the turnover rate (i.e., thepercentage of the newly hired graduates whostay with the firm for approximately 3–4 yearsbefore taking a position in one of their client’shospitals) had increased to 50% (from 10% 5years earlier).In order to increase the firm’s productivity andretention rate, Roger initiated a bonusprogram as follows: If a staff member billedout 2000 hours annually, they received abonus equal to 5% of their annual salary. Forevery hour billed over the minimum 2000hours, the employee would be paid twice thehourly rate.

Under the new program, all employees earnedthe 5% bonus, but no one’s productivityincreased over the minimum 2000-hour base.Roger was concerned by this lack ofimprovement in productivity and the turnoverrate. Thinking that the staff needed outsideprofessional recognition, he encouragedeveryone to publish articles for the varioushealth management journals discussingaspects of their most interesting cases. Allstaff members were willing to do so, as longas the time required to develop the articleswould be applied toward their minimum 2000hours’ bonus calculation.Roger also told the staff that anyone whodemonstrated technical competence and theability to attract and retain clients to the firmwould have the opportunity to become apartner. Even though individuals from theoutside had filled the last two seniormanagement-level positions, four of the sixpartners had been promoted from within (after8–10 years of continuous employment withthe firm). However, the most recent promotionto partner was made to an individual who hadbeen hired from the outside after only 3 yearsof employment with the firm.

Roger thinks that the consulting firm is a greatplace to work, with interesting and challengingcases, an excellent compensation package,and growth opportunity. He cannot understandwhy the staff’s productivity continues todecline and the turnover rate continues toincrease.Using Expectancy Theory, explain to Rogerwhy nonpartner productivity level is low andwhy the firm is experiencing a high turnoverrate among its professional staff.

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Mowday, R. T. (1983). Equity theory predictions of behavior inorganizations. In J. S. Ott (Ed.), Classic readings inorganizational behavior (pp. 94–102). Albany, NY: WadsworthPublishing Company.Nadler, D. A., & Lawler, E. E. (1983). Motivation: A diagnosticapproach. In J. R. Hackman, E. E. Lawler, & L. W. Porter(Eds.), Perspectives on behavior in organizations (pp. 67–78).New York, NY: McGraw-Hill Book Company.Newsom, W. B. (1990, February). Motivate, now! PersonnelJournal, 69(2), 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 tellabout motivation. Harvard Business Review, 46(1), 118–126.Robbins, S. P. (2003). Organizational behavior (10th ed.). UpperSaddle River, NJ: Prentice Hall.Skinner, B. F. (1953). Science and human behavior. New York,NY: Macmillan.Tosi, H. R., & Mero, N. P. (2003). The fundamentals oforganizational behavior: What managers need to know.London, UK: Blackwell Publishing.Vroom, V. H. (1964). Work and motivation. New York, NY: JohnWiley & Sons.

CHAPTER 8Attribution Theory andMotivationPaul Harvey, PhD, Mark J. Martinko, PhDLEARNING OUTCOMESAfter completing this chapter, the student shouldbe able to understand:The basic premises of attribution theory.The differences between optimistic,pessimistic, and hostile attribution styles.The role of attributions, emotions, andexpectations in motivating employees.Techniques that managers can use topromote accurate and motivationalattributions.

▶ OverviewIn this chapter, we discuss how attribution theory isused to provide managers with a betterunderstanding of the highly cognitive andpsychological mechanisms that influenceemployees’ motivation levels. The chapter beginswith an overview of attribution theory. We thendiscuss the different attribution styles that can biasthe accuracy of causal perceptions, potentiallyundermining the effectiveness of motivationalstrategies. We then describe the impact ofattribution-driven emotions and expectations onmotivation. This is followed by an overview oftechniques that health care managers can use topromote motivational attributions among employees.

▶ Attribution TheoryBefore we describe the basic tenets of attributiontheory, it is useful to understand exactly what ismeant by the term “attribution.” An attribution is acausal explanation for an event or behavior. Forexample, a nurse who observes a colleagueperforming a procedure incorrectly is likely to try toform an attributional explanation for this behavior.The nurse might conclude that the colleague ispoorly trained; thus, the observer is attributing thebehavior to insufficient skills. People also formattributions for their own behaviors and outcomes.For example, a physician might attribute theirsuccess in diagnosing a patient’s rare disease totheir intelligence and training or to good luck.People typically engage in the attribution processcountless times each day. For many of us, theprocess is so automatic and familiar that we do notnotice it. However, a wide body of researchindicates that the formation of causal attributions isvital for adapting to changing environments andovercoming the challenges that we confront in ourdaily lives. When we experience desirableoutcomes, attributions help us to understand whatcaused those events so that we can experience

them again. When we experience unpleasantoutcomes, attributions help us to identify and avoidthe behaviors and other factors that caused them tooccur.Fritz Heider (1958) argued that all people are “naïvepsychologists” who have an innate desire tounderstand the causes of behaviors and outcomes.Attribution theory holds that attributions for thesebehaviors and outcomes ultimately help to shapeemotional and behavioral responses (Weiner,1985). A simplified depiction of this attribution–emotion–behavior process is shown in Figure 8-1.In order to understand these relationships, however,it is important to be familiar with the variousdimensions along which attributions can beclassified.Figure 8-1 Attribution–Emotion–Behavior ProcessFirst, attributions can be classified along thedimension of locus of causality, which describes theinternality or externality of an attribution. A physicianwho misdiagnoses a patient and attributes thismedical error to their own carelessness (e.g., theyoverlooked one of the patient’s symptoms) is

making an internal attribution. If the misdiagnosis isattributed to faulty laboratory results, the physicianis making an external attribution. The locus ofcausality dimension is particularly relevant toemotional reactions. Internal attributions forundesirable events or behaviors are frequentlyassociated with self-focused negative emotions,such as guilt and shame. External attributions forthe same behaviors and outcomes are generallyassociated with externally focused negativeemotions, such as anger and resentment(Gundlach, Douglas, & Martinko, 2003; Weiner,1985).Attributions can also be categorized along thestability dimension. Stable causes are those thattend to influence outcomes and behaviorsconsistently over time and across situations.Causes such as intelligence and physical orgovernmental laws are generally consideredrelatively stable in nature because they are difficult,if not impossible, to change. Unstable causalfactors, such as the amount of effort exerted ondoing a task, are comparatively easy to change.Unlike the locus of causality dimension, whichprimarily influences emotional reactions to eventsand behaviors, the stability dimension affectsindividuals’ future expectations (Kovenklioglu &Greenhaus, 1978). When an outcome such as poor

performance is attributed to a stable cause, such aslow intelligence, it is logical to expect that theemployee’s performance is not going to change inthe future. If the same poor performance isattributed to a less stable factor, such as temporaryillness or insufficient effort, we can expect that theemployee could improve their performance in thefuture.Researchers have also classified attributions interms of the intentionality and controllability of thecause (Weiner, 1995). However, for the purposes ofunderstanding the basic impact of attributions onmotivation, we will limit our discussion to thedimensions of locus of causality and stability. Thus,we can consider attributions that are internal andstable (e.g., intelligence), external and stable (e.g.,laws), internal and unstable (e.g., effort), or externaland unstable (e.g., temporary organizationalpolicies). Before examining the influence of theseattributions on motivational states, however, it isuseful to understand how attribution styles can biasand distort the attributions that individuals form.

▶ Attribution StyleIt is important to recognize that, as with allperceptions, attributions are not always an accuratereflection of reality. We can probably all think of aninstance in which someone failed at a task becauseof their own actions but erroneously blamed thefailure on other people or on circumstances. In fact,if we are totally honest with ourselves, we can eachprobably recall making such false attributionsourselves a time or two.Astute observers may also notice that some peoplemake these attributional errors more frequently thanothers do. These individuals are said to have abiased attribution style. An attribution style isdefined as a tendency to consistently contributepositive and negative outcomes to a specific type ofcause (e.g., internal or external, stable or unstable).The tendency to attribute negative outcomes toexternal factors is often coupled with a tendency toattribute positive outcomes to internal factors. Thisself-serving attribution style is referred to as anoptimistic attribution style (Abramson, Seligman, &Teasdale, 1978; Douglas & Martinko, 2001). Thisterm reflects the fact that people with an optimisticattribution style often feel good about themselves

and their capacity for success. An obviousdownside, however, is that this personal optimismmay be unfounded and can set the individual up fordisappointments in the future. 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 pessimisticattribution style, denotes the opposite tendency.Individuals who demonstrate this attributionaltendency frequently attribute undesirable events tointernal and frequently stable factors such as lack ofintelligence while attributing desirable outcomes toexternal and frequently unstable factors such asgood luck. As the name of this style suggests,people who exhibit this tendency often lackconfidence in themselves and are pessimistic abouttheir chances for success (Abramson et al., 1978).This tendency can also promote depression andlearned helplessness.A third attributional tendency, known as a hostileattribution style, also warrants discussion. This styleis similar to the optimistic style in that it denotes atendency toward external attributions for negativeoutcomes. However, the two styles differ in that theexternal attributions for undesirable eventsassociated with a hostile style are also stable innature. A study by Douglas and Martinko (2001)

suggested that the stability of these attributionscould promote anger toward the external entity (e.g.,one’s manager) and increase the likelihood of anaggressive response. It appears, for example, that anumber of highly publicized incidents of workplaceviolence that have occurred in the United Stateswere committed by individuals with a history ofconsistently external and stable causal explanationsfor the negative events in their lives. We canconclude that hostile attribution styles in theworkplace are not only unproductive but can also bedangerous.Before we discuss the implications of theseattribution styles (see Table 8-1) and of attributionsin general for employee motivation, one point shouldbe clarified. In many situations, the causes of anevent are perfectly clear. For example, a driver whois rear-ended at a traffic light well after coming to acomplete stop is going to blame the other driverregardless of the first driver’s attribution style.Because attribution styles are only tendencies tomake certain types of attributions, they are unlikelyto have an effect in situations where the causes ofan outcome are obvious. However, when thecauses are ambiguous, attribution styles are morelikely to have an effect. A manager’s goal, therefore,should be to make (as well as to encourage)accurate and unbiased attributions so that

employees’ successes can be repeated and thecauses of problems can be rectified (see Exhibit 8-1 at the end of the chapter).Table 8-1 Summary of Attribution StylesAttributionalStyleImpact on AttributionsExamplesOptimisticBiased toward internal(often stable) attributionsfor positive outcomes andexternal (often unstable)for negative outcomes.Successful diagnoses areattributed to personalability; misdiagnoses areattributed to inadequateinformation from others.PessimisticBiased toward internal(often stable) attributionsfor negative outcomesand external (oftenunstable) for positiveoutcomes.Successful outcomes areattributed to good luck;poor outcomes areattributed to lack ofpersonal ability.HostileBiased toward external,stable attributions fornegative outcomes.Most workplace problemsare attributed to a biasedand vengeful manager.

▶ Attributions andMotivational StatesOur discussion of attributions and motivationalstates is divided into four sections, each of whichdescribes a desirable or undesirable motivationalstate and the capacity of specific attributions andattribution styles to bring about these states. Twoundesirable states, learned helplessness andaggression, are discussed first. We then discusstwo desirable motivational states: empowermentand resilience.Learned HelplessnessAfter repeated punishments and failures, a personmay become passive and unmotivated and stay thatway even after the environment changes so thatpersonal or professional success is possible(Abramson et al., 1978; Martinko & Gardner,1987). This phenomenon has been labeled “learnedhelplessness” because it describes a situation inwhich individuals come to believe that effort is futilebecause failure is inevitable. They have, in effect,learned to be helpless.Learned helplessness is a consequence of thereinforcement process. When people see that

behaviors lead to desired rewards and outcomes,they are motivated to repeat those behaviors. Whenspecific behaviors do not achieve desired outcomes,the motivation to perform those behaviors is lost.Learned helplessness was first observed byOvermier and Seligman (1967) in dogs that hadbeen placed in a shuttle box (a type of box used inanimal learning experiments) with two sides. Oneside had an electric grid, and the other side wassafe. Initially, the dogs were tethered to theelectrified half of the chamber. Before administrationof an unpleasant but nonlethal, shock, a lightflashed. Because of classic conditioning, the dogsquickly learned to associate the flash of light withthe impending electrical shock. After theconditioning was complete, the experimentersremoved the tethers that had previously madeescaping to the nonelectrified side of the chamberimpossible. However, instead of leaping to safetywhen the light flashed, most of the dogs froze,whimpered, and braced themselves for the shock.The researchers concluded that the dogs hadlearned to be helpless, believing that the shock wasinevitable regardless of their efforts.More recent research suggests that this tendencytoward learned helplessness is also common inpeople and that organizational rules and norms cancause learned helplessness among employees

(Martinko & Gardner, 1987). Specifically,organizational policies and norms and leaders’behaviors that cause employees to feel that successor recognition is unobtainable are likely to inhibitmotivation. For instance, a manager who routinelytakes credit for their subordinates’ successes whileblaming them for their failures may find themselfwith employees who see little reason to work anyharder than is necessary to keep their jobs.Similarly, an organization that forces employees tofollow outdated and ineffective procedures may finditself with employees who show little urgency orinterest in their work, given that they expect theeffort to fail. If you expect to fail, why bother trying?The significance of organizationally induced learnedhelplessness is that, as Overmier and Seligman’sexperiments with dogs demonstrated, thehelplessness often remains even when the barriersto success are removed. To continue the previousexamples, if the unfair manager is replaced orrestrictive policies are removed, we might expectemployee motivation and performance to improveimmediately. However, the reality is that employeeswho work under such conditions for an extendedperiod of time often retain their learnedhelplessness and remain unmotivated even after thesituation and conditions have changed.

This tendency can be explained by the attributionprocess. External barriers to success in theworkplace can, ironically, promote internal andfrequently stable attributions for failures whilepromoting external attributions for successes. Overtime, these attributions can manifest themselves inthe form of a pessimistic attribution style, causingemployees to accept blame for failures they did notcontribute to while attributing successes to theirmanager or to other external factors. To illustrate, amanager who consistently takes credit fordepartmental successes while blaming employeesfor failures can, over time, cause employees tobelieve and feel that they are incompetent at theirjobs. This perception can remain even after themanager has been removed if proper steps torestore employees’ confidence are not taken. Thisexample also illustrates one of the downsides of theoptimistic attribution style. Organizational leaderswho demonstrate this tendency may feel good aboutthemselves (at least in the short term), but theirtendency to take credit for successes and attributeblame for failures to others may cause theiremployees to lose confidence and experiencelearned helplessness.Aggression

Aggression, another undesirable motivational state,differs from learned helplessness in several ways.Perhaps most significantly, unlike the diminishedmotivation associated with learned helplessness,aggression refers to a state of heightenedmotivation. The problem is that this motivation isfocused on an undesirable behavior or goal.Instrumental aggression describes behaviorstargeted at obtaining a goal that the employingorganization is not providing. For instance, anemployee who feels that they are underpaid andsteals from their employer is performinginstrumental aggression. Hostile aggression refersto behaviors aimed primarily at harming anotherperson or entity. For example, an employee whophysically attacks a manager probably does so notto get anything from the manager except thesatisfaction of inflicting physical pain. Beyond theobvious surface-level differences in these forms ofaggression, there are different underlyingmotivations (Martinko, Douglas, Harvey, &Joseph, 2005). Whereas instrumental aggression ismotivated primarily by a desire to obtain something,hostile aggression is motivated by a desire toretaliate and harm others.Both types of motivation may be sparked by thecausal perceptions associated with hostileattribution styles. Case Study 8-1, at the end of the

chapter, describes a study that indicated thatindividuals can more easily justify instrumental actsof deviance, such as forging paperwork or lyingabout their performance, in response to negativeworkplace events that were attributable to stableorganizational factors (e.g., inadequate resources).Research has also shown that the attribution ofundesirable workplace outcomes to external andstable causes can increase the likelihood of ahostile aggressive response. Similarly, researchsuggests that individuals with a hostile attributionstyle are more likely to engage in acts of hostileaggression than other people are (Douglas &Martinko, 2001). In addition to empirical researchevidence, anecdotal reports suggest that a numberof workplace shootings in the United States, such asthose at several U.S. Post Office facilities, wereperpetrated by individuals with external attributionaltendencies.Several studies have suggested that an employeewith a hostile attribution style can pose dualproblems for managers. In addition to having aheightened tendency toward aggressive behaviors,employees with hostile attribution styles appear tobe prone to perceive that they themselves arevictims of such behavior. One study found thatemployees with hostile attribution styles weresignificantly more likely than other employees to

view their supervisors as abusive in their behaviorstoward them (Martinko, Harvey, Sikora, &Douglas, 2011). Building on this finding, a laterstudy compared pairs of employees who shared thesame supervisor and found that employees with astronger hostile bias consistently rated the sharedsupervisor as being more abusive than moreobjective employees did (Harvey, Harris, Gillis, &Martinko, 2014). Worse, this study also showedthat although the perceptions of mistreatment inthese employees may have been inaccurate, theywere correlated with retaliatory behavior targetingthe employees’ supervisors.From this evidence, we can conclude thatemployees who attribute negative events at work toexternal and stable causes are more likely thanothers to become motivated to engage inaggressive behaviors. A key element in determiningwhich form of aggression will occur, or whether anyaggression will occur at all, appears to be theperceived intent of the responsible party. When anundesirable workplace event is deemed to becaused by factors beyond the control of any specificparty (e.g., an economic downturn), aggressionbecomes less likely (Harvey, Martinko, &Borkowski, 2007). However, there is someevidence that some individuals will remainmotivated to engage in acts of instrumental

aggression in these situations (see Martinko et al.,2005). When such individuals perceive that anexternal and stable factor caused a negativeoutcome and could have been prevented, hostileaggression toward the “guilty” party becomes morelikely. This is probably due to the feelings of angerassociated with such perceptions (Weiner, 1995). Inother words, when causality and intent can beattributed to a specific person or entity, people oftenfeel anger, which, in turn, frequently motivates actsof hostility.EmpowermentTurning our attention to desirable motivationalstates, we first discuss the notion of empowerment.Empowerment refers to a heightened state ofmotivation caused by optimistic effort–rewardexpectations (Conger & Kanungo, 1994). Putdifferently, empowered individuals expect theirefforts toward their goals to succeed and aretherefore motivated to exert high levels of effort.Empowerment is also associated with high levels ofinnovation and managerial effectiveness (Spreitzer,1995).Because empowerment among employees isgenerally good for overall organizationaleffectiveness, it is helpful to understand thecognitive processes that help foster this state of

heightened motivation. Research has shown thatthe causal attribution process can tell us a lot abouthow employees become empowered. Unlikelearned helplessness, empowerment appears toresult from the attribution of negative workplaceevents to factors that either are internallycontrollable or are external, unstable, anduncontrollable. Thus, a physician who misdiagnosesa patient’s disease but believes that the error wasdue to a factor that is under their control (e.g., “Ididn’t think to check for this disease, but I will knowto do so in the future”) is less likely to experiencestrongly negative emotions and learnedhelplessness than is a physician who attributes theerror to their own incompetence. Similarly, aphysician who attributes a similar error to anexternal, unstable, and uncontrollable factor (e.g.,the patient gave incomplete information and therewas not enough time to run a full battery ofdiagnostic tests) is likely to feel optimistic about theirfuture chances for successful diagnoses.Naturally, we can also expect individuals whoattribute positive events to internal factors, such astheir intelligence, skill, and effort, to experienceempowerment (Martinko & Gardner, 1987). Itfollows that individuals with an optimistic attributionstyle are more likely to demonstrate empowermentthan those with pessimistic or hostile attribution

styles. Recall, however, that attribution styles cancause individuals to form inaccurate perceptions ofcausality. A caveat, therefore, is that people with anoptimistic attribution style may feel empowered evenwhen their skills and abilities are lacking. Therefore,as we discuss later in the chapter, it may be moreimportant to promote attributions that are accuratethan to encourage attributions that are optimistic.ResilienceResilience can be defined as a “staunch acceptanceof reality … strongly held values, and an uncannyability to improvise and adapt to significant change”(Coutu, 2002, p. 47). Research suggests thatresilient people are relatively good at developingaccurate attributions (Huey & Weisz, 1997). Morespecifically, it appears that people with low levels ofresilience have a tendency to be overly external orinternal in their attributions for negative outcomes.Thus, people who are nonresilient are likely to err intheir attributions and are prone to blame others orthemselves for their failures. As we have discussed,either of these attributional errors can promotenegative motivational outcomes. High levels ofresilience have the opposite effect, helping peopleto keep their attributions in line with reality. (Recallthat resilience denotes a “staunch acceptance ofreality.”)

Resilience, then, can be thought of as a factor thathelps individuals to avoid the attributional errors thatcan hurt motivation levels. By promoting accuratecausal perceptions, resilience helps to keep peoplegrounded in reality and helps to prevent pessimisticand hostile attributional tendencies. It is also likelythat resilience can help to prevent overly optimisticattributions and the disillusionment and unfoundedoptimism noted in the previous section.If we assume that resilience is good for promotingmotivation through accurate attributions, the nextlogical question is, “Where does resilience comefrom?” We begin the next section by addressing thisquestion, after which we discuss some additionaltechniques for promoting empowerment whilediscouraging learned helplessness and aggression(Table 8-2).Table 8-2 Summary of Attributions Associated withMotivational StatesMotivationalStateAssociated Attributional TendencyLearnedhelplessnessTendency to favor internal and stable attributions forfailures, external attributions for successesAggressionTendency to favor external and stable attributions forfailuresEmpowermentTendency to favor internal and stable attributions forsuccesses, external and unstable attributions for

failuresResilienceTendency to favor accurate attributions, not biasedtoward overly internal or external attributions forsuccesses or failures

▶ Promoting MotivationalAttribution ProcessesIn this section, we summarize five techniques thatmanagers can use to promote and maintainemployee motivation. These techniques aregrounded in the formation of accurate andempowering attributions.Screening for ResilienceIn the previous section, we discussed the benefits ofresilience for forming attributions that are accurateand motivational. Individuals’ baseline levels ofresilience appear to form very early in life (Masten,2001). With proper emotional support, children haveshown remarkably high levels of resilience indealing with undesirable circumstances, such aspoverty and violence. Conversely, we are probablyall familiar with both children and adults who breakdown in response to relatively minor problems. Thissuggests that resilience levels begin to form early inlife. (Note that drastic events such as war andserious disease often result in increased resiliencelevels in adults, but these do not fall under theumbrella of “normal life events.”)

Employers may determine that their organizationrequires that employees have a high level ofresilience . Hospitals, for example, can provide avery stressful and emotionally draining workingenvironment. If employees form overly hostile orpessimistic attributions in response to the negativeevents that are bound to happen in such settings,motivational problems are likely to arise. This typeof organization will probably benefit from a resilientworkforce. A less stressful organization, by contrast,might not require such resilience among employees.Organizations such as hospitals that require highlevels of resilience should try to attract and hireindividuals who demonstrate high levels ofresilience. Although it is unlikely that they candrastically increase their employees resilience levelsin the short-term, managers can try to form aworkforce that has high preexisting levels. This canbe accomplished through the use of standardizedmeasures of resilience (for an example, see Huey &Weisz, 1997) during the employee screeningprocess or through simple interview questions.Asking potential candidates to describe pasthardships and how they responded to thosehardships is likely to shed light on both candidates’resilience levels and their attributional tendencies(Campbell & Martinko, 1998).

Attributional TrainingAlthough resilience is a fairly stable and unchangingpersonal characteristic, accurate and optimisticattributional tendencies can be fostered in otherways. One technique for accomplishing this isattributional training (Martinko & Gardner, 1987).This can take several forms, one of which ismeasuring employees’ attribution styles with anexisting assessment device (for examples of theseinstruments, see Kent & Martinko, 1995; Lefcourt,1991; Lefcourt, Von Baeyer, Ware, & Cox, 1979;Peterson, Bettes, & Seligman, 1985; Peterson etal., 1982; and Russell, 1982) and discussing theirattributional biases with them. Often, by simplyrealizing that they favor overly optimistic,pessimistic, or hostile attributions, individuals canbegin to deliberately adjust their “perceptual lenses”to correct for their biases. Over time, this correctioncan become subconscious, allowing employees toform accurate attributions without additionalcognitive effort.A second form of attributional training is less formaland involves discussing the causes of employees’successes and failures on a case-by-case basis.This can help employees to understand both theinternal and external factors involved with workplaceoutcomes by helping them to see the big picture interms of the multiple personal and situational factors

that are likely to contribute to positive and negativeevents. This promotes a more thorough causalsearch process and can help employees to avoidthe cognitive shortcuts that enable overly optimistic,pessimistic, or hostile attributions.ImmunizationAnother technique recommended by Martinko andGardner (1987) is to immunize againstdemotivational attributions by enabling successesearly in an employee’s career or tenure with anorganization. An employee who fails miserably atthe first few tasks they are assigned in a newposition may quickly decide that they lack the abilityto succeed at the job (an internal and somewhatstable attribution). However, if they are allowed totackle a number of more easily surmountableassignments before engaging in more difficult tasks,they are likely to see that they have the basic abilityto succeed at the job. This will probably promotemore optimistic attributions throughout theemployee’s tenure by providing a basic level ofconfidence at the beginning.Increasing Psychological ClosenessIn addition to individual attributional biases,employees can become the unwitting victims of theirmanagers’ inaccurate attributional tendencies

(Martinko, 1995). Managers provide an importantand often highly valued source of feedback foremployees. If this feedback consistently attributesblame for negative outcomes to employees’ internalcharacteristics, employees might accept thefeedback as accurate even if it is not and might thenexperience organizationally induced learnedhelplessness (Martinko & Gardner, 1987).Research suggests that people in observationalcapacities (which is often the case for managers)frequently tend to be overly dispositional in theirattributions for others’ performance (Jones &Nisbett, 1971). That is, they tend to focus on theinfluence of actors’ effort and ability levels whileoverlooking situational factors that contribute toperformance. In other words, managers can beoverly hard on employees when their performanceis low. Managers might also demonstrate anoptimistic attribution style and take credit for thesuccesses of their departments without giving creditto their subordinates while also blaming employeeswhen the department’s performance suffers. Again,these tendencies can be demotivational, particularlyif employees believe their managers’ attributionalexplanations for their performance.One technique for avoiding this tendency is topromote psychological closeness. Psychologicalcloseness describes the extent to which two or more

people form the same perceptions of their situation.Research has shown that managers who havedirect experience with the work their employeesperform are less likely to form inaccurate attributionsregarding employee performance. Managers whohave little or no experience with their employees’tasks (or who have not performed them in a longtime) appear to be less familiar with the situationalchallenges associated with the work and are morelikely to blame employees’ effort and ability levelswhen their performance is low (Fedor & Rowland,1989).To increase psychological closeness betweenmanagers and employees, organizations shouldwork to ensure that managers have experience withthe work their subordinates perform. This can beaccomplished through internal promotions (i.e.,selecting future managers from the pool ofemployees currently performing the job to besupervised) and by requiring existing managers toperform the jobs they are managing from time totime. These techniques will ensure that managersare familiar with both the internal and externalfactors associated with performance, allowing moreaccurate and motivational attributional feedback tobe formed and communicated to employees.Multiple Raters of Performance

A final recommendation for improving the accuracyand motivational capacity of employees’ attributionsis the use of multiple raters of performance whenpossible (Martinko, 2002). As mentionedpreviously, managers can demonstrate attributionstyles that bias them toward demotivationalexplanations for employee performance. Thistendency can be offset by the use of multipleperformance raters.An illustrative example of this style of judgingperformance is the use of multiple judges toevaluate figure skaters in the Olympics. This systemis used to help ensure that potential biases held byone or more raters can be offset by the accuracy orcounteracting biases of other judges. Similarly,organizations can use more than one individual torate the performance of employees. An increasinglycommon example of this is the use of 360°evaluations, in which peers, managers,subordinates, customers, and the employeesthemselves rate performance. Although each ofthese parties may demonstrate some attributionalinaccuracy, the hope is that through the use ofmultiple sources, an accurate picture of the causesof each employee’s successes and failures willemerge. With this information, the proper steps canbe taken to correct poor performance andencourage future successes, ultimately promoting

empowerment among employees (see Case Study8-1 at the end of the chapter).

▶ ConclusionOur overarching goal in this chapter was to illustratethe importance of attributional perceptions inpredicting employee motivation. One of the keyfindings from research on this topic is that internaland stable attributions for successes in theworkplace, as well as external and unstableattributions for negative workplace events, areassociated with higher levels of empowerment.However, we have seen repeatedly that suchattributions are desirable only when they areaccurate. If an employee fails at a task because theemployee is simply not cut out for the type of workbeing performed, it is generally better for theemployee to realize that the task is too demanding.Similarly, if failures are caused by unstable internalfactors such as insufficient effort, it is important foremployees to make that attribution even if it is notthe most desirable short-term conclusion. Theseaccurate attributions help to steer employees alongthe path toward empowerment, and managers canassist in the process by providing honest andaccurate assessments of the causes of employees’performance.

Discussion Questions 1. What is an attribution? 2. Differentiate between optimistic, pessimistic,and hostile attribution styles. 3. Why might an optimistic attribution style beundesirable? 4. How can different types of attributions andattribution styles encourage high or low levelsof learned helplessness, aggression, andempowerment? 5. How does resilience promote motivationalattributions? 6. How can organizational leaders promoteaccurate and motivating attributions amongtheir employees?

CASE STUDIES ANDEXERCISECase Study 8-1 Managing Employees’AttributionsDavid, who was just promoted to manage asmall medical transcription department, hasinherited a problem. His predecessor recentlycompleted the staff’s annual performanceevaluations, and it is now time to distributeannual raises based, in large part, on theseevaluations. Of the seven employees whomDavid now manages, all received fairly strongevaluations, mostly in the “above average”range, although none received the highestrating of “excellent.” The budget for David’sdepartment will not be growing much for thenext few years, and there is very little room forsalary increases. Had any of the employeesachieved the highest performance level, Davidmight have been able to apply for extra meritpay funding, but this does not appear to be anoption.Because all seven employees receivedrelatively strong evaluations and there was not

much difference between the highest andlowest performers, David has decided toallocate the raises equally among them.However, these raises will probably bedisappointingly small. David is trying to decidehow to break the disappointing news to hisstaff in the least demotivational way possible.He is weighing the following options:1. Explain to the staff that they deservelarger raises but, given the long-termdepartmental budget, this was the best hecould do for them.2. Explain to the staff that he could havegotten them larger raises if theirperformance levels had been higher.3. Explain to the staff that they deservelarger raises and that he, as theirmanager, failed them by not doing morefor them.4. Explain to the staff that these raises arefair, given their performance levels.Discussion Questions1. What attributions are beingcommunicated in each of theseexplanations? Are they internal orexternal? Are they stable or unstable?

2. From a motivational standpoint, whatpotential pros and cons do you see foreach of these explanations?3. Which of these four options (or whichcombination of two or more) do you thinkwould be the least demotivational for thestaff? Why?Case Study 8-2 “Unhealthy”Motivation: How Physicians Justify DeviantBehaviorWe probably all know the feeling: somethingbad happens at work, and there are a fewchoices for dealing with it. You can go “by thebook” and potentially suffer some unpleasantconsequences, or you can bend the rules justa bit to make the whole thing go away. Forexample, suppose you miss a deadline by afew hours. You can choose to tell yourmanager or, because your manager happensto be in a long meeting, finish the job late andslip it under some paperwork on their desk,claiming that it has been there all day. Youknow what you should do, but you also knowthat the sneakier alternative is probably thepath of least resistance. What would you do?Your answer to this question would probablydepend, at least in part, on why you missed

the deadline in the first place. If you missedthe deadline because you procrastinated allweek and took an extended lunch break onthe day the work was due, you might feelsome guilt over lying to your manager.Attribution theory suggests that this isbecause you are attributing the misseddeadline to an internal and unstable/controllable factor: insufficient effort. This guiltmight, depending on other factors, such asyour values and the consequences if yourmanager learns of the missed deadline,reduce your willingness to lie about finishingthe work on time.Your response might be different if you believethat you missed the deadline because theamount of time your manager gave you tocomplete the work was unreasonably short. Ifyou worked late and skipped lunch all weekbut still needed a couple of extra hours to getthe work done, you are much less likely toblame yourself. Instead, you will probablyattribute the missed deadline to an externaland relatively stable factor: your manager.Such attributions are associated with anger,which is a strong motivator of deviantbehavior. This attribution-driven anger mighthelp you feel justified in sneaking the work

onto your manager’s desk. After all, whyshould you get in trouble if the request wasunreasonable?To test the strength of attributions such asthese to motivate deviant behaviors, Harvey etal. (2005) examined the relationship betweenattributions, emotions, and the justification ofworkplace deviance using a sample ofphysicians. The researchers gave thephysicians a hypothetical scenario similar tothe one just described and asked themwhether they would feel comfortable alteringdates on paperwork to disguise the fact that anonlethal procedural mistake had been madein diagnosing a patient. Each physician wasgiven the same hypothetical scenario with onedifference: The cause of the mistake (i.e., theattribution) was varied so that in some casesthe mistake was due to internal and stable orunstable factors (the physician has poorattention to detail or was distracted) and inother cases it was due to external and stableor unstable factors (the physician’sdepartment is chronically understaffed, or anemergency meeting was called and therequired test could not be ordered on time).

As you might expect, physicians were morelikely to say that they would alter thepaperwork when the cause of the mistake wasbeyond their control and was stable (i.e., likelyto occur again). Before taking an overly dimview of these physicians, remember that thehypothetical mistake described in thescenarios was deliberately designed to beminor and inconsequential. Still, this studyprovides some insight into the power ofattributions to motivate behaviors that wemight not normally consider.This justification process is an almostunavoidable part of life. There are alwaysgoing to be times when it is tempting to breakthe rules because we feel that it is a justifiableresponse to a wrongdoing we have suffered.Indeed, many timeless stories are based onthe notion of justifiable wrongdoing—RobinHood returning the king’s wealth to thepeasants, for example.There is a decidedly darker side to thejustification process, however. Perpetrators ofmany serious crimes throughout history have,at least at the time of the crime, convincedthemselves that they were justified in theirbehavior. In many cases, the justification can

be traced to a desire for revenge resultingfrom the attribution of negative events toexternally controllable, stable factors. Thus,we can see that there is more at stake thanproductivity when it comes to forming accurateattributions.Exhibit 8-1 Attribution Style Self-Assessment: Measure Your Attribution Stylefor Negative EventsTo complete this assessment, begin by readingeach of the hypothetical scenarios below andimagine them happening to you. Then, try toimagine what the most likely cause of eachevent would be if it did happen to you.1. You recently received a below-averageperformance evaluation from yoursupervisor. What is the most likely causeof this outcome? ____________________a. To what extent was this outcomecaused by something about you?Nothing to do with me 1 2 3 4 5 6 7Totally due to meb. Will this cause be present in similarfuture situations? Never present 1 23 4 5 6 7 Always present

2. Today, you were informed thatsuggestions you made to your supervisorin a meeting would not be implemented.What is the most likely cause of thisoutcome? ___________________a. To what extent was this outcomecaused by something about you?Nothing to do with me 1 2 3 4 5 6 7Totally due to meb. Will this cause be present in similarfuture situations? Never present 1 23 4 5 6 7 Always present3. You recently learned that you will notreceive a promotion that you have wantedfor a long time. What is the most likelycause of this outcome?___________________a. To what extent was this outcomecaused by something about you?Nothing to do with me 1 2 3 4 5 6 7Totally due to meb. Will this cause be present in similarfuture situations? Never present 1 23 4 5 6 7 Always present4. You recently discovered that you are beingpaid considerably less than another

employee who holds a position similar toyours.What is the most likely cause of thisoutcome? ___________________a. To what extent was this outcomecaused by something about you?Nothing to do with me 1 2 3 4 5 6 7Totally due to meb. Will this cause be present in similarfuture situations? Never present 1 23 4 5 6 7 Always present5. You recently received information that youfailed to achieve all of your goals for thelast performance reporting period.What is the most likely cause of thisoutcome? ___________________a. To what extent was this outcomecaused by something about you?Nothing to do with me 1 2 3 4 5 6 7Totally due to meb. Will this cause be present in similarfuture situations? Never present 1 23 4 5 6 7 Always present6. You have a great deal of difficulty gettingalong with your coworkers. What is themost likely cause of this outcome?___________________

a. To what extent was this outcomecaused by something about you?Nothing to do with me 1 2 3 4 5 6 7Totally due to meb. Will this cause be present in similarfuture situations? Never present 1 23 4 5 6 7 Always present7. You just discovered that a patient recentlycomplained about the services youprovided. What is the most likely cause ofthis outcome? ___________________a. To what extent was this outcomecaused by something about you?Nothing to do with me 1 2 3 4 5 6 7Totally due to meb. Will this cause be present in similarfuture situations? Never present 1 23 4 5 6 7 Always present8. A large layoff has been announced at yourorganization, and you are told that you willbe one of those laid off.What is the most likely cause of thisoutcome? ___________________a. To what extent was this outcomecaused by something about you?Nothing to do with me 1 2 3 4 5 6 7Totally due to me

b. Will this cause be present in similarfuture situations? Never present 1 23 4 5 6 7 Always presentEnter the sum of your A scores here:Enter the sum of your B scores here:Scoring KeyYour A score represents the locus of causalitydimension of your attribution style for negativeoutcomes. A score above 28 represents aninternal attribution style, with scores closer tothe maximum of 56 indicating a relatively moreinternal style (i.e., a tendency to attributenegative outcomes to internal causes). A scorebelow 28 represents an external attributionstyle, with scores closer to zero indicating arelatively more external style (i.e., a tendencyto attribute negative outcomes to externalcauses).Your B score represents the stability dimensionof your attribution style for negative outcomes.A score above 28 represents a stableattribution style, with scores closer to themaximum of 56 indicating a relatively morestable style (i.e., a tendency to attributenegative outcomes to stable causes). A scorebelow 28 represents an unstable attribution

style, with scores closer to zero indicating arelatively less stable style (i.e., a tendency toattribute negative outcomes to unstablecauses).Discussion Questions1. According to this test, do you have anattribution style that favors internal orexternal attributions for negativeoutcomes?2. According to this test, do you have anattribution style that favors stable orunstable attributions for negativeoutcomes?3. Would you characterize your attributionstyle as optimistic? Pessimistic? Hostile?4. If you were managing an employee withthe attribution style that you identified, howwould you help them to stay motivatedwhen negative events occur?Modified from Kent, R. L., & Martinko, M. J. (1995). Themeasurement of attributio ns in organizational research. In M.J. Martinko (Ed.), Attribution theory: An organizationalperspective (pp. 53–75). Delray Beach, FL: St. Lucie Press.Reprinted with permission.

ReferencesAbramson, L. Y., Seligman, M. E. P., & Teasdale, J. D. (1978).Learned helplessness in humans: Critique and reformulation.Journal of Abnormal Psychology, 87, 49–74.Campbell, C. R., & Martinko, M. J. (1998). An integrativeattributional perspective of empowerment and learnedhelplessness: A multi-method field study. Journal ofManagement, 24, 173–200.Conger, J. A., & Kanungo, R. N. (1994). Charismatic leadership inorganizations: Perceived behavioral attributes and theirmeasurement. Journal of Organizational Behavior, 15, 439–452.Coutu, D. L. (2002). How resilience works. Harvard BusinessReview, 80, 46–55.Douglas, S. C., & Martinko, M. J. (2001). Exploring the role ofindividual differences in the prediction of workplaceaggression. Journal of Applied Psychology, 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). Thedecision to blow the whistle: A social information processingframework. Academy of Management Review, 28, 107–123.Harvey, P., Harris, K. J., Gillis, W. E., & Martinko, M. J. (2014).Abusive supervision and the entitled employee. LeadershipQuarterly, 25(2), 204–217.

Harvey, P., & Martinko, M. J. (2009). An empirical examination ofthe role of attributions in psychological entitlement and itsoutcomes. Journal of Organizational Behavior, 30(4), 459–476.Harvey, P., Martinko, M. J., & Borkowski, N. (2007). Unethicalbehavior among physicians and students: Testing anattributional and emotional framework. Presented at the 2007Academy of Management Conference, Philadelphia, PA.Heider, F. (1958). The psychology of interpersonal relations. NewYork, NY: John Wiley & Sons.Huey, S. J., & Weisz, J. R. (1997). Ego control, ego resiliency,and the five-factor model as predictors of behavioral andemotional 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:Divergent perceptions 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 ofbehavior (pp. 79–94). Morristown, NJ: General LearningPress.Kent, R., & Martinko, M. J. (1995). The development andevaluation of a scale to measure organizational attributionstyle. In M. Martinko (Ed.), Attribution theory: An organizationalperspective (pp. 53–75). Delray Beach, FL: St. Lucie Press.Kovenklioglu, G., & Greenhaus, J. H. (1978). Causal attributions,expectations, and task performance. Journal of AppliedPsychology, 63, 698–705.

Lefcourt, H. M. (1991). The multidimensional-multiattributionalcausality scale. In J. P. Robinson, P. R. Shaver, & L. S.Wrightsman (Eds.), Measures of personality and socialpsychological 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). The multidimensional-multiattributional causality scale:The development of a goal specific locus of control scale.Canadian Journal of Behavioural Science, 11, 286–304.Martinko, M. J. (1995). The nature and function of attributiontheory within the organizational sciences. In M. J. Martinko(Ed.), Attribution theory: 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 CoastPublishing.Martinko, M. J., Douglas, S. C., Harvey, P., & Joseph, C. (2005).Managing organizational aggression. In R. Kidwell & C. Martin(Eds.), Managing organizational deviance: Readings andcases (pp. 237–260). Thousand Oaks, CA: Sage.Martinko, M. J., & Gardner, W. L. (1987). The leader-memberattribution process. 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 attributionstyle. Leadership Quarterly, 22, 751–764.Masten, A. S. (2001). Ordinary magic: Resilience processes indevelopment. American Psychologist, 56, 227–238.

Overmier, J. B., & Seligman, M. E. P. (1967). Effects ofinescapable shock upon subsequent escape and avoidancelearning. Journal of Comparative and PhysiologicalPsychology, 63, 23–33.Peterson, C., Bettes, B. A., & Seligman, M. E. P. (1985).Depressive symptoms 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 stylequestionnaire. Cognitive Therapy and Research, 6, 287–300.Russell, D. (1982). The causal dimension scale: A measure ofhow individuals perceive causes. Journal of Personality andSocial Psychology, 42, 1137–1145.Spreitzer, G. M. (1995). Psychological empowerment in theworkplace: Dimensions, measurement, and validation.Academy of Management Review, 38, 1442–1465.Weiner, B. (1985). An attributional theory of achievementmotivation and emotion. Psychological Review, 97, 548–573.Weiner, B. (1995). Judgments of responsibility: A foundation for atheory of social conduct. New York, NY: Guilford Press.

Other Suggested ReadingSchermerhorn, J. R. (1987). Improving health care productivitythrough high-performance. Health Care Management Review,12(4), 49–55.

PART IIILeadershipPower is the ability to influence other people’sactions, thoughts, or emotions. When discussingpower, the topic of leadership always enters into theconversation because the two terms are almostinseparable. In Part III, we attempt to answer theoften-asked question, “What does it take to be aneffective leader?” In Chapter 9, we provide anoverview of the definition of power and the types,sources, and uses of power as well asorganizational politics. In Chapter 10, we discussthe early theories of leaderships, such as the GreatMan Theory and trait theory. In Chapter 11, we turnour attention to the next generation of leadershiptheories: contingency theories and situationalmodels. These theories state that leaders applydifferent styles in different situations, depending onthe factors involved. Chapter 12 provides insightinto some of the contemporary theories inleadership, such as transformational, servant, andcollaborative leadership. These contemporary

theories of leadership look to the person and theorganization’s culture in the attempt to determinewhat it takes to be an effective leader.

CHAPTER 9Power, Politics, andInfluencePower is the ability to define reality and have othersaccept that definition as if it were their own.– Wade NoblesLEARNING OUTCOMESAfter completing this chapter, the student shouldbe able to understand the:Definition of power.Difference between potential and kineticpower.Different sources of power.Ways in which managers develop a powerbase.Definition of organizational politics and thevarious political behaviors.

Definition of upward influence and the variousinfluence tactics categories.

▶ OverviewSince 2002, Modern Healthcare has annuallypublished a list of the 100 most powerful people inhealth care. Modern Healthcare’s readers developthe list. The readers are asked first to nominate andthen to vote for individuals they believe have thegreatest power to influence the U.S. health caredelivery system. Burda (2003) related that the onetheme that caught his attention was control. Hestated, “Controlling something of value makes youpowerful, and that’s what the people on the list havein common” (p. 36). It should be no surprise to learnthat many of the top 100 powerful people each yearare elected or appointed federal employees (withthe President of the United States often taking thenumber-one position) who hold the purse strings onan annual budget in excess of $1 trillion or have thepower to impose, delay, or eliminate costlyregulatory requirements on health care providers.Power has been defined in a variety of ways.Thibaut and Kelley (1959) defined power as havingbehavioral or fate control over the behavior ofanother person. Mechanic (1962) defined power asany force that results in behavior that would nothave occurred if the force had not been present. Siu

(1979) defined power as the influence over thebeliefs, emotions, and behaviors of people, which isthe definition adopted for our discussions.Power exists only when there is an unequalrelationship between two people and one of the twois dependent upon the other (Emerson, 1962).Using the example of the annual 100 most powerfulpeople ranking in health care reflects these twocomponents of power: unequal relationship anddependency. Health care providers depend on thefederal government, specifically the Medicare andMedicaid programs, for reimbursements. Anychange in the levels of reimbursement can havepositive or negative effects on the industry. Forexample, the Affordable Care Act of 2010transformed Medicare from a passive payer to anactive purchaser of higher-quality, more efficienthealth care through the value-based purchasing(VBP) initiative. The Centers for Medicare andMedicaid Services rule that denies payment forhospital-acquired conditions referred to as “neverevents” strongly encouraged patient safety efforts.There is an unequal relationship because of thefederal government’s ability to enact newregulations that require major changes in howhealth care providers and suppliers conductbusiness (e.g., Affordable Care Act of 2010 and the

Medicare Access & Chip Reauthorization Act of2015).Potential power exists when an individual has theability to influence but does not use it (e.g., asupervisor sits at her desk completing paperworkbut does not interact with staff). When the individualactually uses the power to influence, it is referred toas kinetic power (e.g., a supervisor awards a bonusto a subordinate for completing a challenging taskon time and correctly) (Siu, 1979).The concept of power is an integral part oforganizational behavior. For example, power iscentral to the topics of attitudes, perception, andmotivation as well as leadership, group dynamics,and change management.Sources of PowerJohn French and Bertram Raven (1959) identifiedfive bases or sources of social power: rewardpower, coercive power, legitimate power, referentpower, and expert power. An individual is not limitedto one source of power; individuals may hold andexercise multiple sources of power simultaneously.1. Reward power is defined as the ability to giverewards, something that holds value toanother individual. Reward power has twocomponents. First, the individual (P) must

perceive that the other person (O) has theability to reward. Second, the reward musthave some value to P. If O offers a reward toP and then fails to deliver, future attempts byO to change P’s behavior by using rewardpower will have been diminished.2. Coercive power is defined as the ability topunish either by administering a punishmentor by withholding something that an individualneeds or wants. Coercive power stems fromP’s expectation that O will administer apunishment if P fails to conform to theinfluence attempt. As with reward power, forcoercive power to be effective, P mustperceive that O has the ability to punish orsanction, and this negative valence musthave some value (e.g., avoidance ofpunishment) to P.3. Legitimate power is authority given to anindividual on the basis of a given role orposition. There are three bases of legitimatepower: culture, social structure, anddelegation of power. In some cultures, certaingroups are granted the right to prescribebehavior for others. For example, in somecultures, the elders or one sex is granted thepower to demand conformity of behavior byothers. Social structure is the second basis

for legitimate power. In formal organizations,this power is granted by the position thatsomeone holds in the company’s hierarchy.The third base of legitimate power isdelegation of the power by the legitimizingagent. For example, a department managermay accept the authority of a vice presidentin certain areas because the organization’spresident has specifically delegated theauthority to the vice president. It is importantto remember that O holds legitimate poweronly if P accepts O as holding a legitimatepower position.4. Referent power stems from P’s affectiveregard (i.e., attraction) for, or identificationwith, O. Interestingly, O has the ability toinfluence P even though O may be unawareof this referent power. Also, because Pdesires to be associated with or identifiedwith O, P will assume attitudes, beliefs, orbehavior displayed by O. Therefore, thegreater the attraction, the greater theidentification and the greater the referentpower.5. Expert power exists when P awards power toO on the basis of P’s perception of O’sknowledge in a given area. P evaluates O’sexpertness in relation to their own knowledge

as well as against an absolute standard. Theexpert is seen as having superior knowledgeor ability in very specific areas. Therefore, theattempt to exert expert power outside of thespecific area will reduce that expert power,and an undermining of confidence may takeplace.Two other sources of power have been discussed:informational and connection (Hersey & Blanchard,1982). A person who has access to valuable orimportant information possesses informationalpower. Connection power is related to who youknow, vertically and horizontally, both within andoutside the organization. These two sources ofpower are discussed further in the followingsections.

▶ Other Sources of Power inan OrganizationDavid Mechanic (1962) found that employeeswithout formally defined power positions exercisesignificant personal power within an organization bycreating a sense of dependency. Employees createthis dependency by controlling access to thefollowing:1. Instrumentalities, which includes any aspectof the physical plant of the organization or itsresources (e.g., equipment, materials,budgets).2. People, including anyone within theorganization or outside the organization onwhom the organization is in some waydependent.3. Information, which includes knowledge of thenorms, procedures, and techniques of doingbusiness within the organization.The most effective way for lower-level employees toachieve power is to have higher-ranking employeesbe dependent on them. Thomas Scheff’s research(1961) provides us with an illustration of thisdependency relationship and the power associated

with it. Scheff’s study involved a state mentalhospital that failed to implement reforms because ofthe opposition of the hospital attendants. The failurewas due largely to the ward physicians’ dependencyon the attendants. The dependency resulted fromthe physicians’ short tenure, their lack of interest inadministration, and the large amount ofadministrative responsibilities they had to assume.An implicit trading agreement developed betweenphysicians and attendants whereby attendantswould take on some of the responsibilities andobligations of the ward physicians in return forincreased power in decision-making processesinvolving patients. Failure of the ward physician tohonor their part of the agreement resulted ininformation being withheld, disobedience, lack ofcooperation, and unwillingness of the attendants toserve as a barrier between the physician and a wardfull of patients demanding attention and recognition.When the attendants withheld cooperation, thephysicians had difficulty in making gracefulentrances and departures from the ward, in handlingnecessary paperwork (officially their responsibility),and in obtaining information needed to dealadequately with daily treatment and behaviorproblems. When the attendants opposed change,they could wield influence by refusing to assume

responsibilities that were officially assigned to thephysician.Another example is new physician residents’dependency on the floor nurses in a large teachinghospital. These new physicians depend on thenurses to provide information that will help themmaneuver through the hospital maze to obtain thenecessary care for their patients. How are testsordered? What paperwork must be completed?Does the patient need an authorization from theirinsurance company? The new residents depend onthe nurses’ goodwill. If the nurses withhold theircooperation, the physicians have little or noalternative but to attempt to decipher the hospital’spolicies and procedures by themselves, whichwould be a very time-consuming process.Increasing complexity in organizations has madethe expert or staff person more powerful as a resultof the organization’s dependency on theirspecialization, knowledge, and skills. Experts havetremendous potential for power by withholdinginformation or providing incorrect information. Forexample, Mechanic (1962) discusses the situationof a lay hospital administrator (in contrast to ahospital administrator who is also a physician) whomakes an administrative decision that physiciansoppose on the basis of medical necessity. A layadministrator is not in a position to contest these

claims independently. To evaluate these claims, theadministrator would need to engage medicalconsultants to serve as a buffer between themedical staff and the lay administration.Employees also form coalitions that demonstratethe power to get things done in a highly functionallystructured organization such as a hospital. Hospitalsare complex entities organized into functional unitssuch as medical, nursing, administration, andphysical plant, which are controlled at high levels ofauthority. It is not unusual for coalitions to form atthe intermediate and lower levels that overlap thefunctional units. For example, the hospital’sorthopedic unit secretary knows the person inpatient support services who schedules patienttransport or the person in the centralized supply unitwho coordinates deliveries to the variousdepartments. The secretary can handle informallywhat would be very time consuming if handledformally. Thus, managers become dependent onemployees who know how to get around thesystem, which gives those employees power.Employees also gain power because others havedelegated responsibilities to them that the others donot want to do themselves but that bring with them acertain amount of power. For example, a physicianusually delegates the responsibility of schedulingtheir appointments to a secretary. The secretary

schedules both patient and nonpatient appointmentsand therefore wields an enormous amount of powerin terms of who will or will not see the physicianduring any given time period. Ask anypharmaceutical representative trying to schedule anappointment to discuss a new drug with a physician!An administrative assistant in a primary carephysician’s (PCP’s) office who issues patientreferrals has the power to select what specialists thephysician’s patients will be referred to within themanaged care network. A specialist couldexperience a decrease in their patient referrals bynot cooperating with the PCP’s administrative staff’srequests (e.g., seeing referred patients in a timelyfashion).

▶ Uses of PowerRecall that McClelland (1985) relates that a highneed for power may be expressed as personalizedpower or socialized power. Individuals with a highneed for personalized power tend to displayimpulsive aggressive actions, to abuse alcohol, andto collect prestige “toys” such as fancy cars. Theyseek to control others for their own benefit. Theirattitude is “I win, you lose.” Individuals with a highneed for personalized power demand personalloyalty from staff, not loyalty to the organization.Yukl (2001) points out that when a highpersonalized power leader leaves an organization,the result tends to be chaos, loss of direction, andlow morale.Socialized power need is associated with effectiveleadership. These leaders direct their power in waysthat benefit others and the organization rather thanfor their own personal gain. As McClelland (1985)and Yukl (2001) relate, these leaders are interestedin seeking power because it is through power thatthey can influence other people to accomplish tasks.They empower others who use that power to enactand further the leader’s vision for the organization.

Magee and Langner (2008, p. 1548) provides thefollowing example of individuals’ use of personalizedand socialized power. Three individuals decide topursue a career in politics. One of them, who is highin socialized power motivation but not personalizedpower motivation, pursues this career to improvethe welfare of a constituent group. Another, who ishigh in personalized power motivation but notsocialized power motivation, seeks political office toachieve recognition and to coerce others intobenefiting them. The third, who is high in both typesof power motivation, is motivated both by thepromise of helping others and by the trappings ofpolitical office.

▶ Developing a Power BaseManagers are dependent on others because of twoorganizational factors: division of labor and limitedresources (Kotter, 1977). Managers are dependenton subordinates, peers, supervisors, other unitswithin the organization, outside suppliers, and manyothers. Managers are sensitive to this issue, andthey cope with their dependency by eliminating it,limiting it, or establishing power over others (Kotter,1977). Kotter describes four ways in whichmanagers have been successful in developing apower base:Creating a Sense of Obligation: Managers willgo out of their way to do favors for people whothey expect will feel an obligation to returnthose favors.Building a Reputation as an Expert in a CertainArea: Managers will establish themselves asexperts in one or more areas so that others willdefer to them on those matters. This can beaccomplished through visible achievement(e.g., professional reputation and track record,executing a successful high-profile project).Identification: Managers will try to foster otherpeople’s unconscious identification with them or

ideas for which they stand. Managers try to lookand behave in ways that others respect. Theygo out of their way to be visible to theiremployees and give speeches about theirorganization’s goals, values, and so on.Perceived Dependence: Managers will attemptto have other people believe that they aredependent on the manager for either help ornot being hurt. The manager can accomplishthis by securing resources that an employeerequires to perform their job. At the same time,the manager makes it known that they can alsohave the same resources removed. Managersmay also resort to influencing others’perception of the manager’s availableresources, which may be more than theypossess in reality. In trying to influence people’sjudgments, managers pay attention to thetrappings of power and to their own reputationsand images. They associate with people andorganizations that are known to be powerful.Kotter (1977) notes that managers who build theirpower based on perceived expertise or onidentification can often use it to influence attitudesas well as someone’s immediate behavior, whichwould result in a lasting impact.

▶ Organizational PoliticsAllen, Madison, Porter, Renwick, and Mayes(1979, p. 77) describe organizational politics as theintentional acts of influence to enhance or protectthe self-interest of individuals or groups. On thebasis of their research, eight types of politicalbehaviors were identified:Attacking or Blaming Others: Attacking orblaming others is often associated withscapegoating—blaming others for a problem orfailure. It may also include trying to make a rivallook bad by minimizing their accomplishments.Using Information as a Political Tool: Usinginformation as a political tool may includewithholding important information when doingso might further an employee’s politicalinterests. This type of behavior can also includeinformation overload—for example, by buryingor obscuring among other information someimportant (but potentially damaging) details thatthe employee hopes will go unnoticed.Creating and Maintaining a Favorable Image:Creating and maintaining a favorable imageinclude drawing attention to one’s successesand the successes of others, creating the

appearance of being a player in theorganization, and developing a reputation ofpossessing qualities considered to be importantto the organization (i.e., impressionmanagement). The behavior also includestaking credit for the ideas and accomplishmentsof others.Developing a Base of Support: Examples ofdeveloping a base of support include gettingprior support for a decision before a meeting iscalled and getting others to contribute to anidea to secure their commitment.Ingratiation/Praising Others:Ingratiation/praising includes praising otherpeople and establishing good rapport for self-serving purposes. Organizational jargon for thisbehavior includes buttering up the boss, applepolishing, and brown-nosing.Developing Allies and Forming PowerCoalitions: Developing allies and forming powercoalitions include developing networks ofcoworkers, colleagues, and/or friends withinand outside the organization for purposes ofsupporting or advocating a specific course ofaction.Associating with Influential People: Associatingwith influential people includes developing

professional connections with organizationsand people that are known to be powerful.Creating Obligations and Reciprocity: Creatingobligations and reciprocity includes performingfavors to create obligations from others,commonly known as “you scratch my back andI’ll scratch yours.”From an organizational perspective, withholding anddistorting information are the most dysfunctional andshould be safeguarded against by the company.Note the similarities between Kotter’s power basesand Allen et al.’s types of political behavior: creatinga favorable image, developing allies and formingpower coalitions, creating obligations, andassociating with influential people. Although Kotterand Allen et al. developed their arguments 40 yearsago, they are still valid today.

▶ Upward InfluenceThere has been a growing recognition amongorganizational behavior researchers that a politicalinfluence perspective is a useful way to examine theeffectiveness of managers (Falbe & Yukl, 1992;Farmer & Maslyn, 1999; Pfeffer, 1992). Thisperspective has focused on employees’ influencetactics directed upward at those higher levels in theformal organizational structure. Kipnis, Schmidt,and Wilkinson (1980), on the basis of theirresearch, grouped influence tactics into variouscategories, of which six relate to upward influence:Assertiveness includes such influence tacticsas demanding compliance, ordering, andsetting deadlines, as well as nagging andexpressing anger.Ingratiation includes behaviors such aspraising, politely asking, acting humble, makingthe other person feel important, and actingfriendly.The rationality tactic consists of using reason,logic, and compromise in attempting toinfluence others. This also includes attempts toconvince others that certain actions are in theirown best interests.

The exchange category refers to such behavioras offering to help others in exchange forreciprocal favors.Upward appeal is indicated by behavioralattempts to gain support from superiors in anorganization.Coalition formation refers to attempts to buildalliances with others.Kipnis and Schmidt (1988) assessed the use ofupward influence with hospital supervisors, clericalworkers, and chief executive officers. Using thetactics of the six categories of upward influence,Kipnis and Schmidt identified four clusters:Shotguns: Individuals who use all tactics butespecially assertiveness and higher authority.Tacticians: Individuals with a high use of reasonor rationality but average use of other tactics.Bystanders: Individuals with lower than averagescores on all tactics.Ingratiators: Individuals with the highest use offriendliness or ingratiation tactics but averageuse of other tactics.In the early stages, this research stream has beenproductive. There is growing knowledge of howvarious tactics that employees use to influencebehaviors of those in higher positions in theorganization work or do not work under certain

circumstances and in different cultures (Farmer &Maslyn, 1999; Ralston, Hallinger, Egri, &Naothinsuhk, 2005; Ralston et al., 2001).A study by Carney, Cuddy, and Yap (2010)explored the use of body language to increase one’spower position. The researchers found (p. 1) thatposing in high-power nonverbal displays (as opposedto low-power nonverbal displays) would causeneuroendocrine and behavioral changes for both maleand female participants: High-power posersexperienced elevations in testosterone, decreases incortisol, and increased feelings of power and tolerancefor risk; low-power posers exhibited the oppositepattern. In short, posing in displays of power causedadvantaged and adaptive psychological, physiological,and behavioral changes, and these findings suggestthat embodiment extends beyond mere thinking andfeeling, to physiology and subsequent behavioralchoices.Reproduced from Carney, D. R., Cuddy, A. J. C., &Yap, A. J. (2010). Power posing: brief nonverbaldisplays affect neuroendocrine levels and risktolerance. Psychological Science, 21(10), 1363–1368.In other words, Carney et al. (2010) showed that anindividual’s nonverbal displays can govern how theperson thinks and feels about themselves and that aperson’s body movements can change their mind.

The technique study is referred to as the “powerpose.”

▶ ConclusionIn this chapter, we discussed what is meant bypower and how individuals can use it to influenceothers. As was noted in the chapter, the concept ofpower is an integral part of organizational behavior.Power is central to the subject of leadership.

Discussion Questions 1. Discuss what is meant by the term “power.” 2. Explain the difference between potential andkinetic power. 3. Describe the different sources of power. 4. Explain what is meant by a manager’s powerbase and the ways in which managersdevelop it. 5. Describe organizational politics and theresulting political behaviors. 6. Discuss what is meant by upward influenceand the various influence tactics categoriesassociated with it.

CASE STUDIESCase Study 9-1 What Can Joe DoAbout Betty?Just before quitting time, Joe, the hospital’shealth information department manager,watched his three new trainees struggling withthe complicated electronic medical recordssoftware they had to learn to use to do theirjobs. Across the room, Betty, who was anexpert with the software, was preparing toleave for the day, her tasks done ahead oftime as usual. Also as usual, she gathered upher belongings and left without saying good-bye to any of her coworkers. “There goes theanswer to my problem,” thought Joe. “If only Iknew how to reach her.” With her expertiseand experience in using the system, Bettywould seem to be an ideal coach for the newemployees. However, she had begged offfrom taking on training duties when Joe hadasked her. Her reasons were that she wasn’tcomfortable telling anyone else what to do,didn’t want the responsibility for someone

but obviously senior management thought sowhen they selected him over me. I could careless what happens from this point forward. Ionly have 5 more years until I can retire withmy full pension. As long as my work continuesto be excellent, there is no way Joe can upsetmy plans. Not that he could, since he hardlyunderstands the complexity of the software weuse. It requires a person with a lot oftechnology knowledge and experience.”Describe French and Raven’s five sources ofpower. In this case, who has power(s) andwhy?Case Study 9-2 Scott’s DilemmaScott is a licensed physical therapist whoworks for a national rehabilitation company.The rehabilitation facility in which Scott worksis located in an urban Southwest city. He hasworked at this facility for 4 years and, up untilrecently, was satisfied with his workingenvironment and the interactions he sharedwith his coworkers. In addition, Scott receivedpersonal fulfillment from helping his patientsrecover from their disabilities and seeing themreturn to productive lives.

Last year the health system went throughreorganization, with some new people beingbrought in and others reassigned. Scott’s newboss, George, was transferred from one of thesystem’s Midwest facilities. Almostimmediately upon taking his new position,George began finding fault with Scott’s careplans, patient interactions, and so on. Scottbegan feeling as if he couldn’t do anythingright. He was experiencing feelings of anxiety,stress, and self-blame. Although his previousperformance evaluations had been aboveaverage, Scott was shocked by his firstperformance review under George’s authority—it was an extremely low rating.Scott began trying to work harder, thinkingthat by working harder he could exceedGeorge’s expectations. Despite Scott’s longhours and addressing George’s critiques,George continued to find fault with Scott’swork. Staff meetings began to be a greatsource of discomfort and stress becauseGeorge would belittle Scott and single him outin front of his colleagues.Scott began to feel alienated from his family,friends, and colleagues at work. His eatingand sleeping habits were adversely affected

as well. Scott’s activities held no joy for himany more, and the career that he had onceloved and been respected in became a sourceof pain and stress. He began to call in sickmore often and started visualizing himselfconfronting and even hurting George, whichcreated even more guilt and anxiety for Scott.As time went on, George encouraged Scott’scoworkers to leave Scott alone to do his work.The perception of the coworkers becamemore sympathetic to George’s point of view.Scott’s coworkers mused that perhaps Scottreally was a poor worker and that Georgeknew better because of his position as thesupervisor of the rehabilitation department.Eventually, Scott’s coworkers began todistance themselves from him, in order toprotect their own interests. They began to seeScott as an outsider, with whom it was unsafeto associate.In an effort to resolve the situation, Scottspoke to George directly, stating his feelingsand expressing an interest in how they mightimprove the situation. Rather than making thesituation better, what George perceived asScott’s insubordination served to enrageGeorge, and the personal attacks against

Scott intensified. Feeling frustrated andhelpless, Scott then decided to take hisproblem to the Human Resources Department(HRD). A human resources manager listenedto Scott’s complaints and suggested that Scottreturn with documented evidence of whatScott perceived to be George’s mistreatment.In an effort to help ease the situation, the HRDmanager discussed the issue with George,which only stirred the flames of George’sanger and his negative behavior toward Scott.As a last resort, Scott decided to go toGeorge’s boss, Rebecca. Rebecca met withGeorge to get his side of the story. Georgeportrayed Scott as an unproductive employeewith no respect for authority. The result was astrong letter of reprimand in Scott’s file forinsubordination.Describe French and Raven’s five sources ofpower. What power(s) do the individuals inScott’s dilemma hold?Reproduced from Pinto, J., Vecchione, M., & Howard, L.(2004, October). Case discussion: Workplace bully. Presentedat the 12th Annual International Conference of the Associationon Employment 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 andcharacteristics of its actors. California Management Review,22, 77–83.Burda, D. (2003, August 25). Command and control: To makepowerful list, you need to hold the purse strings or hire theworkers. Modern Healthcare, p. 36.Carney, D. R., Cuddy, A. J. C., & Yap, A. J. (2010). Power posing:Brief nonverbal displays affect neuroendocrine levels and risktolerance. Psychological Science, 21(10), 1363–1368.Emerson, R. M. (1962). Power-dependence relations. AmericanSociological Review, 27(1), 31–41.Falbe, C. M., & Yukl, G. (1992). Consequences for managers ofusing single influence tactics and combinations of tactics.Academy of Management Journal, 35(3), 638–652.Farmer, S. M., & Maslyn, J. M. (1999). Why are styles of upwardinfluence neglected? Making the case for a configurationalapproach 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). AnnArbor, MI: University of Michigan Press.Hersey, P., & Blanchard, K. (1982). Management oforganizational behavior: Utilizing human resources (4th ed.).Englewood Cliffs, NJ: Prentice Hall.

Kipnis, D., & Schmidt, S. M. (1988). Upward influence styles:Relationship with performance evaluations, salary, and stress.Administrative Science Quarterly, 33(4), 528–542.Kipnis, D., Schmidt, S. M., & Wilkinson, I. (1980).Intraorganizational influence tactics: Explorations in gettingone’s way. Journal of Applied Psychology, 65(4), 440–452.Kotter, J. P. (1977, July/August). Power, dependence, andeffective management. Harvard Business Review, 55(4), 125–136.Magee, J. C., & Langner, C. A. (2008). How personalized andsocialized power motivation facilitate antisocial and prosocialdecision-making. Journal of Research in Personality, 42,1547–1559.McClelland, D. C. (1985). Human motivation. Glenwood, IL: Scott-Foresman.Mechanic, D. (1962, December). Sources of power of lowerparticipants in complex organizations. Administrative ScienceQuarterly, 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).The effects of culture and life stage on workplace strategies ofupward influence: A comparison of Thailand and the UnitedStates. Journal of World 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: Astudy of six cultures from Europe, Asia, and America. Journalof Cross-Cultural Psychology, 32, 748–755.

Scheff, T. J. (1961). Control over policy by attendants in a mentalhospital. Journal of Health and Human Behavior, 2, 93–105.Siu, R. G. H. (1979). The craft of power. New York, NY: JohnWiley & Sons.Thibaut, J., & Kelley, H. H. (1959). The social psychology ofgroups. New York, NY: John Wiley & Sons.Yukl, G. A. (2001). Leadership in organizations (5th ed.). UpperSaddle River, NJ: Pearson Education.

CHAPTER 10Trait and BehavioralTheories of LeadershipLEARNING OUTCOMESAfter completing this chapter, the student shouldbe able to understand the:Difference between leaders and managers.Importance of early behavioral and traitstudies.Role of behavioral and trait theories in theevolution of leadership research.Contributions of the early leadership studies atOhio State University and the University ofMichigan.Design and application of Blake and Mouton’sManagerial (Leadership) Grid.

▶ OverviewWhat is leadership? Leadership can be describedas a complex process by which a person setsdirection and influences other people to accomplisha mission, task, or objective and directs theorganization in a way that makes it more cohesiveand coherent (Winder, 2003). What makes anindividual a leader? What makes a leader effective?The answers to these questions have been thefocus of organizational researchers for nearly acentury. In this chapter, we discuss some of theearlier studies in leadership, referred to as the traitand behavioral theories, that laid the foundation forother leadership theories such as contingencytheories and contemporary or transformationaltheories.Often, in exploring leadership in organizations, thefirst question asked is, “Are managers leaders?” or“Is there a difference between managers andleaders?” Kotter (1988) believes that managers andleaders perform two different but complementaryactivities. Winder (2003) and Hellriegel, Slocum,and Woodman (1995) point out that a manager is aperson who directs the work of employees and isresponsible for results. By contrast, a leader

inspires employees with a vision and helps them tocope with change. Leaders make people want toachieve an organization’s goals and objectives,while managers direct people to accomplish aparticular task or objective. In the words of PeterDrucker and Warren Bennis, “Management is doingthings right; leadership is doing the right things.”Khan (2010) emphasizes that organizations needboth strong leadership and strong management foroptimum effectiveness. Robbins relates (as cited byKhan, 2010, p. 2) that in today’s dynamic world,organizations require leaders who can challenge thestatus quo, create the needed vision, and motivatefollowers toward achieving that vision. To achievethe vision, leaders need strong managers who cansuccessfully develop the plans, create the structureand processes, and efficiently handle the dailyoperations.Management and leadership are two separatebehaviors, but both are necessary for anorganization to achieve its goals (see Table 10-1).Note that the distinctions in the table are based onbehaviors—that is, what an individual does—andnot on particular characteristics, personality, ortraits. Therein, we begin to discover the distinctcontributions and applications of the theoriespresented in this chapter: trait and behavioral.

Table 10-1 Leaders Versus ManagersLeadersManagersInspire employees with avision.Direct the work of employees anddevise systems to monitor employees’progress toward achieving preset goals.Help employees to copewith change.Determine how to achieve preset goalsand be responsible for achieving them.Make people want toachieve high goals andobjectives.Tell employees to accomplish aparticular task or objective.Articulate a direction orvision of what the futuremight look like.Handle activities through planning andbudgeting.Develop strategies forproducing changes neededto move in a new direction.Achieve preset goals by organizing andstaffing.Recruit and keepemployees whounderstand and share theirvisions.Create an organizational structure andsets of jobs for accomplishing theorganization’s strategies.

▶ Trait TheoryThe belief that innate traits could be found and bethe basis for identifying leaders is illustrated by thefollowing quote from Henry Ford: “The question‘who ought to be boss’ is like asking ‘who ought tobe the tenor in the quartet?’ Obviously, the man whocan sing tenor.” One might conclude that not all ofus are born to sing tenor, and not all of us are bornto lead. Similar thoughts were expressed bysociologist Jerome Dowd.In the early 20th century, many people accepted hisbelief that individuals possess different degrees ofintelligence, energy, and moral force and that themasses of society, in whatever direction they maybe influenced, are always led by the superior few(Bass, 1990). Leaders, it was believed, were bornwith personality, social, and physical characteristicsthat set them apart—traits that made them distinctfrom nonleaders.The earliest trait studies of leadership reflect thesocial and psychological context of their times.These studies generally assumed that leaders wereborn—the Great Man Theory—and that these bornleaders possessed specific characteristics or traitsthat set them apart. More than 100 studies

summarized by Stogdill (1948) and Mann (1959)sought to distinguish leaders from nonleaders onthe basis of personality characteristics andindividual traits, including intelligence, initiative,understanding of the task, and preference for aposition of control and dominance. Early traittheorists suggest that characteristics such asintelligence, maturity, inner motivation, achievementdrive, and employee centeredness are more likely tobe found in middle-level and top managers than inteam leaders or first-line supervisors. Leaders tendto be emotionally mature, have a broad range ofinterests, and are high achievers. They are able towork effectively with employees in a variety ofsituations, and they respect other people and realizethat to accomplish tasks, they must be considerateof others’ needs and values (Stogdill, 1974).As research on leadership traits continued, a reviewby Geier (1967) of 20 different studiesdemonstrated the wide variance in the leadershiptraits chosen for investigation. Nearly 80 differenttraits were identified across the 20 studies, and onlyfive traits were common to four or more of theinvestigations. Thus, no clear set of traits by whichwe can distinguish great leaders emerged. Despitethe difficulties in linking traits to successful leaders,evidence based on observed characteristics of bothsuccessful and unsuccessful leaders does reveal

that many successful leaders share some basictraits (see Exhibit 10-1). Other studies establisheddifferences in drive (achievement, ambition, energy,tenacity, and initiative), cognitive ability, honestyand integrity, self-confidence, knowledge ofbusiness, and desire to lead (Kirkpatrick & Locke,1991). However, as Robbins (2005) notes, thepower of these traits to predict leadership wasmodest. No consistent patterns between specifictraits and effective leadership materialized. Lussierand Achua (2012) note that no universal list hasemerged of traits that all great leaders possess orthat will guarantee leadership success in allsituations. Leadership emerges from the combinedinfluence of multiple traits (Zaccaro, Kemp, &Bader, 2004). This is consistent with research fromthe GLOBE study, which involved over 200researchers across 62 cultures over the course ofmore than 20 years. This study found that althoughsome elements of leadership were universallyvaluable, some elements of desirable leadership areculturally contingent and cannot necessarily betranslated across cultures. Furthermore, thisresearch found that leaders who acted inaccordance with the cultural values andexpectations of leaders in their specific contexttended to be more effective (Dorfman, Javidan,

Hanges, Dastmalchian, & House, 2012; Hernandez,O’Connor, & Meese, 2018).Exhibit 10-1 Trait TheoryOne researcher studied a large number ofNorth American organizations and leaders andconcluded that there are some common traitsthat leaders possess. Leaders who possessthese traits are able to lead in a variety ofsituations:Physical vitality and staminaIntelligence and action-oriented judgmentEagerness to accept responsibilityTask competenceUnderstanding of followers and their needsSkill in dealing with peopleNeed for achievementCapacity to motivate peopleCourage and resolutionTrustworthinessDecisivenessSelf-confidenceAssertivenessAdaptability/flexibility

Data from Gardner, J. (1989). On leadership. New York, NY: FreePress.Winder (2003) points out another criticism of earlytrait theory related to its reference to leaders’physical characteristics such as appearance,physique, energy, and health. This is not surprisingwhen one considers that the early leadershipstudies were conducted in the 1930s. Leadersduring that period would have typically been male,Caucasian, authoritarian, and educated. Aside fromthese traits, it would have been difficult to find morethan minor differences from one organizationalleader to the next. However, as we recognize today,physical characteristics are not requirements forleadership.The failure of early studies to determine a clear setof leadership traits led a number of researchers toquestion the value of trait leadership theory and toexplore another area of distinction: leader behavior.Rather than asking what traits distinguish leaders,behavioral theories of leadership ask, “How doleaders act or behave differently than nonleaders?”The underlying assumption or hypothesis shifts frombeing born with innate leadership abilities to beingable to acquire leadership behaviors. Can weidentify and teach particular behaviors that promoteeffective leadership? Many researchers would

support the position that leadership can be learned,cultivated through work experience, training,education, opportunity, motivation, and even a littleluck (Kotter, 1988).

▶ Lewin’s Behavioral StudyOne of the earliest studies to examine the effect ofleadership behavior was performed in the 1930sunder the direction of Kurt Lewin, who is recognizedas the father of group dynamics. Lewin (1951) andhis colleagues observed the behavior of childrenunder different leadership styles used by the adultparticipants. The study involved 10-year-old boyswho were participating in an arts and craft club. Theboys were placed into groups that were matched onpersonal characteristics (e.g., IQ, popularity), and allgroups worked on the same project (producing thesame item). Each group was exposed to three typesof leadership styles:Authoritarian: The authoritarian leaderremained aloof and used orders (withoutconsultation) in directing the group’s activities.Democratic: The democratic leader offeredguidance and encouraged the children whileactively participating in the group’s activities.Laissez-Faire: The laissez-faire leader gave thechildren knowledge but did not direct theactivities; nor did this leader become involvedor participate in the group’s activities.

The researchers measured and recorded both theamount of work produced and the levels ofaggression displayed by the children. The resultsestablished that leadership style had clear impactson group productivity and on the behaviors andinterpersonal relationships among group members.Under the democratic leadership style, groupmorale was high, and relationships between thegroup members and leader were friendly. When thegroup leader was absent, the children continuedwith their work. The group’s work reflected levels oforiginality and quality. However, members of thegroup did not produce as many items as did thegroup under the authoritarian leader. Underauthoritarian leadership, the group displayed twotypes of behaviors: aggressive and apathetic. Theaggressive children were defiant and continuallywanted the leader’s attention. They blamed oneanother when anything went wrong within the group.Although the apathetic children placed fewerdemands on the leader, they displayed outbursts ofaggression when the leader was absent. Under thelaissez-faire leadership style, the children displayedlow levels of satisfaction and a low tendency orability to work independently. In addition, groupmembers displayed little cooperation. The groupproduced the least number of items, and the itemswere of low quality.

Overall, the democratic leadership style appeared tobe the most successful. However, some of thechildren reported that they preferred theauthoritarian style. Thus, this study not onlyprovided us with our initial examination of leadershipbehavior but also alerted us to the possibility thatfollowers may exhibit a preference for specificleadership styles. Gladding (1995) suggested thatdifferent types of groups prefer specific styles ofleadership. He contended that members’ preferencewould be based on the leadership style that theyperceived as right or natural according to theirpersonal socialization process.Comprehensive research projects conducted atOhio State University and the University of Michiganduring the 1940s focused further attention on theidentification of leader behaviors. Thesefoundational studies had a significant impact onfuture conceptualizations and the researchleadership theorists.

▶ Ohio State LeadershipStudiesThe focus of the researchers at Ohio StateUniversity in the late 1940s was on the identificationof independent dimensions of leadership behavior.The researchers developed an assessment tool, theLeader Behavior Description Questionnaire, whichwas used to discover how leaders carry out theiractivities. Leaders from the military, educational,manufacturing, and other sectors were included inthe research project. The researchers found thattwo dimensions of leadership were consistentamong the studied groups: consideration for peopleand initiating structure.The dimension of consideration for people wasfocused on the human side of the business and wasalso called relationship behavior. This dimensionrecognized that individuals have needs and requirerelationships. The initiating structure dimension putan importance on tasks and goals. These findingswere important to the study of organizationalbehavior and leadership by not only identifyingthese concepts but also recognizing that the twodimensions were independent. In other words,consideration for workers and initiating structure

existed simultaneously and to different degrees. Amatrix was created that showed the variouscombinations and quantities of the elements (seeFigure 10-1).Figure 10-1 Ohio State StudiesLeaders who ranked high on both dimensions weremore likely to influence the workforce to higherlevels of satisfaction and performance. A weaknessthat was noted in the Ohio State studies was thatsituational factors were absent from the research.Although a combination of the dimensions wasdeveloped, the effectiveness of each combination inrelation to workplace situations was not identified.Not all workplace situations require an emphasis oninitiating structure. For example, health care

professionals who are intrinsically motivated andhighly skilled might not require initiating structurefrom their manager.

▶ University of MichiganStudiesDuring the same period of time as the Ohio Statestudies, researchers at the University of Michiganwere conducting research in an attempt todetermine the most effective style of leadershipbased on two dimensions of leadership behavior: anemployee-centered focus or a production-centeredfocus. Employee-centered leaders emphasizedinterpersonal relations, took a personal interest inthe needs of their subordinates, and acceptedindividual differences among members. Production-centered leaders emphasized the technical aspectsof the job, focused on accomplishing the tasks, andsaw the members as a means to an end—that is,achievement of the tasks. The researchers foundthat general supervision (i.e., providing support anddirection without being authoritarian) created higherlevels of productivity than did production-centeredsupervision and that low-producing supervisorsplaced an emphasis on production, displaying littleconcern for their employees. Years of researchhave confirmed the University of Michigan studies(Luthans, 2002). A particular point of interest from

these studies is that productivity is not directlyrelated to employee satisfaction.Likert (1961) expanded on the Michigan studieswith extensive research into what differentiateseffective managers from ineffective managers.Likert related that job-centered managers werefound to be the least productive, while employee-centered managers were found to be the mosteffective. In addition, effective managers set specificgoals but gave employees freedom in the way theyachieved those goals (i.e., empowerment).Blake and Mouton’s Leadership GridDuring the 1960s, Blake and Mouton reexaminedthe two dimensions of leaders that were identified inthe Ohio State studies, that is, consideration forpeople and initiating structure. Their work developeda two-factor framework (Razik & Swanson, 1995,p. 53). The Leadership Grid (formerly referred to asthe Managerial Grid) is based upon the assertionthat one best leadership style exists. TheLeadership Grid provides the manager with aconceptual assessment as to what their currentleadership style is and, theoretically, provides anavenue of development in becoming an idealmanager.Although there is a possibility of being categorizedin one of 81 possible positions on the grid, we will

examine five positions to assist our understandingof the Leadership Grid. The Leadership Grid (seeFigure 10-2) identifies a vertical axis, on a scalefrom one to nine, describing a concern for people. Ahorizontal axis, also on a scale from one to nine,identifies a concern for production or results. Thefive notable positions are: impoverishedmanagement (1,1); authority-compliance (9,1);middle-of-the-road management (5,5); country clubmanagement (1,9); and team management (9,9).

Figure 10-2 Blake and Mouton’s Leadership GridLet us examine leadership characteristics in eachone of the five quadrants to better understand howthe grid functions. At the lower left position on thegrid (1,1), the impoverished manager (also referredto as laissez-faire type leader) exercises minimaleffort on getting the task accomplished, doing onlythe amount of work that is required to sustain theirposition within the organization. Additionally, theimpoverished manager is much more focused ontheir own well-being than on the subordinates theysupervise. This manager has a low concern forpeople and a low concern for production. Suchmanagers do just enough to get by, avoidingconflicts, having little social contact withsubordinates, and so on.The authority-compliance/task manager ispositioned at the lower right on the grid (9,1). Thismanager exhibits a true autocratic presence and isoften referred to as a dictator. The managerial focusin this quadrant is efficiency, with an ongoing effortto improve work processes to increase production.There is, at best, negligible concern for people.These managers consider staff to be a means ofproduction. The task manager is unconcerned bythe potential negative impact their leadership stylemight have on staff, such as conflict or stress.

Located directly in the middle of the grid, at the (5,5)position, is the middle-of-the-road manager. Thismanager appears to balance the concern for taskand the concern for people in an effort to boostmorale and satisfaction. On the surface, this mayseem to be a very effective approach tomanagement, but this balancing act is often difficultto sustain over time. One might consider the middle-of-the-road manager the perfect politician. Thesemanagers play both sides of the field, dependingupon situational factors. They will tell you exactlywhat they think you want to hear and then tellsomeone else exactly what they want to hear, evenif this contradicts what they told you. This is not tosuggest that the middle-of-the-road manageroperates exclusively on political alliances, but itshould be clear that under the best ofcircumstances, it is difficult to balance an equalconcern for people and an equal concern forproduction.At the upper left on the grid (1,9), we find thecountry club manager. This individual is mostconcerned with ensuring that employees’ needs aremet and that the work environment is comfortableand friendly. The lack of focus on productiondiminishes the overall capacity for employees tomeet or exceed organizational goals. This style ofmanagement will probably not lead to many

successful ventures based upon productionexpectations.The final quadrant is found in the upper right cornerof the grid (9,9). Blake and McCanse (1991)labeled this position team management (formerlythe ideal manager). As this label suggests, the teammanager develops a sense of purpose andaccomplishment in both concern for people andconcern for task. This is not a balancing act as wasdescribed for the middle-of-the-road manager; it is atheoretically perfect combination of concern forpeople and concern for task. Khan (2010, p. 12)relates that the ideal [team] manager “works tomotivate employees to reach their highest level ofaccomplishment. They believe in creating a situationwhereby people can satisfy their own needs bycommitment to the objectives of the organization.”One might ask, “What is the likelihood of scoring a9,9 on Blake and Mouton’s Leadership Grid?”Although possible, it is very unlikely. One shouldpresume that there is always room for improvement,thereby diminishing the possibility of attaining theelusive 9,9 score.Blake and McCanse added two more styles in 1991:the opportunistic management style and thepaternalistic management style. The opportunisticmanagement style refers to a manager who usesany combination of the five basic styles for personal

reward and advancement. The purpose of theopportunistic manager’s performance and effort is torealize personal gain.The paternalistic management style refers to amanager who uses both 1,9 and 9,1 styles but doesnot integrate the two. In other words, the personacts fatherly or motherly toward their subordinatesbut is the key decision maker, and this managerrewards loyalty but punishes noncompliance.The grid is a useful tool for identifying leadershipstyle, both perceived and real. Managers are oftensurprised at where they score on the grid. Scoresmay lead to self-reflection and increasedunderstanding of their management style, whichthen provides opportunities for increasingmanagerial effectiveness.

▶ ConclusionTrait and behavioral theories focused attention onthe individual. Were differences found? Yes. Werethe researchers able to produce a clear set of traitsor behaviors that can be used to definitelydistinguish leaders? No. Examining the findingsacross numerous studies, we uncover a lack ofconsistency and modest relationships. However, it isimportant not to diminish the importance of the earlyleadership research or of the contribution theseefforts made as traits and behaviors havereemerged in contemporary leadership theories andbehavioral competencies.The theoretical evolution of leadership has led us tothe next generation of research: contingencytheories. Some researchers suggest thequestionable reliability and disputed validity of earlyleadership research efforts may be attributed to theabsence of a single important dimension known asthe contingency factor. The term “contingency”refers to the leader’s contextual situation. “Effectiveleaders analyze the factors pertaining to thesituation, task, followers, and the organization, andthen choose the appropriate style” (Osland, Kolb, &Rubin, 2001, p. 290). The leadership and

management traits and behaviors that work in oneorganizational context might not be effective inanother. Factors both internal and external to theorganization change, and leaders and organizationsmust change in response, particularly in health care.Consider a few of the impetuses that aredramatically reforming the health care system, suchas the call for quality and performance in concertwith cutting costs and the economic, social,technological, and political environments in contextwith a newly emerging diverse workforce. All ofthese factors (and more) provide compellingreasons to incorporate the application ofcontingency leadership theory in attainingorganizational goals.

Discussion Questions 1. Is leadership synonymous with management,or is leading just one of the many things thata manager does? In what ways are they thesame or different? 2. Explain the findings of Lewin’s behavioralstudies on leadership styles and behaviors. 3. Discuss the contributions and theweaknesses of trait theory. 4. Discuss the results of the Ohio State studiesin terms of their significant impact onleadership research. 5. Explain the difference between the Universityof Michigan studies and the Ohio Statestudies. 6. Explain Blake and Mouton’s Leadership Gridin relationship to previous leadershipresearch.

CASE STUDY ANDEXERCISESCase Study 10-1 Leadership StyleA small group of nurses at a large communityhospital were unhappy about their workenvironment and met daily during lunch todiscuss the situation. A recent change in thehospital’s senior management was causing ahigh level of uncertainty and anxiety amongthe nursing staff. The nurses felt overworkedas a result of the industry’s current nursingshortage. Their wages and benefits had beenstagnant, with no salary market adjustmentsfor the past 2 years. The nurses saw thesituation as management requiring them to domore work with fewer resources and with noappreciation or recognition of their efforts.Whenever the nurses approachedmanagement about these matters, theyperceived their concerns as falling on deafears, since no changes were ever made.Feeling that they had no other choice, thenurses contacted a labor union. The laborunion began an organizing effort in the

hospital shortly thereafter, waging anaggressive campaign over a 6-week period.There was tremendous peer pressure, assome of the well-respected members of thenursing staff became active leaders forunionization, although they had not beenamong the initial group of nurses who hadcontacted the union. The election was held,and the union was voted in by two-thirds of thenursing staff. In the weeks that followed, theoriginal group of nurses remarked that theywere surprised by the union’s victory; they hadonly wanted to scare management intomaking changes to their workenvironment.Using Blake and Mouton’sLeadership Grid, explain the leadership styledisplayed by management to the nursing staff.

Exercise 10-1Write a description of an effective manager. Writewords that you would use to describe an effectiveleader. When you review your list, consider thedifferences and similarities in your adjectives. Howdid the review of the concepts in the chapterinfluence your word choices? Are you comfortabledistinguishing the roles? To what degree, if at all, doyou believe that a manager should also be a leaderor that a leader should also be a manager?

Exercise 10-2Think of some individuals who you believe to bereally exceptional leaders. What, if anything, do theyhave in common?Think of some individuals who you believe to betruly poor leaders. What, if anything, do they have incommon?Do your answers identify traits or behaviors? Whichdo you personally view as dominant in effectiveleadership: traits or behaviors?

Exercise 10-3Have you ever known people who were successfulleaders in one situation and failures in another?Why do you think this happened?

Exercise 10-4On a blank piece of paper, draw a picture of aleader. Once your picture is complete, answer thefollowing questions:What does this picture say about you?What does this picture say about what traitsyou associate with leadership?How might implicit biases be a part of yourconceptualization of a leader?

Exercise 10-5 LeadershipQuestionnaireObjective: To determine the degree that a personlikes working with tasks and other people. Time: 45MinutesInstructions1. Complete the 18 items in the Questionnairesection.2. Transfer your answers to the two respectivecolumns provided in the scoring section.Total the score in each column and multiplyeach total by 0.2. For example, in the firstcolumn (people), if you answer 5, 3, 4, 4, 3,2, 5, 4, 3, then your final score is 5 33 3 0.2 56.6.3. The total score for the first column (people) isplotted on the vertical axis in the matrixsection, and the total score for the secondcolumn (task) is plotted on the horizontalaxis. Intersect the lines to see whichleadership dimension you normally operateout of:Task manager (authoritarian)Impoverished manager

Ideal manager (team leader)Country club managerQuestionnaireBelow is a list of statements about leadershipbehavior. Read each one carefully, then, using thefollowing scale, decide the extent to which it actuallyapplies to you. For best results, answer as truthfullyas possible.Never Sometimes Always0 1 2 3 4 51. ____ I encourage my team to participatewhen it comes decision-making time and I tryto implement their ideas and suggestions.2. ____ Nothing is more important thanaccomplishing a goal or task.3. ____ I closely monitor the schedule to ensurea task or project will be completed in time.4. ____ I enjoy coaching people on new tasksand procedures.5. ____ The more challenging a task is, themore I enjoy it.6. ____ I encourage my employees to becreative about their job.

7. ____ When seeing a complex task through tocompletion, I ensure that every detail isaccounted for.8. ____ I find it easy to carry out severalcomplicated tasks at the same time.9. ____ I enjoy reading articles, books, andjournals about training, leadership, andpsychology; and then putting what I haveread into action.10. ____ When correcting mistakes, I do notworry about jeopardizing relationships.11. ____ I manage my time very efficiently.12. ____ I enjoy explaining the intricacies anddetails of a complex task or project to myemployees.13. ____ Breaking large projects into smallmanageable tasks is second nature to me.14. ____ Nothing is more important than buildinga great team.15. ____ I enjoy analyzing problems.16. ____ I honor other people’s boundaries17. ____ Counseling my employees to improvetheir performance or behavior is secondnature to me.18. ____ I enjoy reading articles, books, andtrade journals about my profession; and thenimplementing the new procedures I havelearned.

Scoring SectionAfter completing the questionnaire, transfer youranswers to the spaces below:PeopleTaskQuestionQuestion1.2.4.3.6.5.9.7.10.8.12.11.14.13.16.15.17.18.TotalTotal× 0.2 =× 0.2 =(Multiply the total by 0.2 to getyour final score)(Multiply the total by 0.2 to getyour final score)Matrix SectionPlot your final scores on the graph below [Figure10-3] by drawing a horizontal line from the peoplescore (vertical axis) to the right of the matrix, anddrawing a vertical line from the task score on the

horizontal axis to the top of the matrix. The area ofintersection is the leadership dimension that youoperate out of.Figure 10-3The ResultsThis chart will give you an idea of your leadershipstyle.However, like any other instrument that attempts toprofile a person, you have to take in other factors,such as how your manager and employees rate youas a leader, do you get your job done, do you takecare of your employees, or are you are helping to“grow” your organization.

You should review the statements in the survey andreflect on the low scores by asking yourself, “If Iscored higher in that area, would I be a moreeffective leader?” And if the answer is yes, then itshould become a personal action item.Available at http://www.nwlink.com/donclark/leader/matrix.html.Created January 27, 1998; last update October 20, 2013. Copyright1998 by Donald Clark. Reprinted with permission.

ReferencesBass, B. M. (1990). Bass & Stodgill’s handbook of leadership (3rded.). New York, NY: The Free Press.Blake, R. R., & McCanse, A. A. (1991). The leadership grid.Houston, TX: Gulf Publishing Co.Blake, R. R., & Mouton, J. S. (1964). The managerial grid.Houston, TX: Gulf Publishing Co.Dorfman, P., Javidan, M., Hanges, P., Dastmalchian, A., & House,R. (2012). GLOBE: A twenty year journey into the intriguingworld of culture and leadership. Journal of World Business,47(4), 504–518.Geier, J. G. (1967). A trait approach to the study of leadership insmall groups. Journal of Communications, 17(4), 316–323.Gladding, S. T. (1995). Groupwork: A counseling specialty.Englewood Cliffs, NJ: Prentice-Hall Inc.Hellriegel, D., Slocum, J. W., & Woodman, R. W. (1995).Organizational behavior. New York, NY: West PublishingCompany.Hernandez, S. R., O’Connor, S. J., & Meese, K. A. (2018). Globalefforts to professionalize the healthcare managementworkforce: The role of competencies. Journal of HealthAdministration Education, 35(2), 157–174.Khan, A. (2010). The dilemma of leadership styles andperformance appraisal: Counter strategies. Journal ofManagerial Sciences, 4(1), 1–30.

Kirkpatrick, A., & Locke, E. (1991). Leadership: Do traits matter.Academy of Management Executive, 5(2), 48–60.Kotter, J. (1988). The leadership factor. New York, NY: FreePress.Lewin, K. (1951). Field theory in the social sciences. New York,NY: Harper & Row.Likert, R. (1961). New patterns of management. New York, NY:Garland Science Publishing.Lussier, R., & Achua, C. (2012). Leadership: Theory, application,and skill development. 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 betweenpersonality and performance in small groups. PsychologicalBulletin, 66(4), 241–270.Osland, J., Kolb, D., & Rubin, I. (2001). Organizational behavior:An experiential approach (7th ed., p. 290). Upper SaddleRiver, NJ: Prentice Hall.Razik, T. A., & Swanson, A. D. (1995). Fundamental concepts ofeducational leadership and management (pp. 51–52). UpperSaddle River, NJ: Prentice Hall.Robbins, S. P. (2005). Organizational behavior (8th ed.). UpperSaddle River, NJ: Prentice Hall.Stogdill, R. M. (1948). Personal factors associated withleadership: A survey of 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 andattributes. In J. Antonakis, A. T. Cianciolo, & R. J. Sternberg(Eds.), The nature of leadership (pp. 101–123). ThousandOaks, CA: Sage Publications, Inc.

CHAPTER 11Contingency Theoriesand Situational Modelsof LeadershipLEARNING OUTCOMESAfter completing this chapter, the student shouldbe able to:Appreciate the contributions of contingencytheories in understanding leadership.Distinguish between the various contingencytheories.Apply the various contingency theories ofleadership to today’s work environments.

▶ OverviewLeadership is truly a complex concept involving amultitude of factors that extend beyond theindividual to include situational factors. Thesimplicity of examining leadership on the basis ofindividual traits and behaviors gives way to a morecomplex situation as we add the interrelationships ofleadership style, personal and professional values,one’s ability to control by means of influence,subordinate relationships, subordinate development,and the variability of other situational factors. Incontingency theories, the critical componentbecomes the characteristics of the situation ratherthan those of the individual. Analyzing contingentfactors and properly matching leadership style to thesituation can allow an individual, in the right context,to effectively move an organization toward itsstrategic goals by influencing other organizationalmembers to participate in the collaborative effort toachieve corporate success and economicsustainability.Understanding the development and application ofleadership theory prepares the health care managerto fulfill three explicit administrative responsibilities:predict, explain, and control. Successful leaders

must have the capability to predict how, when,where, and why things happen. Prediction permitsthe leader to enhance opportunities and diminishthreats, which constantly arise in the workplace. Theability to explain these occurrences instills a senseof confidence on the part of peers and subordinates,further augmenting the legitimacy of the manager’sability to lead in a variety of situations. Finally, aleader recognizes and accepts the role of control,whereby individuals are influenced to participate inthe achievement of strategic goals andorganizational sustainability.A contingency is an event that may occur but is notlikely or intended. It is a possibility that must beprepared for, and it is dependent on chance oruncertainty. As such, contingency leadership isabout possessing the knowledge, skills, and abilitiesto respond to a changing situation. Analyzing andresponding to the contingencies that influenceleader effectiveness may provide one with the abilityto succeed in an ever-changing health careenvironment. Health care leadership is aboutstepping up in times of uncertainty and movingforward to minimize potential threats and exploitopportunities to benefit the organization.In this chapter, we discuss the various contingencyleadership theories and their implications for theleader, the employee, and the health care

organization. To maximize your understanding ofthese theories, consider how they apply to you andyour work environment. Developing knowledge anda working application of contingency theories willenhance your ability to successfully accomplish yourmanagerial responsibilities to predict, explain, andcontrol.

▶ Fiedler’s ContingencyTheoryIn studies of the relationship between leadershipstyle and situation variables, Fiedler and hisassociates (1965, 1967, 1974) posit that individualshave dominant leadership characteristics that arewell established and generally inflexible. In Fiedler’stheory, leaders are characterized as either task-oriented (active, controlling, and structuring) orhuman relations–oriented (passive, permissive, andconsiderate). Fiedler believed that an individual’sleadership style was grounded and somewhatinflexible; therefore, leaders would improve theiroverall effectiveness by being placed in situationsthat best suited their orientation. Situations thatdisplay more variability and provide contingenciesare analyzed across three dimensions:Leader–Member Relations: The degree ofcertainty, trust, and deference between thesubordinate and the leader. This factoraddresses the manager’s perception of theircooperative relations with subordinates. Inother words, is the cooperation between themanager and subordinates good or poor?(Rating: good or poor.)

Task Structure: The extent to which jobassignments are clear through theimplementation of formalization and policy. Thisfactor relates to whether the work task is highlystructured, subject to standard procedures, andsubject to adequate measures of assessment.Certain tasks are easy to structure,standardize, and assess, such as the operationof an assembly line. (Rating: high or low.)Leader Position Power: The degree of controland influence the leader legitimately possessesin dealing with organizational activities. Thisfactor, which is highly dependent on the supportthe leader receives from senior management,asks whether the manager’s level of authority isbased on punishing or rewarding behavior. Forexample, does the manger derive authorityfrom providing bonuses profitability goals orterminating employees for failure to meet thegoals? (Rating: strong or weak.)A leader’s contribution to successful performance bytheir group is determined by the leader’s style (i.e.,task or relations) in conjunction with situationvariables (i.e., relationships, task structure, andpower position). Effective leaders seek or areplaced in situations that best match their leadershipstyle.

Fiedler’s research and the identification ofleadership styles were based on a questionnaireknown as the Least Preferred Coworker (LPC)Scale. Fiedler (1970) developed the LPC by askingthe participants to describe their most- and least-preferred coworkers. Each participant was asked tothink of all others with whom they had ever workedand then to describe the person with whom they hadworked best (i.e., most-preferred coworker) andthen the person with whom they had worked leastwell (i.e., least-preferred coworker [LPC]). From theitems identified, Fiedler created a scale thatcontains contrasting adjectives (such aspleasant/unpleasant, supportive/hostile,considerate/inconsiderate, andagreeable/disagreeable) to measure whether aperson was task-oriented or relations-oriented.Fiedler believed that the ratings individuals ascribedto their least-preferred coworker reflected moreabout themselves than about the person whom theyleast enjoyed working with. Thus, individuals whoscored the LPC in relatively positive terms werelabeled “relations-oriented,” while individuals whoscored the LPC in relatively unfavorable terms werelabeled “task-oriented.”In assessing the three situational dimensions(leader–member relations, task structure, andposition power), four levels of situational

favorableness can be determined. Figure 11-1identifies these four levels in a continuum ofsituational favorableness, from Very Unfavorable toUnfavorable and Favorable to Very Favorable.Fiedler’s research suggests that aligning theleadership style with the favorableness of thesituation determines the effectiveness of the leaderregarding a group’s performance. If the leader isgenerally accepted and trusted by subordinates(good leader–member relations), the tasks for whichindividuals are responsible are clear and fullyunderstood through formalization and direction (hightask structure), and the leader’s power is recognized(strong position of power), then the situation is veryfavorable. On the opposite side of the coin, if theleader lacks acceptance or trust by subordinates(poor leader–member relations), the tasks for whichindividuals are responsible are unclear and not fullyunderstood because of a lack of formalization andan absence of direction (low task structure), and theleader’s power is not recognized (weak positionpower), then the situation is very unfavorable. Ineither scenario, the leader with a task-orientedleadership style would be the most effective. Whenthe situation variables are determined to be mixed(i.e., moderately unfavorable or moderatelyfavorable), the human relations–oriented leadershipapproach would be most effective.

Figure 11-1 Fiedler’s Contingency TheoryIn a very unfavorable situation (i.e., leader–memberrelations are poor, there is low task structure, andthe leader has little position power), one canunderstand the importance of a task-orientedleadership approach. But why would a task-orientedleadership approach be best suited for a veryfavorable situation? In a very favorable situation, theleader–member relationship is good, the taskstructure is high, and the position power is strong.This combination provides an environment in whichindividuals are prepared to be guided and expect tobe told what to do. For example, Fiedler suggestsconsidering the captain of an airliner during its finallanding. We would hardly want the captain to turn tothe crew for a discussion on how to land the plane!Fiedler’s Contingency Theory made a tremendouscontribution toward contingency theories for threereasons. It was the first theory to systematically

account for situational factors (i.e., relationships,task structure, and position power). Second, thetheory considers the leader’s dominant orientation(i.e., a function of a leader’s needs and personality),not the leader’s behavior (Tosi & Mero, 2003). AsTosi and Mero (2003) point out, although thisorientation may affect the leader’s behavior, it is theleader’s orientation toward their group thatdetermines how effective the group will be. Third,because the leader’s orientation is relatively stable,it is not likely that a leader will change orientationswhen confronted with different situations, though theleader can change their behavior when necessaryand when the leader wants to (Tosi & Mero, 2003).Fiedler believed that it would be easier to changethe situation (i.e., work environment) to fit theleader’s style. However, organizational andsituational change may be difficult to achieve or mayoccur very slowly. Therefore, an organization shouldnot choose a leader who fits a situation but shouldchange the situation to suit the style of its leader,since the leader’s personality is not likely to change(Fiedler, 1970) (see Case Study 11-1). Thisconcept is a major criticism of Fiedler’s theory,because it is difficult to enact in reality.CASE STUDY 11-1 The NewChief Safety and Compliance

Officer PositionBen Allrod, chief executive officer of a 300-bed community hospital located in Midwestsuburbia, received a call from the hospital’sdirector of nursing, Paul Muir, to ask whetherthey could meet immediately to discuss aproblem. It was unlike Paul to make such arequest, so Ben agreed to meet immediately.When Paul arrived, Ben could see that he wasdistressed. His face was pale and heappeared nervous. Ben asked, “What’s up?”Paul related, “A few hours ago a patientreceived the wrong blood type during atransfusion. The nurse realized somethingwas wrong when the woman began reactingadversely to the transfusion. Although thistype of mistake is not automatically fatal, thepatient died a few minutes ago. However, wecannot be certain that the wrong blood typewas the cause of her death because 60% ofpeople who receive the wrong blood typewould not exhibit any symptoms of theproblem. The patient may have expiredbecause of other reasons. She was very sickwith multiple diagnoses.” Paul reminded Benthat, in addition to the family, the state’s

Medical Error Oversight Board would need tobe notified of this medical error.Ben was shocked to hear this news,considering that 2 months ago the hospitalhad had to report to the state’s Medical ErrorOversight Board that a metal clamp had beenleft inside a patient after surgery because thesurgeon forgot to order a postsurgical X-ray.Fortunately, the patient was not injured. Atthat time, the hospital’s chief operating officer,Harry Benson, stated that new procedureswould be implemented, so the problem shouldnot happen again.Ben thanked Paul for the information,instructed him to notify the state’s MedicalError Oversight Board, and said that he, Ben,would personally meet with the family toexpress his sympathy for the loss of theirloved one and inform them that “we” will belooking into the matter.After Paul left, Ben knew that he had to dosomething immediately. Although HarryBenson had been responsible for developingand implementing all the necessary policiesand procedures to prevent medical errors, hewas not doing enough, and things were goingto have to change—now! He would deal with

Harry later. His first priority was creating anew position: Chief Safety and ComplianceOfficer. This new position would report directlyto Ben and would have full authority to dowhatever was needed to ensure that nofurther problems of this kind would occur. Benimmediately drafted the job description.The selected candidate will play akey role in the development of theorganization’s compliance culturewith a focus on prevention. Thisposition will be responsible fordeveloping, implementing, andcommunicating the organization’scompliance and safety standards,policies, and procedures. Theposition will oversee the design,organization, and implementationof systemwide complianceeducation and training programs.The position is responsible formonitoring and evaluatingcompliance activities to ensureprogram goals are being metacross all functional areas. Theposition is responsible forestablishing and participating ininternal disciplinary actions forcompliance violations.

The candidate must have an MHAor related degree and 10 years ofexperience in the safety andcompliance area, including 7 yearsin the health care industry and 5years in a managerial role. Theposition offers a competitivecompensation package withexcellent benefits.Using Fiedler’s Contingency Theory, analyzethe situational factors and determine whattype of individual would be the most effectivefor Ben Allrod to hire. Could he changesituational factors instead of hiring a newleader? If so, what changes would yourecommend?In further work, Fiedler and colleagues introducedother variables into the original Contingency Theory(Fiedler, 1995; Fielder & Garcia, 1987; Fiedler,Potter, Zais, & Knowlton, 1979). Fiedler (1996)suggests that when leaders are under stress, theirintelligence and experience tend to interfere witheach other, diminishing the leader’s ability to thinkrationally, logically, and analytically. Fiedler andGarcia (1987) refer to this reconceptualization ascognitive resource theory.

This theory describes how group performance is aconstruct of a complex interaction between (1) twoleader traits—intelligence and experience, (2) onetype of leader behavior—directive leadership, and(3) two aspects of the leadership situation—interpersonal stress and the nature of the task(Yukl, 1998, p. 286). In other words, cognitiveresource theory states that (1) a leader’s intellectualabilities correlate positively with performance underlow stress but negatively under high stress and (2) aleader’s experience correlates negatively withperformance under low stress but positively underhigh stress (Fiedler, 2008, p. 99). For example,leaders under stress will fall back on their previouslylearned knowledge and behavior (e.g., relying onintuition and hunches); therefore, the greater therange of their experience, the better theirperformance will be. Under low-stress conditions,more experienced leaders are not challenged andtend to get bored and cut corners (Fiedler, 1996).

▶ House’s Path–GoalLeadership TheoryPath–Goal Leadership Theory was introduced byEvans (1970) and further developed by House(1971). House (1971) suggests that effectiveleaders provide the path, the support, and resourcesto assist subordinates in attaining organizationalgoals. This theory combines elements of the OhioState studies (i.e., consideration and initiatingstructure) with expectancy theory of motivation.Four separate but fully integrated components makeup House’s Path–Goal Leadership Theory:Leadership Behaviors, Environmental ContingencyFactors, Subordinate Contingency Factors, andOutcomes (see Figure 11-2). The first component,Leadership Behavior, identifies four specificleadership styles:

Figure 11-2 House’s Path–Goal Leadership TheoryReproduced from Robbins, S. P. (2003). Organizational behavior(10th ed., p. 326). Upper Saddle River, NJ: Prentice Hall.1. The directive leader provides employees witha detailed understanding of expectations, aplan to accomplish those expectations, andthe resources to achieve the tasks. Thedirective leadership style can increaseemployees’ motivation and satisfaction whererole ambiguity exists.2. The supportive leader shows concern forpeople, ensuring that the work environmentdoes not impede specific tasks that leadtoward organizational goals, and creates a

supportive atmosphere. The supportiveleadership style may increase employeemotivation and satisfaction where tasks areroutine or stressful.3. The participative leader seeks input from amultiplicity of internal sources, including thetechnical core of employees, to assist in thedecision-making process. The participativeleader maintains responsibility for the finaldecision but includes the workforce in theprocess, ultimately enhancing buy-in fromaffected parties. The participative leadershipstyle can improve motivation and satisfactionin environments that are uncertain or in theprocess of change.4. The achievement-oriented leader establishesstimulating goals and expects high levels ofperformance in achievement of the statedgoals. The achievement-oriented style ofleadership creates an environment of trust, inwhich the leader acknowledges theworkforce’s abilities to accomplishorganizational goals.Whereas Fiedler proposed that leadership styleswere grounded and inflexible, House proposed thatleadership styles are adaptable and that managersmay be called on to utilize any one of the fouridentified styles of leadership, depending on the

situation (Razik & Swanson, 1995; Robbins,2005).Leadership style depends on two contingencyfactors: environmental and subordinate. Houseconsidered external dynamics, which are referred toas environmental contingency factors. These factorsinclude (1) clarity of the task to be performed, (2)hierarchical authority systems, and (3) groupdynamics (i.e., workgroup members’ relationships).These factors are generally considered to beoutside the control and influence of the worker andthe manager. The second set of contingencyfactors, considered internal dynamics, are referredto as subordinate contingency factors. These factorsinclude the employee’s locus of control; knowledge,skills, and abilities (real or perceived); andexperience. Subordinate contingency factors arecharacteristics exhibited by the employees(Robbins, 2005).The integration of leadership style, environmentalcontingency factors, and subordinate contingencyfactors leads to outcomes (performance andsatisfaction). According to House and Mitchell(1974), a leader’s role is to influence subordinates’perceptions and motivate them toward achieving thedesired outcomes. To be effective, managersshould do the following:

1. Increase personal payoffs to subordinates forwork goal attainment,2. Provide coaching and direction whenneeded.3. Clarify expectations of workers.4. Reduce frustrating barriers.5. Increase opportunities for personalsatisfaction contingent on effectiveperformance.The appropriate leadership style that a managershould use is the one that compensates for anyquality that the employee lacks (e.g., experience,ability) or the work setting (i.e., task structure). Theleadership style should not duplicate what is alreadyavailable to the employee. For example, the nursemanager should not provide direction (i.e., directiveleadership style) on how to complete a patient’shistory and physical to a nurse who has 20 years ofexperience. However, the nurse manager shouldprovide direction and/or training when a nurse with20 years of clinical experience but little or noexperience with technology must use an electronicmedical records system for the first time todocument a patient’s history and physical.

▶ Tannenbaum andSchmidt’s Continuum ofLeadership BehaviorTannenbaum and Schmidt (1958, 1973)conducted one of the first studies that indicated aneed for leaders to evaluate the situational factorsbefore implementing a particular leadership style(Ott, 1996). The Continuum of Leadership Behaviormodel is based on the variety of behaviors noted inearlier leadership studies, particularly the distinctionof task versus human relations orientation. Thismodel identifies two styles of leadership, whichoccur across a continuum from boss-centered (task)through subordinate-centered (relationship).As Figure 11-3 illustrates, the Tannenbaum andSchmidt (1958) model covers a range of leadershipbehaviors. The model identifies the amount ofauthority (boss-centered) used by the manager andthe amount of freedom afforded to employees(subordinate-centered). At one end of the continuum(boss-centered), the manager takes completecontrol of the situation, makes a decision, andannounces it to the employees. There is no effort tosolicit feedback, ideas, or input. At the other end ofthe continuum (subordinate-centered), the manager

and employees collaboratively make decisionswithin clearly defined organizational constraints.Within the two extremes of the continuum lie amultitude of managerial options to either include orexclude employee involvement in decision-makingprocesses. The appropriateness of the behaviordepends on situational (contingent) factors.Figure 11-3 Tannenbaum and Schmidt Continuum of LeadershipBehavior

Reproduced from Tannenbaum, R., & Schmidt, W. H. (1958,March–April). How to Choose a Leadership Pattern. HarvardBusiness Review (p. 96). Used with Permission.How do managers determine where on thecontinuum they should position themselves?Determinants may include (1) the manager’s style ofleadership, (2) the culture of the organization, (3)the complexity of the task at hand, or (4) therelationship between the manager and theemployee, specifically the level of confidence themanager has in the employee and the manager’slevel of comfort in delegating a task or seekingparticipation in the decision-making process.Another important situational factor is theemployee’s level of acceptance of this participationand acknowledgment of responsibility for delegatedtasks. When an employee conveys a desire toparticipate, the subordinate-centered leadership isappropriate. Conversely, when an employee avoidsinvolvement beyond what is minimally expected, theboss-centered leadership style would be the moresuitable approach.One approach is not universally preferred over theother. Situational factors will determine which isappropriate. Today’s health care managers arefaced with an onslaught of ongoing critical decisionsfor which they are accountable and responsible.

With this in mind, it is imperative that managersfunction effectively at each place on the leadershipcontinuum. Attempts to maintain a subordinate-centered position on the continuum will not meet theneeds of the organization when a manager mustmake a decision that requires information thatemployees might not possess or when the situationis so critical that there is no time to collaborate withemployees.Given appropriate time to seek involvement in adecision, the subordinate-centered approach ispreferred for obvious reasons. Employees who arepermitted to participate in the decision-makingprocess tend to be less threatened by theimpending change because they feel that they arepart of the solution rather than being observers whohave no control over what may or may not happen.Unnecessary exclusion from a participatory effortcan create an environment of distrust, fear,hopelessness, and anger. A manager’s decision asto where on Tannenbaum and Schmidt’s continuumthey should be positioned is critical to both the taskand how the manager is perceived by the peoplewho are affected by the positioning.

▶ Hersey and Blanchard’sSituational LeadershipModelThe work of Hersey and Blanchard (1988)suggests that leaders should adapt their leadershipstyle along three dimensions (1) task behavior, (2)relationship behavior, and (3) level of maturity of thesubordinate. Task behavior refers to a leader’s cleardefinition of work roles and responsibilities whileensuring task clarity. Relationship behavior refers tothe development of personal relationships as well asemotional and psychological contracts between theleader and the subordinates. These two dimensions,task behavior and relationship behavior, are shapedby the final dimension: the level of maturity of thesubordinate, which is characterized by three specificcriteria:1. The level of motivation exhibited by thesubordinate.2. The willingness of the subordinate to assumeresponsibility.3. The experience and educational level of thesubordinate.

According to Hersey and Blanchard’s SituationalLeadership Model (see Figure 11-4), as theemployee cultivates the knowledge, skills, andabilities to perform at increasing levels ofexpectations, the manager modifies their leadershipstyle. As the subordinate passes through differentstages of commitment and competence, the leadervaries the amount of direction and support given.The leader plays various roles of directing,coaching, supporting, and delegating as thesubordinate’s level of maturity increases and theemployee becomes able to perform more activities.The varying amounts of direction and support givenare conceptualized into four leadership styles:Telling, Selling, Participating, and Delegating.

Figure 11-4 Hersey and Blanchard’s Situational Leadership ModelReproduced from Luthans, F. (2002). Organizational behavior (9thed., p. 616). Boston, MA: McGraw-Hill.Telling: The Situational Leadership Modelidentified that when the subordinate’s level ofmaturity is very low, a high-task, low-relationship style of leadership is mosteffective. For example, this situation occurswhen an employee is new to an organization,attempting to learn task expectations whileassimilating into a new culture. The employeeseeks direction by being told what to do; hence,the effective leader uses a telling style ofleadership.Selling: As the new employee developsknowledge, skills, and abilities, therebyincreasing their level of performance, the leadercan incorporate a selling style of leadership.This method of leadership (high-task, high-relationship) is effective when the employeebecomes increasingly confident and is willing toaccept additional responsibilities. The leader nolonger merely directs the employee as to whatmust be done but makes the effort to tell theemployee what to do and how their rolecontributes to achieving departmentalobjectives and organizational goals. It is

important that the leader recognize theimportance of both the task behavior and therelationship behavior at this stage of maturitydevelopment.Participative: As the employee’s maturity levelcontinues to rise, the leader is required to placeless of an emphasis on the task but continuesto advance the relationship (low-task, high-relationship). At this level of maturity, theemployee has demonstrated the ability toperform to organizational expectations withminimal managerial influence, allowing theleader to function most effectively using aparticipative style of leadership. In this stage ofthe model, the leader seeks input from thesubordinate in areas concerning processes,tasks, and productivity concerns. The leaderstill makes the decision and ensurescompliance, but the employee participates inthe decision-making process through anexchange of information between the leaderand the employee.Delegating: When the employee has fullydeveloped, exhibiting an unquestionable abilityto perform expected tasks, the subordinate’smaturity level is very high (low-task, low-relationship), creating an environment that isconducive to a delegating style of leadership.

At this point in the model, the leader modifiestheir own behavior to a level at which the leaderis comfortable not only delegating, but alsoallowing the employee to identify innovativeways to accomplish the task.Other empirical leadership studies research havenot fully supported the Situational LeadershipModel. Critics question the coherence of the resultsof the model, in which a questionnaire identifies 12situations that are supposed to represent levels ofsubordinate maturity, and the premise thatmanagers have only one of four styles of leadership.Hersey and Blanchard admit that the model may beoversimplified, yet one can clearly apply the modelin a practical workplace environment (Luthans,2002).

▶ Leader–Member ExchangeTheoryWhereas the contingency theories discussed thusfar relate leadership style to general situational andsubordinate factors across a group of employees,Leader–Member Exchange Theory (LMX) directs usto the differentiated relationships that arise betweenindividual subordinates and their supervisors.The foundation for LMX comes from the work ofGeorge Graen and James Cashman (1975), whocoined the phrase Vertical Dyad Linkage (VDL) todescribe how leaders develop dyadic (two-person)relationships with subordinates that affect thebehavior of both the leader and the subordinate.Over time and through a process of role-taking, role-making, and routinization (see Exhibit 11-1), theleader cognitively assigns subordinates to an in-group or an out-group. Individuals who are assignedto the in-group are perceived by the leader as beingmore committed to organizational goals and morelikely to fulfill responsibilities with higher levels ofperformance. The in-group is “rewarded with moreof the leaders’ positional resources (i.e., information,confidence, and concern) than individuals assignedto the out-group” (Luthans, 2002, p. 583). For

example, a group of early careerists are enrolled inthe hospital’s management development program,in which they must interact with the vice president ofhuman resources, the facilitator of the program. Theyoung careerists who are considered to be in the in-group may have a higher number of interactionswith the vice president than do young careeristswho are considered to be in the out-group. Forinstance, if Valerie’s personality is similar to the vicepresident’s personality, then the vice president mayspend extra time meeting with and coaching Valerieregarding her career development. This high level ofinteraction will increase the likelihood that Valeriewill be in the vice president’s in-group and thatValerie and the vice president will develop a high-quality relationship. Additionally, Valerie may begiven special projects during the developmentprogram that will further enhance her careeropportunities within the hospital because she is inthe vice president’s in-group. Bob, another of theyoung professionals, may have relatively littleinteraction with the vice president outside of theprogram’s scheduled training time because the vicepresident dislikes Bob’s communication style.Therefore, Bob would be in the vice president’s out-group, and Bob and the vice president would have alow-quality relationship.

Exhibit 11-1 The Three Phases of LMXThe Leader–Member Exchange Theory statesthat all relationships between leaders andsubordinates go through three stages. Theseare:1. Role-Taking.2. Role-Making.3. Routinization.1. Role-TakingRole-taking occurs when team members firstjoin the group. Leaders use this time to assessnew members’ skills and abilities.2. Role-MakingNew team members then begin to work onprojects and tasks as part of the team. In thisstage, leaders generally expect that new teammembers will work hard, be loyal and provetrustworthy as they get used to their new role.The theory says that, during this stage, leaderssort new team members (often subconsciously)into one of two groups.In-Group—if team members provethemselves loyal, trustworthy andskilled, they’re put into the In-Group.

This group is made up of the teammembers that the leader trusts the most.Leaders give this group most of theirattention, providing challenging andinteresting work, and offeringopportunities for additional training andadvancement. This group also getsmore one-to-one time with the leader.Often, people in this group have asimilar personality and work-ethic to theirleader.Out-Group—if team members betraythe trust of the leader, or prove thatthey’re unmotivated or incompetent,they’re put into the Out-Group. Thisgroup’s work is often restricted andunchallenging. Out-Group memberstend to have less access to the leader,and often don’t receive opportunities forgrowth or advancement.3. RoutinizationDuring this last phase, routines between teammembers and their leaders are established.In-Group team members work hard to maintainthe good opinion of their leaders, by showingtrust, respect, empathy, patience, andpersistence.

Out-Group members may start to dislike ordistrust their leaders. Because it’s so hard tomove out of the Out-Group once the perceptionhas been established, Out-Group membersmay have to change departments ororganizations in order to “start over.”Once team members have been classified,even subconsciously, as In-Group or Out-Group, that classification affects how theirleaders relate to them from then on, and it canbecome self-fulfilling.For instance, In-Group team members areoften seen as rising stars and the leader truststhem to work and perform at a high level. Thisis also the group that the leader talks to most,offering support and advice, and they’re giventhe best opportunities to test their skills andgrow. So, of course, they’re more likely todevelop in their roles.This also holds true for the Out-Group. Theleader spends little, if any, time trying tosupport and develop this group. They receivefew challenging assignments or opportunitiesfor training and advancement. And, becausethey’re never tested, they have little chance tochange the leader’s opinion.

Mind Tools.com, Available at:http://www.mindtools.com/pages/article/leader-member-exchange.htm Reprinted with permissionNot surprisingly, in-group members report fewerproblematic issues with leader–member interactionsand higher levels of responsiveness with the leaderthan do members of the out-group. Additionally, in-groups are more often led with less emphasis onformal authority to control and influence, while out-groups are more often supervised with a muchstronger emphasis on formal authority to control andinfluence. The mere nature of the high quality of theleader–member relationship that occurs with the in-group generates individuals who accept greaterresponsibility and exhibit higher levels ofcontribution to organizational goals (Graen &Ginsburgh, 1977; Liden & Graen, 1980).The Leader–Member Exchange (LMX) theory takesVDL one step further. LMX examines thecharacteristics of individuals who belong to the in-group, noting similarities that exist between in-groupmembers and the leader in the dyadic relationship.Individuals with high self-efficacy will tend to form in-group relationships with the leader. In this dyadicrelationship, the leader perceives the follower to bemore friendly, approachable, and similar inpersonality to the leader themselves. The

perception of similarity becomes a very importantfactor for inclusion in the in-group and the resultantdevelopment of relationships and contributions totask accomplishment. However, this can have theeffect of leaders developing and promoting peoplewithin the organization who look and think likethemselves. This may lead to reduced diversity ofmanagers and leaders within the organization,which can lead to groupthink and discrimination.Leaders must be aware of their own internal biaseswhen investing time and resources in developingtheir employees. Are only employees who look, actand think like the leader getting fair opportunities?According to Robbins (2005, p. 163), “Studiesconfirm many of the LMX predictions that leaders dodifferentiate among followers and those with in-group status have higher performance ratings, lowerturnover intentions, and higher satisfaction withsuperiors than those in the out-group.”

▶ ConclusionContingency theories provide us with theunderstanding that one leadership style is noteffective across all the variable situations that existin organizations. The leader who is able to respondto ever-increasing levels of environmentaluncertainty through the utilization of more than onestyle of leadership will be most likely to increaseemployees’ levels of motivation, satisfaction, andproductivity. Managers should not underestimatethe importance of the interrelationship of applyingthe appropriate leadership style based on theaccurate analysis of situational factors.

Discussion Questions 1. Describe Fielder’s Contingency Model. Whatis the impact of his assumption thatleadership style is fixed? 2. Summarize Path–Goal Leadership Theory.What theories of motivation can you tie to theassumptions of the model? 3. Identify health care situations in whichTannenbaum and Schmidt’s Continuum ofLeadership Behavior would suggest theautocratic leadership style as the mostappropriate. 4. Discuss the role of leadership style inresponse to employee maturity(development) as presented in the work ofHersey and Blanchard. 5. What impact does the assignment ofemployees to the in-group or out-group(LMX) have on workers’ performance andsatisfaction? 6. Apply the contingency theories discussed inthis chapter as they relate to your workenvironment to assess the appropriate styleof leadership and the implications formotivation, satisfaction, and productivity.

Exercise 11-1Write a brief description of a personal experience aseither the leader or follower 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 answeringthe following questions:1. Did it work?2. Could a different style have worked better?3. Which style do you prefer your supervisor touse with you?4. Which style are you most comfortable usingyourself? Why?Form a group of three or four individuals, and shareand discuss your questions with your group.CASE STUDY 11-2 What CanJoe Do About Betty?Just before quitting time, Joe, the hospital’shealth information department manager,watched his three new trainees struggling withthe complicated electronic medical records

software they had to learn to use to do theirjobs. Across the room, Betty, who was anexpert with the software, was preparing toleave for the day, her tasks done ahead oftime as usual. Also as usual, she gathered upher belongings and left without saying good-bye to any of her coworkers. “There goes theanswer to my problem,” thought Joe. “If only Iknew how to reach her.” With her expertiseand experience in using the system, Bettywould seem to be an ideal coach for the newemployees. However, she had asked not totake on training duties when Joe had askedher. Her reasons were that she wasn’tcomfortable telling anyone else what to do,didn’t want the responsibility for someoneelse’s work, and preferred to work by herselfat her own job.Joe was stunned by her refusal. He enjoyedhelping his coworkers and thought that it waswhy he had advanced to department managerlast year instead of Betty, who had moreseniority and experience with the companythan he did. Since her work was excellent, Joehesitated to make it an “either you do what Iwant or you’re in trouble” situation; hebelieved that employees worked best at whatthey wanted to work at. But his problem still

remained: There was no money in the trainingbudget, and there were no other employeesas skilled with the system as Betty was. Wasthere an approach he hadn’t thought of that hecould use to convince her to help?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 onepromoted to department manager last year,not him. I’m the one with seniority and thenecessary experience. In fact, I was the onewho trained Joe when he first joined thehospital! Just because he has a master’s inhealth information management and I shouldnot have been the determining factor, butobviously senior management thought sowhen they selected him over me. I could careless what happens from this point forward. Ionly have 5 more years until I can retire withmy full pension. As long as my work continuesto be excellent there is no way Joe can upsetmy plans. Not that he could, since he hardlyunderstands the complexity of the software weuse. It requires a person with a lot oftechnology knowledge and experience.”Using Fiedler’s Contingency Theory, explainwhat style of leadership Joe should use with

Betty, given the current situation in hisdepartment (Case Study 11-2).CASE STUDY 11-3 A NewEmployee Scheduling SystemYou are the director of human resources ofBaptist Health System, an integrated networkof nonprofit hospitals, physician clinics, andhome medical services with over 4000employees. You plan to implement a newsoftware application to upgrade and automateemployee-related scheduling. You estimatethat replacing the organization’s antiquatedsystem and automating this labor-intensive,time-consuming task will save the healthsystem thousands of dollars each year. Frankis an employee in the organization’s Office ofTechnology (OT) who has the skill set youneed. However, Frank does not report to you,and you know that the OT is understaffed andoverworked. You have permission fromFrank’s boss, Jane, to use some of his timebut only if it does not interfere with his regularduties.Scenario OneOn obtaining Jane’s permission, you send

Frank an email stating, “I need you to assiststaff in my department with theimplementation of a new software applicationto upgrade and automate the organization’semployee-relateaccad scheduling. This needsto be completed within 2 weeks. My assistantwill contact you tomorrow to discuss thespecific details of this project so you can startimmediately.”Scenario TwoYou schedule a meeting with Frank for thenext day to discuss your situation. “Frank, Iwant to talk to you about this project I amworking on because I understand that youhave experience with database conversions,and Jane told me that you were the bestperson to talk to about this subject. Thisproject is very important to the organizationbecause, like most health care organizations,we are facing ongoing challenges of labor costcontrol and maintaining the appropriate stafflevels necessary to maintain high levels ofpatient care. Baptist has been using anantiquated application to manage staffing andscheduling for several years. The software isoutdated and no longer fulfills the needs of theorganization. We need a new employeescheduling system that is flexible and scalable

enough to accommodate continuedorganizational growth. Let me tell you what I’mtrying to accomplish in the next 30 days. Thesystem has to integrate with our existing timeand attendance system so that informationcan be shared between our facilities. We alsowant to get a handle on our data in real time,not 14 days after the pay period. Additionally,The Joint Commission has high levels oftracking and reporting, so the organization hasto find a way to deal with these reportingexpectations. Frank, how can you help usreach our goal?”Using Hersey and Blanchard’s SituationalLeadership Model, discuss how Frank willreact in each of these scenarios. Why?Exhibit 11-2 Leadership Style SurveyDirectionsThis questionnaire contains statements aboutleadership style beliefs. Next to eachstatement, circle the number that representshow strongly you feel about the statement byusing the following scoring system:Almost Always True: 5Frequently True: 4

Occasionally True: 3Seldom True: 2Almost Never True: 1Be honest about your choices, as there are noright or wrong answers—this is only for self-assessment.Leadership Style Survey

On the fill-in lines, mark the score of each itemon the questionnaire. For example, if youscored item one with a 3 (Occasionally), thenenter a 3 next to Item 1. When you haveentered all the scores for each question, totaleach of the three columns.

This questionnaire is to help you assess whatleadership style you normally use. The lowestscore possible for a leadership style is 10(Almost never), while the highest scorepossible for a stage is 50 (Almost always).The highest of the three scores indicates whatstyle of leadership you normally use. If yourhighest score is 40 or more, it is a strongindicator of your normal style. The lowest of thethree scores is an indicator of the style you useleast. If your lowest score is 20 or less, it is astrong indicator that you normally do not usethis leadership style.

If two of the scores are close to the same, youmight be going through a transition phase,either personally or at work, except:If you score high in both the participative andthe delegative, then you are probably adelegative leader.If there is only a small difference between thethree scores, then this indicates that you haveno clear perception of the leadership style youuse, or you are a new leader and are trying tofeel out the correct style for you.Available at: www.nwlink.com/~donclark/leader/survstyl.html.Created July 15, 1998; last update August 21, 2010. © Donald Clark.Reprinted with permission.

ReferencesEvans, M. G. (1970). The effects of supervisory behavior on thepath-goal relationship. Organizational Behavior and HumanPerformance, 5, 277–298.Fiedler, F. E. (1965). Engineer the job to fit the manager. HarvardBusiness Review, 43, 115–122.Fiedler, F. E. (1967). A theory of leadership effectiveness. NewYork, NY: McGraw-Hill Book Company.Fiedler, F. E. (1970). The contingency model: A theory ofleadership effectiveness. In C. W. Backman & P. F. Secord(Eds.), Problems in social psychology (pp. 279–289). NewYork, NY: McGraw-Hill Book Company.Fiedler, F. E. (1995). Cognitive resources and leadershipperformance. Applied Psychology—An International Review,44, 5–28.Fiedler, F. E. (1996). Research on leadership selection andtraining: One view of the future. Administrative ScienceQuarterly, 41(2), 241–250.Fiedler, F. E. (2008). The curious role of cognitive resources inleadership. In R. E. Riggo, S. E. Murphy, & F. J. Pirozzolo(Eds.), Multiple intelligences and leadership. Mahwah, NJ:Lawrence Erlbaum Associates.Fiedler, F. E., & Chemers, M. M. (1974). Leadership and effectivemanagement. Glenview, IL: Scott Foresman.

Fiedler, F. E., & Garcia, J. E. (1987). New approaches to effectiveleadership: Cognitive resources and organizationalperformance. New York, NY: John Wiley & Sons.Fiedler, F. E., Potter, E. H., Zais, M. M., & Knowlton, W. (1979).Organizational stress and the use and misuse of managerialintelligence and experience. Journal of Applied Psychology,64, 635–674.Graen, G., & Cashman, J. F. (1975). A role-making model ofleadership in formal organizations: A development approach.Organization and Administrative Sciences, 6, 143–165.Graen, G., & Ginsburgh, S. (1977). Job resignation as a functionof role orientation and leader acceptance: A longitudinalinvestigation of organizational assimilation. OrganizationalBehavior and Human Performance, 19, 1–17.Hersey, P., & Blanchard, K. H. (1988). Management oforganizational behavior. Upper Saddle River, NJ: PrenticeHall.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 ofleadership. Journal of Contemporary Business, 3(4), 81–97.Liden, R. C., & Graen, G. (1980). Generalizability of the verticaldyad linkage model of leadership. Academy of ManagementJournal, 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 (2nded., p. 168). Albany, NY: Wadsworth Publishing Company.

Razik, T. A., & Swanson, A. D. (1995). Fundamental concepts ofeducational leadership and management. Upper Saddle River,NJ: Prentice Hall.Robbins, S. P. (2005). Organizational behavior (8th ed.). UpperSaddle River, NJ: Prentice Hall.Tannenbaum, R., & Schmidt, W. (1958). How to choose aleadership pattern. Harvard Business Review, 36(2), 95–101.Tannenbaum, R., & Schmidt, W. (1973). How to choose aleadership pattern. Harvard Business Review, 51(3), 1–10.Tosi, H. L., & Mero, N. P. (2003). The fundamentals oforganizational behavior: What managers need to know (p.254). Malden, MA: Blackwell Publishing.Yukl, G. (1998). Leadership in organizations (4th ed.). EnglewoodCliffs, NJ: Prentice-Hall.

CHAPTER 12ContemporaryLeadership TheoriesLeaders would sooner sacrifice what is theirs to savewhat is ours.And they would never sacrifice what is ours to savewhat is theirs.This is what it means to be a leader.It means they choose to go first into danger, headfirsttoward the unknown.And when we feel sure they will keep us safe,We will march behind them and work tirelessly to seetheir visions come to life and proudly call ourselvestheir followers.—Simon Sinek, Leaders Eat LastLEARNING OUTCOMESAfter completing this chapter, the student shouldbe able to:

Define transformational leadership.Identify the similarities and differencesbetween transformational and transactionalleadership approaches.Discuss the appropriate application oftransformational leadership style in thecontemporary work environment.Examine transformational leadership in thehealth management setting.Define charismatic, servant, and collaborativeleadership.Identify characteristics common tocharismatic, servant, and collaborativeleaders.Describe the effect of charismatic, servant,and collaborative leadership on organizationaloutcomes and the attainment of strategicorganizational goals.Discuss the development of behavioralcompetencies for health care leaders.

▶ OverviewIn this chapter, we examine various contemporaryleadership theories, including transformational,charismatic, servant, and collaborative leadershipapproaches. These theories build on both individualtrait and behavior theories as well as contingenciestheories of leadership. When one first attempts toexamine leadership, the focus is typically on anindividual who has sufficient sources of power toexert influence and control over members of theorganization in the effort to achieve organizationalgoals. The flaw in using this approach is the narrowfocus on the individual. A more appropriateassessment of leadership includes thecharacteristics of the leader as well as subordinates,peers, supervisors, and the organization itself. Thisbroader perspective provides a more detailedexamination of the leader, the external environment,and the situation—all factors that determineappropriateness of leadership style. Contemporarytheories also emphasize emotion, vision, andvalues.While contemporary theories recognize thecomplexities of leadership and expand themultiplicity of variables that affect it, they also return

us to the examination of individual characteristicsand behaviors. Novick, Morrow, and Mays (2008)suggest that transformational leadership seeminglyinvolves the reemergence of trait-based theories.Indeed, numerous studies in the past few decadeshave focused on personality traits of effectivetransformational, transactional, and charismaticleaders (DeHoogh, Den Hartog, & Koopman,2005). Many researchers credit this resurgence tothe work of Judge, Bono, Ilies, and Gerhardt(2002), who group the numerous traits identified inleadership studies into a “Big Five” personalityframework. When similar traits were organized intofive categories (Extroversion, Agreeableness,Conscientiousness, Emotional Stability, andOpenness to Experience), stronger and moreconsistent relationships emerged. This five-factorview of personality provided a new framework forlinking personality and leader behavior andeffectiveness in studies on charismatic,transformational, and transactional leadership(Bryman, 1992; Den Hartog & Koopman, 2001;Digman, 1990). A second individual trait that hasreceived considerable attention is emotionalintelligence (EI). Emotional intelligence involves theability to monitor one’s own and others’ feelings andemotions, to discriminate among them, and to use

this information to guide one’s thinking and actions(Salovey & Mayer, 1990).While innate personality traits play a role inleadership, the variance explained by personalityremains limited. A leader may have intrinsic traitsthat enhance or allow leadership to emerge, butthey must also have knowledge, skills, vision, andvalues to effectively influence followers and facilitateindividual and organizational performance.Therefore, we will conclude this chapter with a briefreview of the development of behavioralcompetencies for health care leadership.

▶ Transformational VersusTransactional LeadershipIt is helpful to define the terms “transactionalleadership” and “transformational leadership” toestablish a foundation for how each approach isappropriate and vital to an organization’s success.In general terms, transactional leadership is directedtoward task accomplishment and the maintenanceof good relations between the leader andsubordinates through consideration of performanceand reward. The transactional leadership model hasbeen considered the most prevalent leadershipmodel used in health care (Schwartz & Tumblin,2002). In contrast, transformational leadership isdirected toward the influence and management ofinstitutional change and innovation throughrevitalization and vision (Dessler, 1998, p. 350).Leader behaviors include characteristics identifiedas consideration and initiating structure.Consideration is the recognition that individualshave needs and require relationships; initiatingstructure denotes an emphasis on tasks and goals.Burns (1978) reported that transactional leadershipstyle is based on both consideration and initiating

structure. Transactional behaviors are “largelyoriented toward accomplishing the task at hand andmaintaining good relations with those working withthe leader by exchanging promises of rewards forperformance” (Dessler, 1998, p. 350). Transactionalleaders seek to maintain the status quo and rewardsubordinates for doing what is expected from them.Expectations of performance and the resultantrewards are clearly identified and delivered oncompletion of the agreement. As DeHoogh et al.(2005, p. 840) put it, “[T]ransactional leadersinfluence followers through task-focused behaviors;they clarify expectancies, rules and procedures,emphasizing a fair deal.” Trastek, Hamilton, andNiles (2014) relate that the transactional leadershipmodel is unable to account for the complexmotivations of health care providers, and it fails tobuild trust between the leader and followers.In contrast to the transactional leadership model,the transformational style of leadership incorporatesemotion, values, and vision to motivate individualsand seeks to change the status quo.Transformational leadership is all about change,innovation, improvement, and entrepreneurshipthrough vision and inspiration. Osland, Kolb, andRubin (2001, p. 297) state that “transformationalleaders are value-driven change agents who makefollowers more conscious of the importance of task

outcomes. They provide followers with a vision andmotivate them to go beyond self-interest for thegood of the organization.”Transformational leadership establishes subordinateeffort and performance that extends beyond thatwhich occurs as a result of transactional leadership.These two approaches to leadership are notmutually exclusive; most leaders exhibit bothtransactional and transformational behaviors indifferent intensities and amounts (Bass, 1990b;Luthans, 2002). According to Bass (1990b) andLuthans (2002, p. 592), each leadership approachdifferentiates itself in the identification of fourspecific characteristics that are unique to each style.Transactional LeadershipContingent Reward: Contracts exchange ofrewards for effort; promises rewards for goodperformance; recognizes accomplishments.Management by Exception (an activeapproach): Watches and searches fordeviations from rules and standards; takescorrective action.Management by Exception (a passiveapproach): Intervenes only if standards are notmet.Laissez-Faire: Abdicates responsibilities;avoids making decisions.

Transformational LeadershipCharisma: Provides vision and a sense ofmission; instills pride; gains respect and trust.Inspiration: Communicates high expectations;uses symbols to focus efforts; expressesimportant purposes in simple ways.Intellectual: Promotes intelligence, rationality,and careful problem solving.Individualized Consideration: Gives personalattention; treats each employee individually;coaches; advises.Transformational leadership elevates the level ofinsight about the importance and value of outcomesthrough the growth of subordinates by encouragingfollowers to question their own way of doing things.Transactional leadership constitutes behavior thatoperates through consideration and covenantsbetween the leader and the follower.

▶ TransformationalLeadership: AContradictory ViewKotter (1995) provided a contradictory view as tothe success of incorporating transformationalefforts. Kotter noted that transformational change(through transformational leadership) is conductedunder many banners: cultural change,reengineering, and total quality management, toname a few. The purpose of transformationalleadership is to address the essential changesnecessary to respond to an ever-changing, globallycompetitive environment.Kotter (1995) added that transformationalleadership resulting in successful change is bestexecuted in phases and that failure to address eachphase to the fullest significantly diminishes thecapacity to succeed. As illustrated in Table 12-1,Kotter identified eight transformational phases andassociated errors and provided strategies toenhance the success of the leader by addressingthe errors. Tichy and Devanna (1986), cited byLuthans (2002, pp. 591–592), found thattransformational leaders shared the following sevencharacteristics:

Table 12-1 Eight Specific Errors That Diminish theTransformational EffortPhaseTransformationalErrorsProcesses to EnhanceTransformational Success1Failure to create atrue sense ofurgencyEstablish a sense of urgency byexamining market/competitive realitiesand conducting a SWOT analysis(strengths, weaknesses, opportunities,and threats)2Failure to create apowerful guidingcoalitionForm powerful coalitions by assemblinggroups of teams with the power to effectchange3Failure to create aclearly understoodvisionCreate a vision with direction and focusconsistent with organizational strategies4Failure toadequatelycommunicate thevisionUse all available channels ofcommunication to convey the changeand lead by example5Failure to removeobstacles inmoving towardtransformationalchangeRemove obstacles, change systemsand structures, encourage creativity andinnovation through empowerment6Failure tosystematically planfor or create short-term successesPlan for and recognize visible, short-term improvements through establishedreward systems7ProclaimingsuccessUtilize credibility to change systems,structures, processes, and policies to

prematurelyarrive at the vision8Failure to anchorthetransformationalchangeInstitutionalize the change by infusingappropriate behaviors that will lead todevelopment and succession in theorganizational cultureKotter, J. P. (1995). Leading change: Why transformationalefforts fail. Harvard Business Review, 73(2), 61.1. They identified themselves as changeagents.2. They exhibited courage.3. They trusted people.4. They were value driven.5. They valued lifelong learning.6. They had the capability to face complexity,ambiguity, and uncertainty.7. They were imaginative, creative, innovative,and visionary.

▶ The Implications ofTransformationalLeadership for the HealthCare IndustryBecause of regulatory changes, financial pressures,and evolving care delivery models, health careorganizations will be transformed in many ways inthe years to come. The health care manager mustacquire the skills, abilities, and knowledge tounderstand effective leadership processes andanticipate environmental change. Changes facingthe health care manager necessitate a strongerfocus on results, creativity, and innovation(Gummer, 1995). The health care manager willexperience increasing demands to demonstratehigh performance and quality outcomes whilereducing costs in the midst of decreasing revenues.Leaders must increase their transformational skillswhile balancing the requirements of transactionalmanagement.Despite the importance of transformationalleadership, the transactional leadership model hasbeen considered the most dominant leadershipmodel actually used in health care (Schwartz &

Tumblin, 2002). A 2003 study by Thyler providesinteresting insight into the hold of the transactionalapproach to health care leadership and its impacton nursing care. Thyler reported that thetransactional leadership style may be causingnurses to leave the profession because theystruggle ideologically with the system in which theywork. Numerous other studies have been conductedon the relationship between leadership style and jobsatisfaction (or dissatisfaction). For example,Medley and Larochelle’s (1995) research reportedthat staff nurses view behaviors associated withtransactional leadership (e.g., negative feedback)unfavorably in relation to their jobs. This studyindicated that head nurses with hightransformational scores were more likely to havestaff nurses with higher job satisfaction scores andlonger association with their staff nurses thantransactional leaders have. These results providestrong support for the idea that a transformationalleadership approach advances retention efforts anddiminishes turnover rates—a conclusion that hassignificant fiscal implications for health carefacilities.Chaffee (2001) addressed the implications oftransformational leadership in a military health careenvironment. The purpose of Chaffee’s study was toidentify the ideal characteristics of a Navy health

care executive of the future. Sixty-sevenrespondents 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 interpersonalrelationship skills.Possesses credibility, honesty, and integrity.Embraces and drives change.Strives for excellence and continuousimprovement.Has excellent communication skills.Exhibits a passion for work.Maintains a focus on the organizationalmission.As Chaffee (2001, p. 241) points out, “Thecharacteristics identified by respondents describeleadership traits rather than management skills.None of the respondents identified the traditionalmanagerial skills of planning, organizing,coordinating, directing, and controlling. Additionally,the most frequently identified characteristics fit thedefinition of transformational leadership.”These leadership characteristics support fourmanagerial competencies sustained by successful

leaders (Bennis, 1984; Chaffee, 2001):1. Management of Attention: The ability to getthe attention of a group through a compellingvision that brings others to a place they havenot been before.2. Management of Meaning: The ability to makea vision clear to others and the ability tocommunicate ideas and create meaning.3. Management of Trust: The ability to inspiretrust through reliability and constancy.4. Management of Self: Knowing one’s skillsand deploying them effectively.Transformational leadership is, without question,very well suited to today’s economic, social,political, and technological conditions.Transformational leadership thrives on change andinnovation. Transformational leadership providesthe knowledge, skills, and abilities to facilitateinnovation and transformation, beyond those thatare available in a traditional approach. Doing thingsbecause that is the way they were always done isbeing replaced by dynamic solutions to old and newproblems (Sofarelli & Brown, 1998; Trofino,2000).Bennis and Nanus (1985), while noting theimportance of both management and leadership,recognized a philosophical dissimilarity between the

two approaches: “Managers are people who dothings right and leaders are people who do the rightthings” (p. 21). Lieutenant General George J. Flynnof the U.S. Marine Corps noted, “I know of no casestudy in history that describes an organization thathas been managed out of a crisis. Every single oneof them was led” (Sinek, 2017 p. xi). Theimplications of these statements provoke questionsas to how the health care industry will respond to anenvironment in which leadership focuses less onmanaging technical skills and more on managingknowledge processes. Technical skills arecontrolled through clearly stated goals andmeasurable performance objectives. Mentalprocesses have replaced the mechanistic tasks thatmust be carefully monitored and managed, meaningthat critical decisions are arrived at throughcognitive processes, not controlled through clearlystated goals and measurable performanceobjectives. The transformational leadershipapproach is well suited to serve this new healthservices environment (Trofino, 1995).

▶ Other ContemporaryLeadership ApproachesMore than 70 years ago, the Office of StrategicServices published a book titled The Assessment ofMen, in which two types of leaders were described:(1) the leader in articulation, who was forceful andinspirational in expression and who spelled outclearly what was needed and how it was to beaccomplished, and (2) the leader in action, who, bysetting themselves in motion, demonstrated how toaccomplish a goal and whose successesencouraged others to join in the pursuit of the goal.In either case, “the leader—by words or action—inspired others to achieve something beyond theordinary by appealing to a goal worthy of humaneffort” (Curtin, 1997, p. 7).Although the primary topic of this chapter istransformational leadership, other leadership stylesand their respective characteristics also focus ontransformation or change. Recall that transactionalleadership is directed toward task accomplishmentand good relations between the leader andsubordinates through consideration of performanceand reward, while transformational leadership isdirected toward the influence and management of

institutional change and innovation throughrevitalization and vision (Dessler, 1998). Here, weexamine some other change styles and theirconceptual similarities.Bolman and Deal (1997) offer for consideration thesymbolic leader. Symbolic leaders interpret andreinterpret experiences, developing the capacity toimpart purpose and meaning. Symbolic leaders usesymbols to seize attention. They frame experiencesin an uncertain environment, providing a reasonableinterpretation and understanding of events.Symbolic leaders disseminate information throughpersuasive communication, especially through theuse of stories, rites, and rituals, both current andpast. Symbolic leaders are consistent in their use ofrules and customs (Bolman & Deal, 1997).Another contemporary view of leadership is thesuperleadership perspective. Because today’sleaders are required to function effectively in anever-changing, fast-paced global environment,traditional leadership approaches lack the depth ofknowledge, skill, and ability required of today’sleaders. As contemporary work environmentsincreasingly develop and implement new andinnovative structural designs, there is anunprecedented level of employee participation, andthe myriad of prevailing management practicesmake it difficult, at best, to identify an appropriate

leadership approach. In response to these issues,the superleader willingly shares power and controlwith the employees and instills in them a sense ofempowerment that redirects the basis of vision anddirection from the leader to the follower. Liketransformational leadership, superleadershipencourages followers to do or become more—todiscover, use, and maximize their abilities. Thesuperleader continues to lead but recognizes thevalue of vision and direction that can be assembledby individuals at all levels of the organization. Thesuperleadership approach is effective in that theleader creates a positive atmosphere, promotesself-leading teams, provides appropriate reward andconstructive reprimand, and fosters a corporateculture that contributes to high levels ofperformance (Osland et al., 2001).The Charismatic LeaderCharisma is a tricky thing. Jack Kennedy oozed it—butso did Hitler and Charles Manson. Con artists,charlatans, and megalomaniacs can make it theirinstrument as effectively as the best CEOs,entertainers, and Presidents. Used wisely, it’s ablessing; indulged, it can be a curse. Charismaticvisionaries lead people ahead and sometimes astray.(Sellers, 1996, pp. 68–72)

Charismatic leaders are individuals who exhibit highlevels of self-confidence and trust in subordinates,high expectations for subordinates, and anideological vision and purpose that are enactedthrough personal example. In return, followers ofcharismatic leaders demonstrate loyalty to,confidence in, and trust in the charismatic leader’svalues, behaviors, and vision. The relationship andconnectedness are critical elements between thefollowers and the charismatic leader. The effect isprofound, often producing performance results thatexceed established expectations (Luthans, 2002).Followers will transcend their own self-interests forthe sake of the team, department, or organization(Bass, 2008).In light of the high esteem in which the charismaticleader is held, one would expect the charismaticleader to exhibit high ethical standards. Thispresumption, in most cases, is correct. The ethicalcharismatic leader will, in general, use their power insocially constructive ways to serve others (e.g.,Mother Teresa and Martin Luther King, Jr.). Yet notall charismatic leaders are ethical (e.g., Adolf Hitlerand Osama bin Laden). Howell and Avolio (1992)noted that charismatic leaders “deserve this labelonly if they create transformations in theirorganizations so that members are motivated tofollow them and to seek organization objectives not

simply because they are ordered to do so, and notmerely because they calculate that such complianceis in their self-interest, but because they voluntarilyidentify with the organization, its standards ofconduct and willingly seek to fulfill its purpose”(Luthans, 2002, p. 590).Although the components of transformationalleadership and charismatic leadership differsomewhat (Yukl, 1999), these theories are oftenseen as equivalent. As we discussed earlier,research supports the position that transformationalleadership qualities can be learned as long as theindividual is comfortable and confident in thecontrolling and influencing roles. Thus, bycombining the desire to lead with learning andunderstanding the position and responsibility of atransformational leader, a person may develop thecapacity to transform organizations. Given thissupposition and the close association oftransformational leadership and charismaticleadership, the question is “Can an individualacquire charismatic characteristics sufficient todevelop a following based on trust, expectations,and purpose?”Benton (2003) describes a six-step plan fordeveloping executive charisma. She suggests thatmany people, who might otherwise be changeagents, accept the fact that, given organizational

constraints and the competition amongorganizational leaders, they will achieve only acertain level of success. She also suggests that theone missing component to assuming charismaticpositioning—beyond one’s exemplary character,instincts, judgment, integrity, and positive energy—is executive charisma. Benton (2003, p. 10) definesexecutive charisma as “the ability to gain effectiveresponses from others by using aware actions andconsiderate civility in order to get useful thingsdone.” Benton’s six steps to developing executivecharismatic qualities are as follows:Step 1: Be the first to initiateStep 2: Expect and give acceptance tomaintain 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 toinitiate action establishes one’s willingness toaccept uncertainty head-on, to acknowledge that asituation can be either a problem or an opportunityto initiate transformation. This first step requires aconsistent willingness to act. Recognition, as both agiver and a receiver, fulfills the second step of theplan: to provide a sense of esteem to oneself and

others. This provision of esteem provides a cycle ofoptimism that can pervade the organization,affecting the other people who are involved in thetransformative effort.The third step provides for an exchange ofinformation as required to meet organizationalobjectives. Choosing one’s words and tone carefullywhile being specific and concise is important toensuring that information is timely, relevant, andaccurate. Do not be too timid to ask questions orsolicit favors. Be mindful to recall favors providedand extend thanks in return. Perception is importantwhen one is exhibiting charismatic qualities. Stepfour demands that the executive leader not only playthe role, but also look the role. Standing tall with arelaxed confidence enhances one’s charismaticappearance.Interestingly, step five mandates that charismaticleaders take on responsibilities that others will not—but without overdoing it. By this, Benton means thatbeing human is imperative to being charismatic, butdon’t be too human. Be humorous with a sense ofappropriateness. Do not cross social, ethnic, orgender boundaries. Stepping across acceptableboundaries into indefinable territory can quicklyextinguish one’s effort to create charismaticleadership qualities.

The final step involves maintaining a pace thatpermits decision making, implementation, andfocus. Not talking (shutting up) allows one theopportunity to listen. Listening allows one to hearwhat others have to say, develop a response to theinformation, and gain the trust necessary to initiatetransformational efforts. “Executive charisma isn’t asmuch about you as about your effect on others andthat comes not just from what you say and do butfrom what you don’t say and don’t do” (Benton,2003, p. 153).Servant LeadershipSome scholars in the leadership area, such as PeterSenge, Warren Bennis, Peter Block, and MargaretWheatley, see servant leadership as the emergingleadership paradigm for the 21st century for allcorporations and institutions. The concept of servantleadership is captured in the following quote fromDisraeli: “I must follow the people. Am I not theirleader?”The term “servant leadership” was first used byRobert K. Greenleaf in 1969 as a way to describe atype of leadership that focuses on serving thehighest needs of other people in an effort to help theothers to achieve their goals. Servant leadership isan approach to managing people that “begins with aclear and compelling vision that excites passion in

the leader and commitment in those who follow”(Blanchard & Hodges, 2003). A servant leadervalues others’ strengths and talents and encouragesthe use of these strengths and talents for thebetterment of the organization.Servant leadership focuses on the leader’sdevelopment through awareness and self-knowledge. Spears (2004) identified the qualitiesand characteristics of servant leadership: listening,empathy, healing, awareness, persuasion,conceptualization, foresight, stewardship,commitment to the growth of people, and buildingcommunity. These characteristics, along with amoral core, drive servant leaders to help peoplemeet their goals and overcome challenges (Trasteket al., 2014).Servant leadership recognizes the importance ofperformance coaching while acknowledging thatindividual development and performance arestrongly related. According to Blanchard andHodges (2003, p. A2), instrumental to theimplementation of servant leadership are threecomponents of performance coaching:1. Performance Planning: The setting of goalsand objectives.2. Day-to-Day Coaching: Providing theresources and an environment conducive to

the accomplishment of established goals.3. Performance Evaluation: The timely andrelevant evaluation of individual performanceand the identification of professionaldevelopmental needs.Anderson (2003) believes that servant leadershipcan build effective hospital–physician relationships.He states that servant leaders accept as theirresponsibility the need to invest in the lives of theirfollowers, believing that they are “not superior to thefollower and also know that on any given day or in agiven circumstance the follower may become theleader. It is the servant leader’s hope that thefollower will indeed one day become a servantleader and, therefore, will make an investment in thefollower’s career to better ensure that indeed thishappens” (Anderson, 2003, p. 45).Although empirical research in the area of servantleadership in the health care industry is stillsomewhat limited, Ornelas (2003) found a positivecorrelation between organizational outcomes andperception of servant leadership characteristicsamong departmental leaders in a large healthsystem. The results of Ornelas’s study showed thatemployees working in departments that hadmanagers with servant leadership characteristicsreported lower turnover rates, higher job

satisfaction, and increased commitment to theorganization than did employees working indepartments whose managers did not embrace theservant leadership philosophy. Jenkins andStewart (2010) reported similar results. Theresearchers found a positive impact on individualnurse employees’ job satisfaction in departmentswhere the nursing staff perceived that theirmanagers had a stronger servant leadershiporientation.In their studies of health care leadership, Peloteand Route (2007) concluded that the mostsuccessful leaders, whom they refer to asmasterpiece leaders, displayed a form of servantleadership. These leaders viewed themselves asthe leader-coach first and the leader-expert second.“Masterpiece leaders create, energize, and motivatethe health care climate; exhibit a high level ofpassion, excitement, and drive to perpetuate theirsuccess” (p. 282).Many people equate servant leadership withtransformational leadership; however, there aredifferences. The primary difference between the twoleadership styles is the focus of the leader (Stone,Russell, & Patterson, 2003). Stone et al. (2003, p.1) explain that

the transformational leader’s focus is directed towardthe organization, and his/her behavior builds followercommitment toward organizational objectives, whilethe servant leader’s focus is on the followers, and theachievement of organizational objectives is asubordinate outcome. The extent to which the leader isable to shift the primary focus of leadership from theorganization to the follower is the distinguishing factorin classifying leaders as either transformational orservant leaders.Collaborative LeadershipIbarra and Hansen (2011, p. 73) definecollaborative leadership as the “capacity to engagepeople and groups outside one’s formal control andinspire them to work toward common goals—despite differences in convictions, cultural values,and operating norms.” Collaborative leadership iscomplex because it requires a leader to achievesuccess by motivating individuals in multiple groupsand/or organizations in addition to bringing togetherand aligning the goals of many stakeholders(Borkowski & Deppman, 2019). Al-Sawai (2013)states that collaborative health care leadershiprequires a synergistic work environment in whichmultiple parties are encouraged to work togethertoward the implementation of effective practices andprocesses. Such collaborations promoteunderstanding of different cultures and facilitate

integration and interdependency among multiplestakeholders who are unified by shared visions andvalues.Borkowski and Deppman (2019) point out that ashealth care reform moves the industry fromsegment-based delivery models to integratedsystems such as accountable care organizations(ACOs), collaborative leadership becomes critical toorganizational success. The leader of an ACO isexpected to integrate and coordinate the variouscomponent parts of health care, such as primarycare, specialty services, hospitals, and home healthcare, and to ensure that all parts function welltogether to deliver efficient, high-quality, and cost-effective patient-centered care. Managers of 21st-century health care organizations must be able tolead diverse groups of people and facilitate theirprofessional efforts and problem solving both withinan organization and across formal organizationalboundaries.According to Carter (2006), the collaborative leadershould demonstrate:1. The confidence that the goals and objectivesare achievable.2. The skills to clearly communicate with thestakeholders about the issues that need 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 authoritywith the collaborators.5. The ability to assess and handle varyinglevels of risk in decision making andimplementation.The good news is that these behaviors and therequired skill set (see Appendix 12-A) can belearned by dedicated leaders who commit thenecessary time and effort (Borkowski & Deppman,2019). The Turning Point Leadership DevelopmentNational Excellence Collaboration has identified sixkey practices that are unique to leading acollaborative process and the necessary steps forleaders to guide successful collaborations (seeAppendix 12-B).

▶ Another Look at Traits andBehaviorAs was mentioned at the beginning of the chapter,contemporary theories of leadership indicate aresurgence of interest in individual traits andbehaviors. Two such theoretical constructs that arereceiving considerable attention are the Big Fivepersonality factors (Judge et al., 2002) andemotional intelligence (EI) (Salovey & Mayer,1990). Following an examination of theseconstructs, we return to behaviors. Bass (1990a, b)emphasized that leadership can be learned andsuggested that one of the most significantapplications of transformational theory is in thetraining of individuals to become transformationalleaders. The success of transformational leadershiptraining appears to be based on actual increases inleader uses of transformational behaviors.Identification of behaviors that define competenttransformational health care leaders has capturedthe attention of both scholars and practitioners.Big Five Personality FactorsThe Big Five personality framework posits that themultitude of personality characteristics identified in

theory and research can be organized into fivefactors that underlie all others (DeHoogh et al.,2005; Robbins, 2005):Extroversion: Extroverts tend to be social, assertive,active, and gregarious.Agreeableness: Agreeable individuals are warm,generous, cooperative, and trusting.Conscientiousness: Conscientious individuals aredependable, responsible, achievement oriented,organized, and proficient.Emotional Stability: This dimension captures anindividual’s ability to withstand stress. People withpositive emotional stability are calm, self-confident,and secure. Some researchers measure this factor asneuroticism, which reflects the tendency to be anxious,insecure, and defensive.Openness to Experience: Individuals who are open toexperience are characterized by imagination,unconventionality, a range of interests, and fascinationwith novelty.Robbins (2005) suggests that the studies of the BigFive approach resulted in consistent and strongsupport for traits as predictors of leadership. Adifferent conclusion is drawn by DeHoogh et al.(2005). These authors suggest considerablevariability in both the strength and direction of the

relationships between the personality factors andtransformational and transactional leadership. Suchvariances, they conclude, result in weak support forthe Big Five factors.The inconsistency of findings led DeHoogh et al.(2005) to suggest that it is not personality itself thatis important in leadership style, but the interaction ofpersonality characteristics and the context. Theirresearch examined both the direct measure of theBig Five personality factors and interactiverelationship with emphasis on perceived leadereffectiveness (transformational and charismaticleader styles were considered equivalent andcontrasted with transactional). The context variable—the work environment—was defined as eitherdynamic (i.e., characterized by a high degree ofchallenge and opportunities for change) or stable(i.e., more structured, and orderly). Results from thisstudy established that the relationships betweenpersonality and leadership style did indeed differdepending on the context.Emotional IntelligenceThe concept of emotional intelligence (EI) isrelatively new in the field of organizational behavior.Emotional intelligence involves assessing one’s ownfeelings, as well as the feelings of others, then using

those assessments to guide personal thought andaction. 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-awarenessas involving self-understanding and knowledge ofone’s true feelings at any given moment. Self-management ensures that a manager can controltheir emotions to assist with the task at hand whilefocusing on the problem’s solution. Self-motivationallows the manager to stay focused on the goal anddesired outcome, overcoming negative emotionalstimulus and accepting delayed gratification.Empathy is having a sense of what others feel andwant while being sensitive to their needs. Finally,social skills relate to one’s ability to read and reactto social situations while interacting with otherpeople and guiding and influencing the behavior ofothers.Goleman (1998), as cited by Luthans (2002, p.306), noted that EI is not the “end all” in determiningleadership characteristics and competencies, butnonetheless, he concludes:

At the individual level, elements of EI can beidentified, assessed, and upgraded.At the group level, EI means fine-tuning theinterpersonal dynamics that make groupssmarter.At the organizational level, EI means revisingthe value hierarchy to make emotionalintelligence a priority—in the concrete terms ofhiring, training and development, performanceevaluation, and promotions.Goleman (1998) believes that EI is more importantthan IQ, proposing that EI is a better predictor ofsuccess in both personal and professionalendeavors. Gibbs (1995) provided the followingevidence as to the importance of EI: “IQ gets youhired, but EI gets you promoted” (p. 64).Druskat and Wolff (2001) have extended theconcept of individual emotional intelligence toteams. The members of creative, productive teamsdemonstrate mutual trust, a sense of group identity,and a sense of group efficacy. These emotionalcomponents enable effective participation,cooperation, and collaboration. They state (p. 83):Group emotional intelligence … [is] about bringingemotions deliberately to the surface and understandinghow they affect a team’s work. It is also aboutbehaving in ways that build relationships both inside

and outside the team and that strengthen the team’sability to face challenges.Health care organizations are just beginning torecognize the importance of developing employees’EI (Grossman, 2000). Only some progressivehealth care facilities have recognized the value of EItraining and have incorporated programs thatemphasize its principles. However, as Freshmanand Rubino (2002) point out, the applications of EIfit well within the industry, as reflected in Table 12-2.Table 12-2 Emotional Intelligence Components Applied toHealthcare AdministrationComponentDefinitionExamples in HealthcareAdministrationSelf-awarenessSelf-understanding andknowledge of one’sfeelings, strengths,weaknesses, andmotivations at any givenmoment.1. Knowing that youhave a tendency tointerrupt othersand insist on yourown way2. Understandingwhat types of workarrangements willinterfere with yourfamily lifeSelf-regulationSelf-management toensure that one can1. Able to maintain

control their emotions toassist with the task at handwhile focusing on theproblem’s solutioncomposure whenan angry oraggressive patientwants a resolutionto a problem withtheir experience2. Learning how towork well with anew boss3. Recognizing yourcontribution to anargument with acolleagueSelf-motivationStaying focused on thegoal and desired outcome,overcoming negativeemotional stimulus andaccepting delayedgratification1. Pursuingexcellence in yourwork even if youthink nobody elsewill notice2. Looking atchallengingassignments asopportunities togrow and learn3. Taking on newprojectsSocialawarenessHaving a sense of whatothers feel and want whilebeing sensitive to theirneeds1. Considering theperspective ofdoctors and nurseswhen making adecision that will

impact them2. Understanding thata colleague’semotions andperformance atwork may berelated tochallenges in theirpersonal livesSocial skillsRelating appropriately tosocial situations whileinteracting with others andinfluencing their behavioraccordingly.1. Gettingdepartmentleaders on boardto support aproject beingimplementedacross the hospitalsystem2. Helping motivateemployees to workin a manner thatsupports themission and visionof the organizationBehavioral CompetenciesIn general, behavioral competencies define theskills, knowledge, abilities, and actions thatdistinguish superior performance. Spencer andSpencer (1993) describe a competency as “whatoutstanding performers do more often, in more

situations, with better results, than averageperformers.” There has been growing interest in thedevelopment of competencies since McClelland(1961, 1985) published his work on achievementand motivation. In the past 10 or 15 years,leadership competency models have proliferated inhealth care education and professionaldevelopment. Numerous consulting organizations,professional associations, health care organizations,and educational programs have created leadershipcompetency lists (Hernandez, O’Connor, & Meese,2018; Dye & Garman, 2006). The acceptance andimplementation of competency-based education andtraining across health care systems may be viewedas acknowledgment that at least a significant portionof leadership may be learned and as the desire toensure exceptional leadership and performance inhealth care.The large numbers of competency models precludean exhaustive review. However, students in healthcare management programs should examine thecompetencies incorporated into their programs ofstudy. The National Center for HealthcareLeadership (NCHL) in conjunction with the RobertWood Johnson Foundation has developed aframework to implement competency-basedlearning and assessment curricula in health caremanagement education. The NCHL project relies on

academics and experts in the field to define thetechnical and behavioral characteristics that leadersmust possess to be successful across the healthprofessions. The full model, which may be found onNCHL’s website (www.nchl.org), contains levels foreach competency that distinguish leaders at eachcareer stage (early careerist, midcareerist, andsenior executive). Future and current health careexecutives may be guided by the competencies setforth by the American College of HealthcareExecutives (ACHE), the international professionalorganization for the more than 30,000 health careexecutives who lead hospitals and health careorganizations around the world (seewww.ache.org). ACHE offers a HealthcareExecutive Competencies Assessment Tool derivedfrom the Healthcare Leadership Alliance (HLA) (seewww.healthcareleadershipalliance.org). Thecompetencies were developed by HLA through jobanalyses and research. Three hundredcompetencies are categorized under five majordomains: (1) leadership, (2) communications andrelationship management, (3) professionalism, (4)business knowledge and skills, and (5) knowledgeof the health care environment. The ACHE self-assessment is designed to assist executives inidentifying areas of strength as well as areas inwhich they might want to improve their performance.

The International Hospital Foundation (IHF) took asimilar approach to identify a global competencydirectory to be used by health care leaders acrosscountries and continents (Hernandez et al., 2018).Do competencies create effective leaders? Dye andGarman (2006) suggest that competency is mostaccurately described as the capacity to perform (p.xxxi). Translating competency into success requiresboth motivation and opportunity. Furthermore,competencies are not just learned but “are moreaccurately described as improving slowly over timeas a result of mindful practice, feedback, and morepractice” (p. xx). Pelote and Route (2007) alsopresent a broader view of leadership competenciesin the Healthcare Causal Flow Leadership Model.As the model demonstrates, individualcharacteristics do not exist in a vacuum and, ofthemselves, are not a source of success.Leadership competencies are viewed as beingamong the variables within a context (e.g., healthcare climate) that ultimately affects performanceoutcomes (i.e., patient outcomes, patientsatisfaction, and financial results).Lieutenant General George J. Flynn remarked, “Inshort, professional competence is not enough to bea good leader; good leaders must truly care aboutthose entrusted to their care.” (Sinek, 2017, p.xii).Therefore, leaders must create an organizational

culture in which other people feel safe andprotected, not only from the outside world, but alsofrom each other. When leaders create anenvironment in which others feel safe to innovate,take risks, and work for the benefit of the group,organizational and group performance improves,innovation goes up, and organizational learningincreases (Edmondson & Lei, 2014).

▶ SummaryContemporary theories recognize the complexity ofleadership yet also bring us back to examining therole of traits and behaviors that were the focus ofthe more simplistic, traditional leadership theories ofthe past. Today, leadership theorists acknowledgethe presence of a symbiotic relationship betweenthe leader’s traits and behaviors, the follower, theenvironment, the situation, and the strategicorganizational objectives. In response to an ever-changing external environment, contemporaryleadership approaches allow interactions betweenthe leader and the follower that are not possible withtraditional leadership approaches. A common threadamong contemporary leadership models is anintegration of ideological, moral, and valueapplications.It is important to recognize that organizationsrequire both transactional and transformationalstyles of leadership if strategic goals are to be met.One approach is not necessarily preferred over theother. Imagine an organization that has onlytransactional leaders. Tasks and processes wouldbe accomplished, but it is unlikely that theorganization would have the ability to transform

itself to respond to an ever-changing environment orredirect its efforts into new markets. At the sametime, an organization that had only transformationalleaders would certainly have the vision to changeand innovate but would not have the capacity to doso because of an absence of transactionalagreements between managers and employees.This scenario is unlikely, but it does portray theimportance of balance of leadership styles withinorganizations.It is essential to create a blend of leadership that isflexible and adaptable to differing situational factors.The formula for balance is difficult. In a time ofcrisis, which style of leadership is most important:transactional or transformational? There is nosimple answer to this question because of themultitude of situational factors. One could argue thatin a time of crisis, transactional leadership would bemore effective if control and efficiency were theprimary concerns. Likewise, transformationalleadership would be more effective in a time of crisisif change and innovation were the dominant interest.There is supportive research that suggests thattransformational, charismatic, and othercontemporary leadership attributes can be learned.This finding is valuable to individuals who find thatthey have reached a plateau in their professionaldevelopment plan. Leaders at all levels of an

organization can enhance, modify, and developleadership skills to increase their ability to influence,control, and manage by identifying personalleadership strengths and weaknesses.Today’s health care managers can move beyondtransactional leadership into areas that createopportunities for ever-increasing levels ofperformance and connection to the workforcethrough visionary and servant approaches toleadership. Contemporary managers should lookclosely within themselves to determineappropriateness of leadership styles on the basis ofsituational, environmental, and personal factors.Leaders in the turbulent health care environmentmust help their followers feel safe, not only fromoutside threats, but also from other people withinthe organization. Understanding the need foraligning one’s leadership approach with thesefactors can generate higher levels of workplacecommitment and performance.

Discussion Questions 1. Identify the similarities and differencesbetween transactional and transformationalleadership. Discuss the appropriateness ofeach style depending on situational factors. 2. Discuss the type of leadership style—transactional, transformational, servant, andcollaborative—that occurs in your specificprofessional environment. List the positiveand negative outcomes that exist as a resultof the leadership approach used. 3. Debate the position that transformational andcharismatic leadership can (or cannot) belearned. Be specific in your support for theposition you take. 4. Discuss Benton’s six-step plan for executivecharisma. Would the plan work for you inyour current health care setting? 5. Deliberate the need for transformational orcollaborative leadership in the next 5 yearsas the health care environment transforms asa result of industry reform.

Exercise 12-1It has been stated that to lead people through thecomplex changes facing the health care industry,transformational leadership is required (i.e., leaderscreating an environment in which staff can bestapply their knowledge, skills, and efforts, engagingcommitment and developing potential). Supposeyou are engaged as the consultant for BeltwayHealthcare System to develop a managementdevelopment program that will be the vehicle thatmanagers can use to develop the necessary skillsand knowledge to drive organizational change andimprove the system’s performance.What would you propose as the goals of themanagement development program?What learning methods would be best suited toachieve these goals?

Exercise 12-2 Are You a CharismaticLeader?If you were the director of a major department in ahealth care company, how important would each ofthe following activities be to you? Answer yes or noto indicate whether you would strive to perform eachactivity.1. Help subordinates to clarify goals and how toreach them.2. Give people a sense of mission and overallpurpose.3. Help to get jobs completed on time.4. Look for the new product or serviceopportunities.5. Use policies and procedures as guides forproblem solving.6. Promote unconventional beliefs and values.7. Give monetary rewards to subordinates inexchange for high performance.8. Command respect from everyone in thedepartment.9. Work alone to accomplish important tasks.10. Suggest new and unique ways of doingthings.11. Give credit to people who do their jobs well.

12. Inspire loyalty to yourself and to theorganization.13. Establish procedures to help the departmentoperate smoothly.14. Use ideas to motivate others.15. Set reasonable limits on new approaches.16. Demonstrate social nonconformity.The even-numbered items represent behaviors andactivities of charismatic leaders. Charismaticleaders are personally involved in shaping ideas,goals, and direction of change. They use an intuitiveapproach to develop fresh ideas for old problems,and they seek new directions for the department ororganization. The odd-numbered items areconsidered more traditional management activities,or what would be called transactional leadership.Managers respond to organizational problems in animpersonal way, make rational decisions, andcoordinate and facilitate the work of other people. Ifyou answered yes to more even-numbered thanodd-numbered items, you may be a potentialcharismatic leader.Data from “Have You Got It?” a quiz that appeared in Patricia Sellers,“What Exactly Is Charisma?” Fortune (January 15, 1996): pp. 68–75;Bass, B. M. (1985).Leadership and performance beyond expectations. New York, NY:

Free Press; and Burns, L. R., & Becker, S. W. (1986). Leadership andmanagership.In S. Shortell & A. Kaluzny (Eds.), Health care management. NewYork, NY: Wiley.

Exercise 12-3 What Is Your EQ?A number of testing instruments have beendeveloped to measure emotional intelligence,although the content and approach of each testvaries. See the About.com Psychology Website atpsychology.about.com/library/quiz/bl_eq_quiz.htmfor a quiz that presents a mix of self-report andsituational questions related to various aspects ofemotional intelligence. Take the quiz to learn moreregarding about your quotient.Do you think you are at a higher or lower level thanmost people when it comes to emotionalintelligence?What might you be able to do to raise your level ofemotional intelligence? How effective do you thinkthis might be, considering that some researcherssuggest that emotional intelligence can be learnedand strengthened, while others claim that it is aninborn characteristic?

Exercise 12-4Access a leadership competency assessment toolof your choice. Review your scores to identifystrengths as well as areas to further develop. Givenyour current strengths, how would youconceptualize your leadership style?

Appendix 12-A Traits and Skills ofCollaborative LeadersTraitsSkillsSelf-confidenceCommunicationDecisivenessSocialResilienceInfluenceEnergyAnalyticNeed for achievementTechnicalWillingness to assume responsibilityContinual learningFlexibilitySelf-managementService mentalityStrategic thinkingPersonal integrityFacilitationEmotional maturityCollaborative mindsetPassion towards outcomesSystems thinkingOpennessRisk-takingSense of mutuality and connectednessHumilityMorse, R. S. (2007). Developing public leaders in an age ofcollaborative governance. University of Delaware, Institute forPublic Administration. Available at:http://www.ipa.udel.edu/3tad/papers/workshop4/Morse.pdf

Appendix 12-B Six Key Practicesand Necessary Steps for Leaders toGuide Successful CollaborationsPracticesAction1Assess theenvironmentA collaborative leader needs to be able torecognize common interests and understandothers’ perspectives. Collaboration seeks goalattainment around shared visions, purposes, andvalue. When different points of views to an issueor problem are addressed, a collaborative leaderfacilities connections and encourages groupthinking that identifies clear, positive change forall participants. The first priority is to set goals.The second priority is to identify the barriers andobstacles to achieving the goals.2CreateclarityHaving and communicating the clarity of purpose(i.e., shared vision) is a quality that characterizescollaborative leaders. Clarity allows the groupmembers to focus so their energy can bedirected toward problem solving. Visioning inrelation to clarity, involves the commitment to aprocess or a way of doing things. Mobilizingrefers to helping people develop the confidenceto take action and sustain their energies throughdifficult times.3Build trustThe collaborative leader must have the ability topromote and sustain trust between and amongthe participants for sharing of innovativeapproaches. If a collaborative leader fails to

engender trust and openness amongparticipants, best Ideas and innovativeapproaches for problem solving will not bedeveloped or shared by the group.4Sharepower andinfluenceThe collaborative leader must allow theparticipants to be empowered to fully contributein the decision-making process. Rather thanbeing concerned about losing power throughcollaboration, the leader needs to recognize thatsharing power actually generates strength.5DeveloppeopleThe collaborative leader needs to bring out thebest in others, maximize the use of otherpeople’s talents and resources, build powerthrough sharing power, and cede authoritarianownership or control. By doing so, the leaderincreases others’ leadership capacities byencouraging experimentation, goal setting, andperformance feedback.6Self-reflection:Successful collaborative leaders demonstratehigh levels of emotional intelligence or maturity.Through self-reflection, leaders can examine andunderstand their values and assess whether theirbehaviors are congruent with their values. Inaddition, successful leaders critically consider theimpact their actions and words have on thegroup’s progress toward achieving its goals andadjust their behaviors if necessary.Turning Point Leadership Development National ExcellenceCollaborative, sponsored by The Robert Wood JohnsonFoundation.

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Other Suggested ReadingsAtchison, T. (2005). Leadership’s deeper dimensions: Buildingblocks to superior performance. Chicago, IL: HealthAdministration Press.Conger, J. A., & Kanungo, R. N. (1988). Behavioural dimensionsof charismatic 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 leaderand capable manager. Healthcare Forum Journal, 41(2), 26–29.Lee, F. (2008). If Disney ran your hospital: 9½ things you woulddo differently. Chicago, IL: Health Administration Press.Yukl, G. (1989). Managerial leadership: A review of theory andresearch. Journal of Management, 15(2), 266.

PART IVIntrapersonal andInterpersonal IssuesIn Part IV, we explore various intrapersonal andinterpersonal issues. The focus in Chapters 13 and15 is on stress and conflict, respectively, and howthe negative effects of both can be avoided or atleast minimized. Having an optimal level of stressand conflict in our lives is good. It can lead us towork efficiently and effectively with creativity.However, when we experience too much of eitherstress or conflict, productivity levels may decrease,and we may experience problems with our physicaland mental health. In Chapter 14, we discuss thevarious ways in which individuals approach decisionmaking. Managers face different types of problems(that cause stress and conflict) and therefore usedifferent types of decision-making models—somemore effective than others.

CHAPTER 13Stress in the Workplaceand Stress ManagementLEARNING OUTCOMESAfter completing this chapter, the student shouldbe able to understand:The definition of stress.The process model of stress and coping.How stress can negatively affect individualsand organizations.The various forms of stress.The three stages of the General AdaptationSyndrome.How personalities, race, and gender affect anindividual’s level of stress.The definition and phases of burnout.The four categories of stress in the workplace.The various coping strategies that areavailable to organizations and individuals.

The definition of stress management and thevarious stress management programs thatorganizations use.

▶ OverviewStress is a complex and highly personalizedprocess. Stress levels can vary widely, even inidentical situations, because of individuals’ varyingabilities to cope with different forms and levels ofstress. The ways in which people are affecteddepend on a number of factors, such as their levelof self-efficacy, their adaptability, and the resourcesavailable to them.Cognitive-transactional theory defines stress as “aparticular relationship between the person and theenvironment that is appraised by the person astaxing or exceeding his or her resources andendangering his or her well being” (Schwarzer,2004, p. 343). Lazarus and his associates (Lazarus,1991; Lazarus & Folkman, 1984; Lazarus,DeLongis, Folkman, & Gruen, 1985) argue thatdifferent individuals may perceive the same stressfulsituation differently on the basis of their cognitiveappraisal. Some individuals see a specific situationas a threat; other individuals see the same situationas a challenge or opportunity.As Figure 13-1 illustrates, an individual’sassessment of the situation includes demandappraisals or resource appraisals. Demand

appraisals relate to the person’s perception of (1)physical demands, (2) task demands, (3) roledemands, and (4) interpersonal demands (seeTable 13-1). Resource appraisals may be material,personal, or social. Material appraisals ask thequestion “Do I have the necessary resources tocomplete this task?” Personal resource appraisalsrefer to an individual’s internal coping options.Individuals who are affluent, healthy, capable, andself-confident are generally less vulnerable tostressful events. Social resource appraisals relate toexternal coping options available to an individual,such as availability of obtaining assistance fromothers, receiving emotional support (reassurance),and/or advice or additional information necessary tocomplete the task (Lazarus, 1991; Schwarzer,2004).

Figure 13-1 The Process Model of Stress and CopingTable 13-1 Demand AppraisalsPhysical DemandsIndoor climate and air qualityTemperatureIllumination and other raysNoise and vibrationsOffice designTask Demands

Occupational categoryRoutine jobsJob future ambiguityInteractive organizational demands (e.g., interface withvarious constituencies, such as with boundary spanning)Work overloadRole DemandsRole conflictInterroleIntrarolePerson/role (i.e., conflicting values or beliefs)Role ambiguityWork/home demandsInterpersonal DemandsStatus incongruitySocial density (i.e., interpersonal need for space anddistance)Abrasive personalitiesLeadership style

Team pressuresDiversityQuick, J. C., Quick, J. D., Nelson, D. L., & Hurrell, J. J. (1997).Preventive Stress Management in Organizations (p. 22).Washington, DC: American Psychological Association.The person’s appraisal of the situation results in oneof three perceptual outcomes: challenge, threat, orharm/loss. When a situation is viewed positively, theperson sees the situation as a challenge and anopportunity to achieve personal growth. When thesituation is viewed as a threat, the person perceivesdanger from either physical injury or a blow to theself-esteem. For example, a task demand that isperceived to be difficult, ambiguous, unexpected, ortime-consuming with an unrealistic deadline is morelikely to induce a threat outcome than is an easytask that can be thoroughly prepared for and solvedat a convenient pace without time constraints. If theappraisal is viewed to be harm or loss, the personhas determined that damage has already occurred,such as loss of self-worth, a lowering of the person’ssocial standing, or physical injury (Lazarus, 1991;Schwarzer, 2004).Building on Lazarus’ work, Schwarzer’s (2004)process model illustrates that, on the basis of an

individual’s perception of the situation, they mayengage in various coping strategies to manage theexperience of stress. The combination of anindividual’s perception of the situation (appraisals)and the coping strategies employed (reactive,anticipatory, preventive, or proactive) will determinethe resulting consequences, which may bebehavioral, psychological, physiological, orcombinations of the three (see Table 13-2).Table 13-2 Individual Distress: Behavioral, Psychological,and Physiological ConsequencesBehavioral ConsequencesTobacco useAlcohol useDrug abuseAccident pronenessViolenceEating disordersPsychological ConsequencesBurnoutFamily problems

Anxiety disordersSleep disturbancesSexual dysfunctionDepressionConversion reaction and somatizationPhysiological ConsequencesHypertension, heart disease, and strokeCancerBack pain, arthritis, and other musculoskeletal conditionsPeptic ulcer disease and other gastrointestinal conditionsHeadacheDiabetes mellitusLiver cirrhosis and other alcohol-related diseasesLung diseaseSkin diseaseOther diseases (e.g., HIV, chronic fatigue syndrome)Quick, J. C., Quick, J. D., Nelson, D. L., & Hurrell, J. J. 1997.Preventive Stress Management in Organizations (p. 66).Washington, DC: American Psychological Association 66.

In this chapter, we first examine the factors thatcontribute to a person experiencing stress in theworkplace. Although many extraorganizationalfactors contribute to an individual’s experience ofstress, such as a pending divorce, housingconditions, and the general economy, this chapterfocuses primarily on stress in the workplace.Second, we examine the various methods of copingwith stress, referred to as stress management, fromboth an organizational perspective and an individualperspective.

▶ Work-Related StressStress is a common phenomenon in today’sworkplace. Numerous surveys and studies confirmthat occupation-related pressures are the leadingsource of stress for adults. Stress, which the WorldHealth Organization has called the “health epidemicof the 21st century,” is estimated to cost U.S.businesses up to $300 billion a year (Smith, 2012)as a result of accidents; absenteeism; employeeturnover; loss of productivity; direct medical, legal,and insurance costs; workers’ compensationawards; and tort and Federal Employers’ LiabilityAct judgments (American Institute of Stress,2004).The National Institute for Occupational Safety andHealth (NIOSH), the federal agency in the U.S.Department of Health and Human Services that isresponsible for conducting research and makingrecommendations for the prevention of work-relatedinjury and illness, determined the following:40% of workers reported that their jobs werevery or extremely stressful.25% viewed their jobs as the number-onestressor in their lives.

75% of employees believed that workers havemore on-the-job stress than a generation ago.29% of workers felt quite a bit or extremelystressed at work.26% of workers said they were “often or veryoften burned out or stressed by their work.”Job stress was more strongly associated withhealth complaints than with financial or familyproblems. (NIOSH, 1999)Workplace ViolenceIn addition to the effects of stress on health andfinancial or family problems, it may lead to physicalviolence in one out of 10 work environments.According to a study of “desk rage” by IntegraRealty Resources (2001), almost half of thosesurveyed said that yelling and verbal abuse werecommon in their workplaces. In a 2013 study, 51%of British workers reported experiencing rage atwork (The Telegraph, 2013). Desk rage or workrage can include behaviors or acts of aggression,hostility, rudeness, and physical violence.Workplace violence affects over 2 million Americansand costs an estimated $36 billion annually(Corporate Alliance to End Partner Violence,2014) due to lost productivity, diminished image,insurance payments, and increased security costs.Workplace violence is not an uncommon problem in

the health care industry. It can occur both ininteractions between coworkers and with patientsand their families.It is estimated that health care workers are 20%more likely to be the victim of workplace violencerelative to other professions. Of all workplaceintentional injuries reported in 2017, 71% occurredin health care and social services workplaces(Coutre, 2019; The Joint Commission, 2018).Health care and social services workers are overfour times more likely to experience intentionalinjuries caused by another person than are workersin all other private sector jobs combined. Healthcare workers often face violent and aggressive orderogatory behaviors from patients and their familymembers. One nurse reports, “I’ve been bitten,kicked, punched, pushed, pinched, shoved,scratched, and spat upon. I have been bullied andcalled very ugly names. I’ve had my life, the life ofmy unborn child, and of my other family membersthreatened, requiring a security escort to my car”(The Joint Commission, 2018).In addition to workplace violence from patients andvisitors, workplace violence or desk rage is commonin interactions among different members of thehealth care team. For example, almost one-third ofphysician executives who participated in a nationalstudy conducted by the American College of

Physician Executives reported that seriousproblems erupted in their organization on either amonthly or a weekly basis as a result of disruptivebehavior by physicians (Weber, 2004). Two-thirdsof the nurses responding to a nurse–physiciancommunication survey reported that they hadsuffered verbal, mental, or physical abuse by aphysician. The most common complaints related tophysicians yelling, cursing, and abruptly hanging upon the nurse during telephone conversations.Another behavior that was cited was being beratedby the physician in front of patients, familymembers, or other staff members. The highestnumber of desk rage responses came from nursesworking in hospital operating rooms, and theincidents included throwing of surgical instruments(Homsted, 2003). Because of these types ofsituations, which undermine a culture of patient andworkplace safety, The Joint Commission issued aSentinel Event Alert on the topic and developed astandard requiring all accredited hospitals to have acode of conduct as well as a process for managingdisruptive and inappropriate behaviors (Wyatt,2013).StressorsEveryone encounters stress in daily life, but theeffects on an individual depend on a number of

factors. Causes or sources of stress, known asstressors, can take on a number of forms, such aspositive or negative, external or internal, or short-term (acute) or long-term (chronic).Positive and Negative StressorsA certain degree of stress is necessary for goodmental and physical health; it can be viewed asconstructive stress, which compels us to act withoptimal performance, helping us to achieve ourgoals. Hans Selye (1956, 1974), a Canadianphysiologist referred to as the grandfather of stressresearch, coined the term “eustress,” incorporatingthe Greek root eu for “good,” to describe good orpositive stress. Selye suggested thinking of eustressas euphoria + stress. It is only when stress is poorlymanaged or becomes overwhelming that thenegative effects appear; this poorly managed stressis referred to as distress (see Figure 13-2).

Figure 13-2 Distress–Eustress (an Expanded Yerkes–DodsonCurve)Quick, J. C., Quick, J. D., Nelson, D. L., & Hurrell, J. J. (1997).Preventive stress management in organizations. Washington, DC:American Psychological Association.Distress refers to the unhealthy, negative,destructive outcomes of stressful events (Quick et

al., 1997). Distress may have behavioral,physiological, and/or psychological effects on theindividual. For example, as early as the 1930s,physiologists were studying the physiologicalchanges in individuals when they were confrontedwith a negative stimulus or environmental change.This is referred to as an individual’s fight-or-flightresponse. In the fight-or-flight response, certainchemicals in the brain cause a reaction to potentiallyharmful stressors or warnings (e.g., danger,harassment, noise). Selye (1956) studied thephysiological effects of the fight-or-flight response,and the result was his description of GeneralAdaptation Syndrome (GAS). GAS describes thethree phases an individual undergoes when theyencounter a stressful situation: the alarm phase, theresistance phase, and the exhaustion phase.The first stage of GAS, the alarm phase, occurswhen an individual’s fight-or-flight response iselicited for mobilization and geared for either a fightor flight. In the second stage, resistance, theindividual fights the stressor or escapes it, and theacute fight-or-flight response ceases. The thirdstage, exhaustion, occurs when the individual canno longer adapt to the stressor (Jacobs, 2001). Inthe first two stages, alarm and resistance, bodilyresponses are adaptive and beneficial.

It is only in the final stage, exhaustion, that anindividual’s stress may be reflected in behavioral,physiological, and/or psychological illnesses.Physiological illnesses related to stress may includechronic headaches or fatigue, hypertension, ulcers,and heart disease. Psychological illnesses or theemotional symptoms of stress in the exhaustionstage are rooted in frustration and/or depression.According to von Onciul (1996), these emotionalsymptoms are the behavioral consequences of theexhaustion stage, which may include emotionaloutbursts, violent or antisocial behavior, eatingdisorders, and general indifference and reducedattention to personal issues such as exercise andappearance. The individual may exhibit other mentaldysfunctions in the exhaustion stage, such as theinability to concentrate and poor memory retention.This causes impaired performance, poor judgment,and indecisiveness as well as a negative attitudetoward life and work, possibly leading to the misuseof alcohol and drugs (von Onciul, 1996).Internal or External Stressors/Acuteor ChronicIndividuals can experience two categories ofstressors: external or internal. External stressorscan be physical conditions, such as excessivetemperatures, or psychological environments, such

as abusive relationships. Internal stressors can bephysical illnesses or psychological tendencies, suchas an individual’s personality type. These stressorscan be described as either short-term (acute) orlong-term (chronic). Short-term acute stress is thereaction to a real or perceived immediate threat (thefight-or-flight response). Long-term chronicstressors are those that are continuous, such aswork pressures, ongoing relationship problems, andfinancial concerns (see Table 13-3).Table 13-3 External and Internal Stressors (Acute and/orChronic)ExternalInternalEnvironment—Noise, poor lighting orbright lights, extreme temperatures of hotor cold, confined spaces, violence andother threats to personal safety, generaleconomy, globalization, technology, war,and terrorismOther People—Rudeness, domineeringattitudes, aggression, peer pressure, anddiscriminationWork—Excessive rules and policies,poor interpersonal relationships, lack ofcommunication, mergers, downsizing,long and/or irregular hours, unrealisticdeadlines, retraining, discrimination, andpromotion or demotionLifestyle—Unhealthylifestyles, such asexcessive caffeine,smoking, drinking, drugs,lack of sleep, trying to dotoo much (e.g.,supermom)Mental State—Pessimistic, self-critical,self-helplessness,unrealistic expectations,and lack of flexibilityPersonality—Perfectionist, workaholic,perceived expectation ofothers and oneself, and

Major Life Events—Death of loved one,poor health and/or disability, loss of job,new job, marriage, divorce, bankruptcyor other financial worries, relocation, newbaby, caring for aging parents, andpending retirementEveryday Hassles—Commuting,misplacing keys or other important items,poor customer service, standing in lines,dealing with teenagers at homeother Type A personalitycharacteristicsIndividuals and StressStress comes in all forms and affects all people.Although there are no external standards that canbe applied to predict stress levels in individuals,research has provided us with some insight as towhich people are more prone to experience higherlevels of stress, such as certain personality types,members of minority groups, and individuals withcertain gender orientations.PersonalitiesRosenman and Friedman, along with theircolleagues (Rosenman et al., 1966), discoveredthe first relationship between stress and personalityby linking coronary heart disease (CHD) andpersonality profiles. Starting in the 1950s, the MountZion Harold Brunn Institute studied the role ofpersonality in CHD and found that participants with

Type A behavior patterns (TABP), such asaggressiveness, anger/hostility, competitiveness,time urgency, impatience, tenseness, and intensecommitment to goals, were at higher risk fordeveloping CHD than were people with Type Bpersonality traits (e.g., patient, low-key,noncompetitive) (Young, 1974). Although Type Bindividuals are as intelligent as Type A individualsand may be just as ambitious, they approach life ina different way (Quick et al., 1997). Friedman andRosenman (1974) define TABP as an “action-emotion complex that can be observed in anyperson who is aggressively involved in a chronic,incessant struggle to achieve more and more in lessand less time, and if required to do so, against theopposing efforts of other things or other persons” (p.84).Other studies suggest that rather than the entire setof Type A characteristics, only particulardimensions, such as tenseness, may be related toCHD (Kim et al., 1998). For example, Barefort,Dahlstrom, and Williams (1983) studied 255physicians over a 25-year period and found thatanger and hostility were the lethal dimensions ofTABP. At this time, researchers are still unsure whatcomponent or components of TABP constitute themost important factor leading to CHD for Type Aindividuals.

Another dimension of personality that is related tostress is the perception of control (Rotter, 1966).Employees with a high need for autonomy andcontrol over their environments, such as thepersonality traits displayed by Type A individuals,will experience a higher degree of stress when theyperceive a lack of control. For example, Kushnir andKasan (1991) found that high-demand jobscombined with high workload and low perceivedcontrol were stressful for Type A but not Type Bindividuals.Perceived control is defined as the amount ofcontrol that an individual believes they have overthe environment, whether direct or indirect, to makethe environment less threatening or more rewarding(Ganster & Fusilier, 1989). In the work setting, thisconcept is reflected in the extent to which anindividual is free to decide how to accomplish a taskor the goals of the job. Very low levels of personalcontrol have been found to be psychologicallyharmful, whereas greater control has beenassociated with better mental health (Evans &Carrere, 1991; Ganster & Fusilier, 1989). Highlevels of perceived control have been found toincrease an employee’s job satisfaction,commitment, and performance (Spector, 1986).Much of the research on perceived control stemsfrom Robert Karasek’s (1979) job demands–

decision latitude model. This model proposes thatthe effects of job demands (psychological stressorsin the work environment) on employee well-beingare influenced by job decision latitude (i.e., thedegree to which the employee has the potential tocontrol their work). Karasek found that individuals inoccupations with high demands and low decisionlatitude suffered the most severe psychosomaticcomplaints and the highest levels of bothdepression and job and life dissatisfaction. Otherstudies have confirmed that employees whoperceive that they are subject to high demands (jobresponsibility) but have little control over theirenvironment (authority and/or choices) are atincreased risk for stress-related illnesses such ascardiovascular disease (Karasek, Baker, Marxer,Ahlbom, & Theorell, 1981). For example, Fox,Dwyer, and Ganster (1993) found that nursesemployed in a medium-sized private hospital in theMidwest who experienced high workloads ordemands with perceived low controllability showedincreased physiological problems and lowerattitudinal outcomes (job satisfaction), with thephysiological responses continuing after the nursesleft work. The researchers suggested that it was notthe higher levels of workload or demands but thenurses’ perception of low controllability over thesituation that caused the nurses to display

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 onehas both the will and the way to accomplish one’sgoals) had a significant, positive relationship withthe perception of their health and ability to deal withthe demands and stressfulness of their jobs.An employee’s sense of loss of control is animportant form of emotional stress. Therefore,employers need to pay particular attention to thismatter in the workplace. Middle managers areamong those with the most stressful positions; theyneed to respond to others’ demands and projectdeadlines while having little perceived control overtheir environments. Savery and Hall (1986) relatethat “managers are beleaguered by demands notonly from their superiors but also from governmentagencies, from subordinates and unionrepresentatives pushing for a greater say in therunning of the enterprise, and from community andother interest groups with their many and risingexpectations. Many of these demands are alsomutually exclusive” (p. 160). Savery and Hall alsofound that a significant relationship existed betweenmanagers’ perceived lack of autonomy (i.e., control)in decision making and stress-related illnesses. Theresearchers further found that middle managers

under 30 years of age felt more stress than seniormanagers because the middle managersexperienced less autonomy, closer supervision, andmore confusion over lines of authority in theorganization.However, a perceived lack of control might not bestressful to some employees. Some employees maywant minimum control in their jobs. Theseemployees may not want the increasedresponsibility that is often connected with greaterjob autonomy. In such situations, a greater degreeof job control would actually have negative effectson the employee’s well-being.Underrepresented PopulationsThe nation’s workforce is becoming more culturallyand ethnically diverse. Surprisingly, the literature islimited about the specific impact of workplacediversity on organizations or about the stress thatsuch diversity imposes on members of differentcultural and ethnic groups (Keita & Hurrell, 1994;Quick et al., 1997). However, managers need to beattentive to the fact that employees fromunderrepresented ethnic groups may be more proneto stress than employees from majority groupsbecause of issues associated with prejudice anddiscrimination, whether perceived or real, as well as

potential language difficulties and differences incultural values and attitudes.Quick et al. (1997) point out that “blatant prejudice isthe most obvious source of stress for those inminority ethnic groups” (p. 57). For example, in anearly study, Kasschau (1977) found that the“overwhelming majority” of 800 minority surveyrespondents identified prejudice and discriminationat work. More recently, a survey of health careexecutives found that over 50% of Blackrespondents and 25% of Asian and Hispanicrespondents felt that that their careers had beennegatively affected by racial or ethnic discrimination,compared to 10% of White respondents (ACHE,2015). African Americans, Hispanic Americans, andWhite respondants who reported that they had beendiscriminated against were found to have poorermental health outcomes than their same-racecounterparts who did not acknowledge beingdiscriminated against (Roberts, Swanson, &Murphy, 2004).James, Lovato, and Khoo (1994) argue thatdifferences in cultural values and attitudes betweenworkers from underrepresented populations andmajority workers are a major source of stress forminority workers. For example, Cox, Lobel, andMcLeod (1991) found that Asian American, AfricanAmerican, and Hispanic American individuals have

a more collectivist orientation than EuropeanAmericans as described by Hofstede’s fourdimensions of national culture. Therefore, as aminority-culture member takes on a work role inwhich they attempt to fit in with a majority-cultureorientation, increased stress levels may occurbecause this attempt to fit in, or assimilate, causes adeparture from the societal role the person isexpected to fill in their collectivist community.Assimilation is the process by which an individualdevelops a new cultural identity. The individual whoassimilates into the dominant culture to becomesuccessful may eventually lose identification withtheir culture of origin. Members of minority culturesthat have a collectivist orientation may experiencestress as they attempt to assimilate into the majorityculture that dominates many workplaces. Forexample, Bell, as cited by Richard and Grimes(1996), found that African American women whowere career-oriented experienced more stress thantheir counterparts who were community-oriented orfamily-oriented. Because minority cultures maydiffer in race, attitudes, and beliefs from the majorityculture in an organization, minority members arelikely to find working in the organization stressful.Richard and Grimes (1996) point out that this is dueto the minority members’ need to work harder tosocialize, or assimilate, into the dominant

organizational culture for a significant portion of theirday.GenderOver the years, research has been conducted onthe stress levels of women, and considering that92% of the 4.3 million nurses and nursing aides inthe United States are female, health care employersneed to be sensitive to the work-related stressissues experienced by women. Statistics fromRoper Starch Worldwide’s (2000) Global 2000Consumer Study of 30,000 people between theages of 13 and 65 years in 30 countries showed thatincreased stress is felt worldwide, with womenconsistently reporting being more stressed thanmen. The most stressed women are mothers withchildren under the age of 13, full-time workingmothers, and full-time working mothers with childrenunder age 13. In addition, one-fourth of womenexecutives and professionals say that they feel“superstressed.”A second study, Creating Healthy CorporateCultures for Both Genders, revealed that stressaffects women differently from men (Peterson,2004). The study indicated that women reportednearly 40% more health problems than their malecounterparts and noticeably higher stress.

Furthermore, Swanson (2000, pp. 77–78) found thefollowing:Women face gender-specific work stress, suchas sex discrimination and the need to balancework and family demands, in addition to generaljob stressors such as work overload, lack ofcontrol over their job, or underutilization of theirskills.Barriers to financial and career advancementbased on sex discrimination have been linkedto more frequent psychological and physicalsymptoms, such as depression and high bloodpressure.Half of all working women will experience on-the-job sexual harassment at some point intheir lives, and women who experience sexualharassment report a range of psychologicalsymptoms, including depression, anxiety,fearfulness, and feelings of guilt and shame aswell as physical symptoms such as headachesand sleep disorders. Sexual harassment is aparticularly noxious stressor for women and hasa significant impact in terms of psychologicaldistress and absenteeism beyond thatattributable to regular job stressors.Beliefs About Stress

Research on stress suggests that one’s beliefsabout stress are associated with whether or notstress leads to heart damage or increased mortality.A 2012 study asked participants whether they hadexperienced high or low levels of stress over thepast year and then linked responses to public deathrecords. They found that people who indicatedexperiencing high levels of stress were 43% morelikely to die. However, the study also asked whetherpeople believed that stress was harmful to theirhealth. Surprisingly, the people who experiencedhigh stress but did not believe that stress washarmful were no more likely to die than were thosewho experienced low stress (Keller et al., 2012).These results suggest that an individual’s beliefsabout stress are significant in shaping whether ornot stress will have harmful effects on that person’shealth. Another study that examined people in astressful environment studied an intervention thathelped people see their body’s stress response aspositive. For example, breathing faster brings moreoxygen to the brain. Subjects who were taught tobelieve that stress could be helpful instead ofharmful to their health actually had a differentphysiological response that minimized potentialheart damage when compared to those whobelieved that stress was harmful to health(Jamieson, Nock, & Mendes, 2012). These

findings suggest that both stress and one’s beliefs

about stress may be important factors in how stressaffects one’s health.BurnoutStress occurs when job requirements do not matchthe employee’s capabilities, resources, or needs .Studies show that stressful working conditions areassociated with increased absenteeism, tardiness,and turnover, which affects an organization’sproductivity and profitability. An extreme case of job-related stress is known as burnout.First discovered in the 1970s, burnout has beenrecognized as an occupational hazard in people-oriented professions such as health care, humanservices, and education (Maslach & Goldberg,1998). Burnout symptoms include overwhelmingexhaustion; feelings of frustration, anger, andcynicism; and a sense of ineffectiveness and failure.Burnout is a major issue among health careworkers. Health care professionals have reportedsubstantially higher degrees of burnout than havemanagers who are not employed in the health careindustry (Golembiewski & Boudreau, 1991).Harvard School of Public Health announced burnoutas a public health crisis (Jha et al., 2019). In 2018, asurvey found that 78% of physicians reportedexperiencing symptoms of burnout (Hawkins,2018). An earlier study reported that 33% of new

nurses seek another job within a year (Lucian LeapInstitute, 2013). Suicide rates have been found to be1.4 times and 2.27 times higher among physiciansthan in the general population for males andfemales, respectively (Schernhammer & Colditz,2014). This has resulted in estimates of more than300 suicides per year (Frank, Biola, & Burnett,2000), which equates to roughly two full medicalschool classes (AMA, 2017).Burnout can have serious implications for a healthcare organization’s ability to provide good care to itspatients and for its bottom line. A more engagedworkforce is associated with higher patientsatisfaction and a lower incidence of medical error(Shanafelt et al., 2010). One study found that thecost of replacing one full-time physician, includinglost revenue, recruitment and startup costs, isapproximately $1.2 million (Scutte, 2012). If multiplephysicians leave or reduce clinical hours because ofburnout, the result could be potentially generatingmillions of dollars in additional costs. Furthermore,as a society, it takes at least 12 years to create onephysician (considering undergraduate and medicalschool and residency training). Therefore, when aphysician leaves the field of medicine altogether, ittakes a long time to produce a replacement. Thereis a physician shortage in the United States, whichis expected to worsen in future years. Total

shortfalls are expected to reach between roughly60,000 to 90,000 physicians by 2025, and currentshortfalls are estimated to be in the tens ofthousands (Shanafelt, Dyrbye, West, & Sinsky,2016).Maslach and Jackson (1981) identified threedimensions associated with burnout: emotionalexhaustion, depersonalization, and diminishedpersonal accomplishment.Emotional exhaustion results in apathy and lossof concern, a feeling that one has reached theend of one’s rope. As their emotional resourcesare depleted, health care professionals feel thatthey cannot give of themselves emotionally orpsychologically.Depersonalization is characterized by thedevelopment of negative and cynical attitudestoward the workplace and toward people withwhom one interacts (patients and coworkers inthe case of health care professionals).Depersonalized individuals distancethemselves and see other people as things orobjects.Diminished personal accomplishment ischaracterized by the tendency to evaluateoneself negatively, including viewing oneself asperforming poorly in the job—a job that is

viewed as having no worth or meaning (lowprofessional efficacy).Golembiewski and his associates (Golembiewski,1986, 1990; Golembiewski & Boss, 1991;Golembiewski & Boudreau, 1991) studied over13,000 managers and health care professionalsregarding burnout. The researchers found thatvarying degrees of burnout existed and that healthcare workers experienced the most advancedphases (Golembiewski & Boudreau, 1991). Asillustrated in Table 13-4, Golembiewski’s phasemodel suggests that employees who are sufferingfrom burnout first experience depersonalization,which induces feelings of inadequacy, followed bydiminishing personal accomplishment and endingwith emotional exhaustion. Golembiewski andBoudreau relate that employees show growingdeficits or deficiencies as they move from phase tophase:Table 13-4 Golembiewski’s Phases of Burnout

Broad ranges of perceptions or attitudes aboutthe worksite deteriorate; for example,satisfaction and job involvement fall, andtension at work increases.Performance appraisals tend to decrease.Physical symptoms increase.Turnover increases.Self-esteem decreases.Various clinical indicators of mental healthshow deterioration.The quality of social andemotional life at work declines; for example,group cohesiveness is down and social supportfalls.In support of Golembiewski’s phase model, Kalliath,O’Driscoll, Gillespie, and Bluedorn (2000) found thatnurses, laboratory technicians, and managersemployed by a general community hospital in aMidwestern city who reported higher levels of

burnout experienced decreased job satisfaction,decreased satisfaction with interpersonalrelationships, and lower levels of organizationalcommitment reflected by either job turnover orincreased intentions to leave their jobs.PresenteeismAs was noted earlier, symptoms of burnout mayinclude lower job performance and satisfaction,higher job tension and turnover, and increasedabsenteeism. However, a low rate of absenteeismdoes not always indicate that employees are notsuffering from burnout. A relatively new buzzword is“presenteeism,” which occurs when employeesshow up for work but are less productive because ofillness. A study of 29,000 U.S. employees estimatedthat absenteeism and presenteeism cost U.S.industry more than $60 billion a year and that morethan three-fourths of lost productivity is explained bypresenteeism, not by absenteeism (Stewart et al.,2003). Dow Chemical Company estimates thatpresenteeism has the largest health-relatedeconomic impact on the company, ahead ofabsenteeism, health insurance, and workers’compensation (Berry, Mirabito, & Berwick, 2004).A pilot study assessing the impact of 28 medicalconditions on workers’ productivity was conductedby Tufts–New England Medical Center researchers

at Lockheed Martin Corporation. The researchersfound that employees who came to work sick duringthe study year—with ailments such as allergies,headaches, lower-back pain, arthritis, colds, and theflu—cost Lockheed Martin approximately $34 million(Hemp, 2004). A study of British workers found thatthe number of sick days workers take was halvedbetween 1993 and 2017, likely owing to a changingworkplace culture that is not supportive of takingsick time off. A survey found that only 42% of seniormanagers thought that having the flu was a seriousenough reason to miss work (Rubinstein, 2019). Inhealth care, workers who continue to work whilecontagious with serious illnesses such as the flu canhave serious and sometimes deadly affects onimmunocompromised patients. (See Case Study13-1.)CASE STUDY 13-1Presenteeism: A Public HealthHazardOn January 19, 2005 (day 1), three nursinghome residents and one staff member at a100-bed, two-floor urban facility developedsymptoms of nausea, vomiting, and diarrhea.General infection control measures werereinforced, including hand hygiene education

for nursing home residents and staff, contactisolation for symptomatic residents, and newsurface disinfection procedures. On days 2and 3 of the outbreak, seven more residentsdeveloped similar symptoms, as well as fouradditional staff. Two of these staff membersreported diarrhea after arriving at work andwere asked to go home after discussions withthe infection control team. At this point, thepublic health department was notified andmore 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; anddiscontinuation of new admissions. Staffingstrategies were also temporarily changed sothat nursing staff did not float in or out of theunit. As per policy, supervisors were instructedto refer employees with signs or symptoms ofan infectious illness to Employee Health fordiagnosis and determination of suitability tocontinue work. However, no daily systematicscreening process took place to identify ill staffmembers at the start of their shift.Over the course of the next 10 days, 23residents and 18 staff developed symptoms of

nausea, vomiting, and diarrhea. Laboratorystudies of affected staff and residentsconfirmed norovirus genotype 2. By day 8 ofthe outbreak, it became increasingly clear thatill staff members continued to work despitestrong recommendations to the contrary bymanagement. Often, symptoms were notreported until employees had arrived for andsometimes completed their shifts. Severalemployees also reported ill family memberswith similar symptoms. Infection Controlresponded by contacting each ill staff memberto verify symptoms, provide education, andask that they remain home. Several nursingstaff members who were symptomatic at workwere asked to leave as soon as they reportedsymptoms and to not return until they receivedclearance from Employee Health. Staffing wasmanaged through the use of registry or perdiem nursing coverage when appropriate.No new cases occurred from days 13 through17 of the outbreak. However, on day 18, astaff member arrived at work ill withgastrointestinal symptoms. On day 21, anadditional two residents developedgastroenteritis. As voluntary measures toprevent presenteeism failed, the localdepartment of public health mandated

enforcement of “back to work” rules. Theserules required employees with gastrointestinalsymptoms to obtain clearance from EmployeeHealth before being allowed to return to work.This clearance was given only after 48symptom-free hours had elapsed. The finalcase was identified 24 days into the outbreak,and gastroenteritis-specific infection controlmeasures were discontinued on day 34.Reproduced from Widera, E., Chang, A., & Chen, H. L. (2010).Presenteeism: A public health hazard. Journal of General InternalMedicine, 25(11), 1244–1247.

▶ Causes of WorkplaceStressWorkplace stress can be related to (1) individualtask demands, (2) individual role demands, (3)group demands, and (4) organizational demands(Kinicki & Williams, 2003) (see Table 13-5).Table 13-5 Job StressorsCategories of JobStressorsExamplesIndividual TaskDemands (factorsunique to the job)Workload (overload and underload)Pace/variety/meaningfulness of workAutonomy (e.g., the ability to makeyour own decisions about your ownjob or about specific tasks)Shift work/hours of workPhysical environment (noise, airquality, etc.)Isolation at the workplace (emotionalor working alone)Individual RoleDemands (role in theorganization)Role conflict (conflicting jobdemands, multiple supervisors ormanagers)Role ambiguity (lack ofclarity about responsibilities,expectations, etc.)Level of responsibility

Difficulties balancing work andpersonal livesGroup DemandsRelationships at work withsupervisors, coworkers, andsubordinatesThreat of violence, harassment, etc.(threats to personal safety)Lack of participation in decisionmakingInappropriateleadership/management styles(autocratic versus participatory)OrganizationalDemands (includingorganizationalstructure andclimate)Management/leadership stylesCommunication patternsCareer development opportunities(under-/overpromotion)Job securityUnplanned changeOverall job satisfactionMurphy, L. R. (1995). Occupational stress management: Currentstatus and future directions. In C. L. Cooper & D. M. Rousseau(Eds.), Trends in organizational behavior (Vol. 2, pp. 1–14). WestSussex, UK: John Wiley & Sons.Individual task demands include unrealisticdeadlines, fear of failure, new technology, lackof necessary resources (e.g., poor physicalwork environment, such as noise, heat, andcrowding), work overload, lack of control, and

repetitive, unchallenging work (workunderload).Individual role demands include job ambiguity,role conflict, and difficulty balancing work andfamily life.Group demands include poor interpersonalrelationships with coworkers and/orsupervisors, inadequate support, and lack ofparticipation in decisions.Organizational demands encompass politics,communication problems, excessive rules andregulations, organizational structure andculture, lack of career development activities,and change without clear strategic direction.How these various demands can affect employees’stress levels is illustrated in Case Study 13-2.CASE STUDY 13-2 Stress inToday’s WorkplaceThe longer he waited, the more David worried.For weeks, he had been plagued by achingmuscles, loss of appetite, restless sleep, anda sense of complete exhaustion. At first, hetried to ignore these problems, but heeventually became so short-tempered andirritable that his wife insisted that he get acheckup. Now, sitting in his primary care

physician’s office and wondering what theverdict would be, David didn’t even noticewhen Theresa took the seat beside him. Theyhad been good friends when she worked inthe billing office at the drug-manufacturingfacility where David worked, but he hadn’tseen her since she left 3 years ago to take ajob as a member service representative at alocal health maintenance organization. Hergentle poke in the ribs brought him around,and within minutes, they were talking andgossiping as if she had never left.“You got out just in time,” he told her. “Sincethe reorganization, nobody feels safe. It usedto be that as long as you did your work, youhad a job. That’s not for sure anymore. Theyexpect the same production rates even thoughtwo people are now doing the work of three.We’re so backed up I’m working 12-hour shiftssix days a week. I swear I hear thosemachines humming in my sleep. Employeesare calling in sick just to get a break. Morale isso bad they’re talking about bringing in someconsultants to figure out a better way to getthe job done.”“Well, I really miss everyone,” she said. “I’mafraid I jumped from the frying pan into the

fire. In my new job, the computer routes thecalls, and they never stop. I even have toschedule my bathroom breaks. All I hear thewhole day are complaints from unhappymembers. I try to be helpful and sympathetic,but I can’t promise anything without getting mysupervisor’s approval. Most of the time, I’mcaught between what the member wants andcompany policy. I’m not sure who I’msupposed to keep happy. The other reps areso uptight and tense they don’t even talk toone another. We all go to our own littlecubicles and stay there until quitting time. Tomake matters worse, my mother’s health isdeteriorating. If only I could use some of mysick time to look after her. No wonder I’m inhere with migraine headaches and high bloodpressure. A lot of the reps are seeing theemployee assistance counselor and takingstress management classes, which seems tohelp. But sooner or later, someone will have tomake some changes in the way the place isrun.”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 notutilize workers’ skills, and provide littlesense of control.Example: David works to the point ofexhaustion. Tied to the computer,Theresa is allowed little room forflexibility, self-initiative, or rest.Management Style: Lack of participationby workers in decision making, poorcommunication in the organization, lackof family-friendly policies.Example: Theresa needs to get hersupervisor’s approval for everything, andher employer is insensitive to Theresa’sfamily needs.Interpersonal Relationship: Poor socialenvironment and lack of support or helpfrom coworkers and supervisors.Example: Theresa’s physical isolationand the tension within the office reduceher opportunities to interact with hercoworkers or receive help from them.Work Roles: Conflicting or uncertain jobexpectations, too much responsibility, toomany “hats” to wear.Example: Theresa is often caught in adifficult situation trying to satisfy both the

members’ needs and her employer’sexpectations.Career Concerns: Job insecurity and lackof opportunity for growth, advancement,or promotion; rapid changes for whichworkers are unprepared.Example: Since the reorganization at thedrug-manufacturing facility, everyone,including David, is worried about theirfuture with the company and what willhappen next.Environmental Conditions: Unpleasant ordangerous physical conditions such ascrowding, noise, air pollution, orergonomic problems.Example: David is exposed to constantnoise at work.Modified from National Institute for Occupational Safety and Health.(1999). Stress at work. DHHS (NIOSH) (Publication No. 99–101).Cincinnati, OH: Author. Available at:https://www.cdc.gov/niosh/docs/99-101/. Last accessed December18, 2019

▶ Coping with StressCoping with stress at work can be defined as “aneffort by a person or an organization to manage andovercome demands and critical events that pose achallenge, threat, harm or loss to that person andthat person’s functioning or to the organization as awhole” (Schwarzer, 2004, p. 342). Coping isconsidered one of the top skills of effectivemanagers. With population samples from business,education, health care, and state governments,Whetton and Cameron (1993) identified 402effective managers on the basis of responses frompeers and superiors. Responses from theparticipants revealed that coping with stress wassecond on a list of 10 skills attributed to effectivemanagers.Stress is inevitable, but the degree of stress that isexperienced can be modified in two ways: bychanging the environment and/or by changing theindividual. This is referred to as stress management.Stress management can refer to a narrow set ofindividual-level interventions (e.g., relaxationtraining, biofeedback, meditation) or a broadermeaning that includes any type of stressintervention (Murphy, 1995). However, to be

successful, stress management interventions needto target characteristics of the individual worker, thejob, and the organization.Schwarzer (2004) provides managers with a modelusing four perspectives for assisting themselves andothers to cope with job-related stress (refer toFigure 13-3). The differences between theperspectives are based on time-related stressappraisals and on the perceived certainty of criticalevents or demands. The four perspectives are (1)reactive coping, (2) anticipatory coping, (3)preventive coping, and (4) proactive coping.Figure 13-3 Four Coping PerspectivesReactive coping refers to efforts to deal with astressful encounter that either is ongoing or has

already happened, such as a job loss ordemotion.Anticipatory coping pertains to efforts to dealwith an inevitable event that is certain to occurin the near future, such as public speaking, ajob interview, or downsizing.Preventive coping refers to an effort to build upresistance resources, whereby the level ofstress felt by an individual is reduced (theseverity of impact is minimized) if a criticalevent is expected to occur in the future. Forexample, an individual might return to school toearn a master’s degree in health administrationor completes the requirements to become aboard-certified health care executive inanticipation of a possible job loss due to amerger or buyout.Proactive coping is defined as an effort to buildup general resources that facilitate movementtoward challenging goals and personal growth,such as hardiness training and learnedoptimism (Schwarzer, 2004).As Schwarzer (2004) points out, “The distinctionbetween these four perspectives of coping is highlyuseful because it moves the individual’s focus awayfrom mere responses to negative events towards abroader range of risk and goal management that

includes the active creation of opportunities and thepositive experience of stress” (p. 349).Organizational Coping StrategiesAt the organizational level, when reactive coping oranticipatory coping occurs, managers’ efforts arefocused on reducing the harm or loss to theorganization. Managers using reactive coping oranticipatory coping are concerned with putting outfires rather than with using their efforts to developand implement preventive and proactive copingstrategies, which are more beneficial for both theorganization and the employee. For example,preventive coping is called for when no specificevent is envisioned but a more general threat in thedistance comes into view, such as an economicdecline, a potential merger or downsizing, an agingworkforce, or new technology (Schwarzer, 2004).The health care industry is using preventive copingstrategies to deal with the envisioned futureshortage of health care leaders as the workforceages. For example, HCA, Inc. anticipated that manyof the baby boom–generation chief executiveofficers (CEOs) at its hospitals would retire within a10-year period. Furthermore, given the likelihoodthat those vacancies would be filled by incumbentchief operating officers (COOs), HCA anticipated ahospital leadership gap at the COO level. To

address this challenge proactively, HCA created anintensive COO development program. This programwas a development-in-place approach whereby theprogram is not supplemental to the duties of aregular hospital job, but instead individuals are hiredby HCA for the sole purpose of participating in theprogram with the goal of developing critical,advanced executive-level skills. Participants weregiven the title of “associate administrator” and wereassigned to an HCA hospital. The current CEO ofthe hospital served as the associate administrator’smentor and superior over a 2- to 4-year period. Aftersuccessfully completing the development program,the associate administrator would be promoted toCOO for one of HCA’s hospitals (HCA, 2004).Preventive coping and proactive coping are alsoreferred to as primary prevention or organizationalprevention (Quick et al., 1997). Organizationalprevention is designed to enhance an employee’shealth and performance at work by eliminating thestressors that lead to distress. Methods toaccomplish this include modifying work demandsand improving relationships in the workplace(Schwarzer, 2004). Anticipatory coping is related tosecondary prevention; the goal is changingindividual stress responses to necessary demands.Reactive coping may be referred to as tertiaryprevention, which attempts to minimize the amount

of individual and organizational distress that resultswhen organizational stressors and resulting stressresponses have not been adequately controlled(Quick et al., 1997) (see Figure 13-3).To illustrate these coping concepts, consider thefollowing scenario: A physician displaysinappropriate behavior* toward a nurse (a stressor),which leads to the nurse experiencing anxiety (astress response), and in turn, the nurse resigns (anorganizational consequence of distress). Primaryprevention would attempt to eliminate the stressorby having the hospital establish a zero-tolerancepolicy regarding inappropriate physician behavior(preventive and/or proactive coping). Secondaryprevention would address the problem by providingprograms to improve interpersonal relationsbetween physicians and nurses (anticipatorycoping). These programs may include improvingteam building and communication skills, wherebythe physician recognizes that nurses are an integralpart of the patient’s health care team andinteractions should therefore be based on mutualrespect and trust. Tertiary prevention might includeestablishing an employee assistance programdesigned to help nurses to cope with inappropriatebehavior by physicians.

The preceding example is based on a study thatlinked inappropriate physician behavior with nursesleaving the nursing profession. Rosenstein (2002)surveyed 1200 nurses, physicians, and executiveadministrators at several hospitals affiliated withVHA, a national network of community-ownedhospitals and health care systems, to assess howthese disparate groups viewed nurse–physicianrelationships, disruptive physician behavior, theinstitutional response to such behavior, and howsuch behavior affected nurse satisfaction, morale,and retention. Rosenstein found that dailyinteractions between nurses and physicians stronglyinfluence nurses’ morale. All respondents indicatedthat they were concerned with the significance ofnurse–physician relationships, and over 90% of allrespondents reported witnessing disruptivephysician behavior and that they saw a direct linkbetween this disruptive behavior and nursesatisfaction and retention. In addition, 30% of thenurse respondents reported knowing at least onecolleague who had resigned because of disruptivephysician behavior.Subsequent research by Rosenstein and O’Daniel(2005, 2006, 2008) found an almost equal amountof disruptive behavior in nurses and other hospitalemployees, but more disconcerting was thedownstream negative impact of disruptive behavior

on stress levels, loss of focus, concentration,communication, collaboration, and informationtransfer resulting in medical errors, adverse events,and significant compromises in patient safety,quality, and even mortality. As was noted earlier,The Joint Commission issued a 2008 standardrequiring hospitals to develop a disruptive behaviorpolicy and provide necessary education about thistopic.* Inappropriate physician behavior may be defined as “anyinappropriate behavior, confrontation or conflict, including verbalabuse to physical and sexual harassment” (Rosenstein, 2002, p.26).

▶ Joy in WorkThe Institute for Health care Improvement hassuggested the “Joy in Work” framework to helpsenior leaders, managers and individuals identifytheir roles in reducing stress and burnout in theworklife by seeking to increase joy in work, resultingin happy, healthy and productive employees, seeFigure 13-4. The basic premise is that employeescan better withstand the stressors that are inevitablein health care if they can find joy in the work theyare doing.

Figure 13-4 Components for Improving Joy in WorkPerlo, J., Balik, B., Swensen, S., Kabcenell, A., Landsman, J., &Feeley, D. (2017). IHI framework for improving joy in work. IHI

White Paper. Cambridge, MA: Institute for HealthcareImprovement. Available from ihi.orgThe IHI suggests nine components that are criticalfor improving joy in work (see Table 13-6).Table 13-6 Description of Components for Improving Joyin WorkPhysical andPsychologicalsafetyPhysical—People feel safe from physical harm atworkPsychological—People feel free to change, to sharefeedback and ideas, and to admit mistakes.Meaning andPurposePeople feel that they are making a difference andcan connect their daily work to the mission andpurpose of the organization.Choice andAutonomyPeople have choice in how they structure andaccomplish their daily work and a voice in changesthat affect them.Recognitionand RewardsPeople are recognized for their contributions andrewarded accordingly.ParticipativeManagementManagers encourage and engage others in theirdecision making processes, and regularly gather andincorporate feedback.CamaraderieandTeamworkPeople feel that they are a part of a team and havemutual support and companionship at work.DailyImprovementA proactive approach to improvement is a part ofdaily practice across the organization .Wellness andThe organization values and invests in the wellness

Resilienceand well-being of its employees. Taking care of one’sown well-being is seen as a part of the largerorganizational effort, not a stand-alone solution.Real-timeMeasurementSystems allow for regular feedback and performancemonitoring to support ongoing improvement.Modified from Perlo, J., Balik, B., Swensen, S., Kabcenell, A.,Landsman, J., & Feeley, D. (2017). IHI framework for improving joyin work. IHI White Paper. Cambridge, MA: Institute for HealthcareImprovement. Reprinted from www.IHI.org with permission of theInstitute for Healthcare Improvement (IHI), ©2019.As noted above, an employee’s work setting maycreate physical stress because of noise, lack ofprivacy, poor lighting or ventilation, and so forth.Therefore, organizations should redesignemployees’ physical settings to minimize distressfuleffects (i.e., primary preventive and proactivecoping). For example, Williams (2003) found thatthe odds of feeling stress because of fear ofaccident or injury were 7.2 times higher foremployees working in health care occupations thanthose in the fields of management, business,finance, or science. This high source of workplacestress by health care workers may be caused bytheir constant exposure to risk of infection, longhours, and irregular shifts. Other studies haveshown that the creation of pleasant and suitablework areas can elevate an employee’s job

satisfaction, job safety, and mental health, whichmay indirectly improve job performance.Job DesignAnother important component of reducing work-related stress is job design. Proper job designaccommodates an employee’s mental and physicalabilities. According to the MFL Occupational HealthCentre (2000), a Canadian community health centerwhose mission is to improve workplace health andsafety conditions and eliminate hazards, employerscan better design jobs by doing the following:Clearly defining jobs and responsibilities thatreduce role conflict and/or role ambiguity;Giving workers a say in how they do their jobs;Giving workers opportunities to learn new skills;Allowing time for social interactions amongworkers;Making work schedules flexible forresponsibilities outside of work;Clearly communicating about job security;Training managers to apply participative-management styles as part of a culture thatemphasizes open communication, support, andmutual respect;Implementing effective performance-management systems with clear expectations

and procedures that are understood bymanagers and staff;Ensuring that effective change managementaccompanies organizational change.

▶ Individual CopingStrategiesAt the individual level, one of the best techniques forreducing stress is through the relaxation response(see Exhibit 13-1). However, relaxation is a reactivecoping strategy as a result of an individual’sappraisal of a threat or harm/loss situation such asfailing to meet a work goal, conflict with a colleagueor supervisor, or job loss. Reactive coping strategiesdo little if anything to solve the underlying problems.Therefore, employees need to learn to usepreventive and proactive coping strategies so thattheir fight-or-flight response is not automaticallyengaged at the first sign of stress (Schwarzer,2004).Exhibit 13-1 How to De-stressOne of the most well-documented techniquesfor reducing stress is through the relaxationresponse, a term coined by Dr. Herbert Bensonof Harvard Medical School to describe a stateof deep, mindful rest that offsets the physicaleffects of stress by lowering heart rate, bloodpressure, and breathing rate. The relaxation

response can be elicited at any time and in anyplace by sitting comfortably with your eyesclosed, breathing slowly, letting your musclesrelax, and repeating a certain word, sound,phrase, or prayer for 10 minutes whiledisregarding all other thoughts. The slow,repetitive movements and meditative thoughtsinvolved in activities such as yoga and T’ai Chihave also been found to evoke a similarphysiological response, which in turn can helpyou to think more rationally about your ownpredicament and how you can work to improveit.Reproduced from Optimistic People Live Longer. (2003, January).Tufts University Health and Nutrition Letter, 20(11), 4-5.Friedman (1999) suggests training employees tocope with stressful situations by improving theirproblem-solving and conflict resolution abilities anddeveloping their leadership skills. For example,when an employee is going to be facing stress dueto increasing workload, they can be trainedbeforehand how to delegate tasks, use good timemanagement skills, and increase their socialsupport system. In addition, employees need tolearn how to maintain a healthy balance betweenwork, family, and leisure activities, although thismay be a difficult process for workaholics and

individuals displaying other Type A personalitycharacteristics. It is known that healthy lifestyles(e.g., nutrition and exercise) provide a protectiveshield against the experience of stress (Schwarzer,2004). In addition, the use of learned optimism andresilience training has been shown to be successfulin assisting employees to reinterpret perceivedthreats (i.e., stressful events) into challenges,thereby transforming distress into eustress.Learned OptimismFrom extensive research throughout his career as apsychologist, Martin Seligman (1991) developed theconcept of learned optimism and applied it directlyto workplace productivity. According to Seligman,when pessimistic people run into obstacles in theworkplace, they give up. By contrast, whenoptimistic people encounter obstacles, they tryharder. Seligman’s learned optimism theorysuggests that people can undo pessimistic thinkingand learn optimism by recognizing and thendisputing their own negative thoughts and beliefs.Optimism is not the same as the popular concept ofpositive thinking. Optimists and pessimists attributethe reasons for success and failure differently.Drawing on attribution theory, Seligman (1991)refers to how a person interprets events as theirexplanatory 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 outcomesare temporary or permanent. For example, ifthe outcome is negative, the optimist tends tothink that the event was an isolated incident. Ifthe outcome is positive, the optimist tends tothink that it will reoccur in the future. Bycontrast, the pessimist views positive outcomesas one-time events and negative outcomes asmore likely to occur in the future.Globality refers to whether the event’soutcomes are specific to this one situation orwhether the outcomes apply to everything in aperson’s life. For example, when a positiveevent occurs, the optimist is more likely toextend the outcomes to their whole life. When anegative event occurs, the optimist will tend toisolate the incident as being specific to thatsituation. The opposite holds true for thepessimist: Positive events are viewed asstrokes of good luck, and negative events areviewed as representative of the person’s wholelife.Locus of control refers to whether the individualbelieves that the outcome is attributable to theiractions or to factors in the environment. Forexample, when a positive event occurs, the

optimist attributes the success to their ownefforts. When a negative event occurs, theoptimist looks to causes outside of their control,such as bad luck, to explain the outcome. Thepessimist will view positive events asattributable to good luck, other people’s hardwork, or something else outside of their controland negative events as being caused by theirown personal deficiencies.Pessimists tend to attribute failure and negativeevents to permanent, personal, and pervasivefactors. Optimists tend to attribute negative eventsto nonpersonal, nonpermanent, and nonpervasivefactors. Optimists attribute their failures to causesthat are temporary rather than stable, specific to theattainment of a particular goal rather than all theirgoals, and see the problem as a result of theenvironment or setting they are in rather than beinginherent in themselves. Optimists have high self-efficacy and view setbacks, obstacles, and anoncontingent environment as challenges thatprovide excitement in their lives (Seligman &Csikszentmihalyi, 2000). The opposite is true forpessimists. Pessimists see no relationship betweentheir actions and goal attainment. Their low outcomeexpectancy causes deficits in future learning as wellas motivational disturbances such as procrastinationand depression (Seligman, 1991). Thus, even when

the situation changes so that they can exert controlover their environment and make progress towardtheir goal, pessimists do not try to do so becausethey have learned that giving up is a rationalresponse. Their attribution has led to what isreferred to as learned helplessness (see Exhibit 13-2) (Seligman, 1991). An individual’s habitualblaming of themselves undermines self-efficacy(Bandura, 1997).Exhibit 13-2 Learned HelplessnessLearned helplessness is an acquired conditionthat has a negative impact on an individual’sphysical, emotional, mental, and spiritual well-being. It is a phenomenon in which people whoexperience failure at a task, often numeroustimes, determine that the task cannot beaccomplished—at least not by them—and sothey stop trying. They internalize their failures(self-blame) and develop a helpless attitude.A study on learned helplessness looked atstress levels in two groups that were subjectedto the same loud and unpleasant noise. Onegroup was given a button that could turn thenoise off, while the second group was not givenany way to turn it off. The subjects who weredenied control over the noise experienced

significant stress and called the noise“unbearable.” The group that had the option ofturning off the noise considered the noise only“unpleasant” but chose not to turn off thesound. Just knowing that they had the option ofturning the noise off was enough.Following the sound session, the researchersobserved that the group that had beensubjected to helplessness in the noiseexperiment tended to act helpless insubsequent situations, whereas the group thathad been given control to turn off the noise inthe experiment looked for and chose toexercise control over subsequent situations.Both helplessness and empowerment arelearned conditions. Once learned, they areextended into other areas of life.Optimism may serve as a buffer against thephysiological effects of stress. Research suggeststhat the immune function in optimists is better thanthat in pessimists. It is not that optimists experiencefewer stressful situations than pessimists; optimistsare just more adept at coping with such situations,so they can work through the problems and developsolutions rather than feeling helpless or like victims.

▶ Stress ManagementProgramsOrganizations are developing comprehensive healthpromotion strategies for their employees, whichinclude various types of individual-level stressmanagement programs (Schwarzer, 2004). Stressmanagement programs often consist of breathingand stretching exercises, yoga, meditation, and/ormassage. The programs’ goals are to lessen theadrenaline response to minor stress. For example,St. Paul Fire and Marine Insurance Companyconducted several studies on the effects of stress-prevention programs in hospital settings. Programactivities included (1) employee and managementeducation on job stress, (2) changes in hospitalpolicies and procedures to reduce organizationalsources of stress, and (3) establishment ofemployee-assistance programs. In one study, thefrequency of medication errors declined by 50%after prevention activities were implemented in a700-bed hospital. In a second study, there was a70% reduction in malpractice claims in 22 hospitalsthat implemented stress-prevention activities. Incontrast, there was no reduction in claims in amatched group of 22 hospitals that did not

implement stress-prevention activities (Jones et al.,1988).In another example, Baptist Health South Florida(BHSF), the largest nonprofit health careorganization in South Florida, provides a holisticapproach to the well-being of its staff. Theorganization sponsors a healthy lifestyle program forits employees, called the Wellness Advantage. On-site fitness coaches are available to employees ateach of the system’s six hospital fitness centers toprovide screening and personal training. Discountsare offered to employees who choose the mealsthat are designated “healthy” in the system’scafeterias. For employees who face life-threateningillnesses, the system offers flexible, reducedscheduling so that the employees can maintainsome level of employment during stressful times.Senior management believes that the organization’ssuccess, as measured by patient satisfaction,physician satisfaction, employee satisfaction, clinicaloutcomes, and operating profits, is directly owed tothe “healthy” infrastructure of its employees. BaptistHealth’s commitment to its employees is recognizednationally. The National Business Group on Healthhas recognized Baptist Health’s longtimecommitment to its employees by naming the healthsystem one of the Best Employers for Healthy

Lifestyles for the past 10 years (BHSF, 2015; May,2004).Crampton, Hodge, Mishra, and Price (1995)contend that stress management programs need tocontribute to the goals and needs of both theorganization and the individual. Organizations needto believe that the benefits of stress managementprograms outweigh their costs. Employees need toperceive that they will benefit from stressmanagement programs or they will not voluntarilyparticipate. To meet both organizational andindividual goals, Crampton and colleagues providethe following recommendations:Preventive and/or Proactive Coping (PrimaryPrevention)1. Identify the major stressors in the workplaceand assess which ones are controllable.Organizations should do more than simplyprovide stress management techniques. Ifthe causes of stress can be reduced oreliminated, they should be. Organizational-level strategies might include redesigningemployees’ jobs; improving the selection,placement, and orientation of newemployees; providing employees with moreparticipation and autonomy in decisionmaking; disseminating information; providing

needed education and training; reducingworkloads or the pace of work; modifyingwork schedules to be compatible withdemands and responsibilities outside of work;conducting time management programs;clearly defining work roles; providingopportunities for career development; andproviding emotional and task support.2. Communicate with employees about thebenefits of stress management. Explain whatstress is, along with the health implications ofexcess stress or distress. Employees shouldbe encouraged to lead healthier lives bylowering their stress on the job as well as athome.Anticipatory Coping (Secondary Prevention)1. Help employees to identify their stressorsand stress-tolerance levels. Before learninghow to deal with stress, employees first haveto identify the stressors to which they react,because not everyone responds the sameway to the same stressors. To aid in thisprocess, organizations can conduct health-risk appraisals that test for their employees’levels of stress.2. Develop individualized stress managementprograms that meet the needs of the

organization’s employees. Programs shouldbe topic-specific and should be implementedin stages. If all aspects of a program areimplemented at one time and parts of theprogram fail, employees will lose faith in theprogram and in management. This will beanother cause of anxiety and stress for theemployee. Stress management programsmay include learning relaxation andmeditation techniques, developing a goodsupport system, undertaking outside hobbies,learning to set realistic goals, developing timemanagement skills, and learning when to sayno rather than taking on more than one canhandle.3. Communicate with employees. Providingmore information about their jobs and otherfactors that affect them will allow employeesto feel more in control of their circumstancesand can help to build cohesion.Organizations must also communicate anddescribe the stress management strategiesthat are available to employees and musthelp employees to develop personalizedaction plans.Reactive Coping (Tertiary Prevention)

1. Make sure employees learn to recognizesymptoms of distress. These may includegastrointestinal problems, rapid pulse,frequent illness, insomnia, persistent fatigue,irritability, lack of concentration, andincreased use of alcohol and/or drugs.Common methods used to help identifystressors and symptoms include self-reportmeasures (e.g., interviews and surveys),behavioral measures (e.g., observation andperformance measures), and physiologicalstress measures (e.g., heart rate and bloodpressure).2. Exercise and maintaining a nutritious diet aretwo of the most agreed-upon stressmanagement techniques. Organizations canhelp employees by providing information andaccess to physical recreation facilities orequipment by either establishing on-sitefacilities or providing memberships to localhealth clubs. One type of organizationalstress management program providesemployees with access to an employeeassistance program, a corporatepsychologist, a toll-free hotline, or some otherform of counseling assistance. Theseprograms can help employees to deal with a

variety of problems that range from learningto cope to dealing with substance abuse.3. Help employees to keep a positiveperspective on life and feel a sense ofpurpose. It is important for employees to feelthat they are making a valuable contributionto the organization.

▶ SummaryStress has become a widely used butmisunderstood term, and a number ofmisconceptions about stress exist. The firstmisconception is that all stress is negative. A certaindegree of stress is necessary for good mental andphysical health; it can be viewed as positive orconstructive stress, which compels us to act withoptimum performance, whereby we achieve ourgoals. The second misconception is that nothingcan be done to eliminate or diminish workplacedistress. Organizations and individuals can usepreventive or proactive coping strategies (primaryprevention) to change negative events into positiveexperiences and growth opportunities.In the past, the phrase “healthy organization” almostalways denoted a firm’s financial health. But studiesof “healthy organizations” suggest that policiesbenefiting workers’ health also benefit theorganization’s bottom line. Today, the healthyorganization focuses not only on financialsoundness but also on the physical and mental well-being of its employees. Healthy employees createstronger businesses and healthier profits (Berry etal., 2004).

Discussion Questions 1. Define the term “stress” and explain thedifference between eustress and distress. 2. Discuss the various components of theprocess model of stress and coping. 3. Discuss the negative effects of distress fromboth an organizational perspective and anindividual perspective. 4. Describe the various forms of stress. 5. Describe the three stages of the GeneralAdaptation Syndrome and positive andnegative effects that occur in each stage. 6. Discuss why personalities, ethnicity, andgender may affect an individual’s level ofstress. 7. Discuss the symptoms of burnout usingGolembiewski’s phase model. 8. Discuss the four categories of causes ofstress in the workplace. 9. Discuss and provide examples of the variouscoping strategies available to organizationsand individuals.10. Discuss the concept of learned optimism andhow it relates to coping with stress byindividuals.11. Discuss the concept of hardiness training andhow it relates to coping with stress byindividuals.

12. Discuss what is meant by the term “stressmanagement” and available interventions fororganizations and individuals.CASE STUDY 13-3 Why AreAll the Employees Leaving?The administrator of a large physician grouppractice is becoming alarmed about thegrowing level of turnover the organization hasrecently been experiencing. It has alreadypassed the industry average, and they areconcerned about the practice’s capacity tostaff the medical clinics for the upcoming fluseason. In conducting exit interviews, theyhave learned that the employees who areleaving generally liked their work and felt thattheir salaries were fair. However, they wereunhappy with the way their managers treatedthem, which was creating stress in their lives.They are leaving to take less stressfulpositions in other health care organizations.Discussion Questions1. How should the managers behavedifferently so that the employeesexperience less stress on the job?2. What strategies can the organization useso that the employees experience less

stress on the job?3. What could the individual employees doto help manage their own stress levelsmore effectively?CASE STUDY 13-4 Scott’sDilemmaScott is a licensed physical therapist whoworks for a national rehabilitation company.The rehabilitation facility in which Scott worksis located in an urban Southwest city. He hasworked at this facility for four years, and upuntil recently was satisfied with his workingenvironment and the interactions he sharedwith his coworkers. In addition, Scott receivedpersonal fulfillment from helping his patientsrecover from their disabilities and seeing themreturn to productive lives.Last year the health system went throughreorganization, with some new people beingbrought in and others reassigned. Scott’s newboss, George, was transferred from one of thesystem’s Midwest facilities. Almostimmediately upon taking his new position,George began finding fault with Scott’s careplans, patient interactions, and so on. Scott

began feeling as if he couldn’t do anythingright. He was experiencing feelings of anxiety,stress, and self-blame. Although his previousperformance evaluations had been aboveaverage, Scott was shocked by his firstperformance review under George’s authority—George gave him an extremely low rating.Scott began trying to work harder, thinkingthat by working harder he could exceedGeorge’s expectations. Despite Scott’sworking long hours and addressing George’scritiques, George continued to find fault withScott’s work. Staff meetings began to be agreat source of discomfort and stress becauseGeorge would belittle Scott and single him outin front of his colleagues.Scott began to feel alienated from his family,friends, and colleagues at work. His eatingand sleeping habits were adversely affectedas well. Scott’s activities held no joy for himanymore, and the career that he once lovedand been respected in became a source ofpain and stress. He began to call in sick moreoften and started visualizing himselfconfronting and even hurting George, whichcreated even more guilt and anxiety for Scott.

As time went on, George encouraged Scott’scoworkers to leave Scott alone to do his work.The perception of the coworkers becamemore sympathetic to George’s point of view.Scott’s coworkers mused that perhaps Scottreally was a poor worker and that Georgeknew better because of his position as thesupervisor of the rehabilitation department.Eventually, Scott’s coworkers began todistance themselves from him, in order toprotect their own interests. They began to seeScott as an outsider, with whom it was unsafeto associate.In an effort to resolve the situation, Scottspoke to George directly, stating his feelingsand expressing an interest in how they mightimprove the situation. Rather than making thesituation better, what George perceived asScott’s insubordination served to enrageGeorge, and the personal attacks againstScott intensified. Feeling frustrated andhelpless, Scott then decided to take hisproblem to the Human Resources Department(HRD). A human resources manager listenedto Scott’s complaints and suggested that Scottreturn with documentation evidence of whatScott perceived 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’sanger and his negative behavior toward Scott.As a last resort, Scott decided to go toGeorge’s boss, Rebecca. Rebecca met withGeorge to get his side of the story. Georgeportrayed Scott as an unproductive employeewith no respect for authority. The result was astrong letter of reprimand in Scott’s file forinsubordination.Discuss the symptoms of stress that Scott isexperiencing. What recommendations can youmake to 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 12thAnnual International Conference of the Association on EmploymentPractices and Principles, Ft. Lauderdale, FL.

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Other Suggested ReadingsGolembiewski, R. T., Hilles, R., & Daly, R. (1987). Some effects ofmultiple OD interventions on burnout and work site features.Journal of Applied Behavioral 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 of Management Review, 10(3), 408–420.Keenan, A., & McBain, G. D. (1979). Effects of Type A behaviour,intolerance of ambiguity, and locus of control on therelationship between role stress and work-related outcomes.Journal of Occupational Psychology, 52, 277–285.Keita, G. P., & Jones, J. M. (1990). Reducing adverse reaction tostress in the workplace. American Psychologist, 45(10), 1142–1145.Kowalski, R., Harmon, J., Yorks, L., & Kowalski, D. (2003).Reducing workplace stress and aggression: An actionresearch project at the U.S. department of veterans affairs.Human Resource Planning, 26(2), 39–53.Kushnir, T., & Melamed, S. (1991, March). Work-load, perceivedcontrol and psychological distress in Type A/B industrialworkers. Journal of Organizational Behavior, 12(2), 155–168.National Institute for Occupational Safety and Health. (2002,April). The changing organization of work and the safety andhealth of working people. Available at: www.cdc.gov/niosh.Last accessed February 15, 2004.

Noblet, A. (2003). Building health promoting work settings:Identifying the relationship between work characteristics andoccupational stress in Australia. Health PromotionInternational, 18(4), 351–359.Rahe, R. H., Meyer, M., Smith, M., & Kjaer, G. (1964). Socialstress and illness 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 and occupational health in the 21st centuryworkplace. Journal of Occupational and OrganizationalPsychology, 74(Pt. 4), 489–509.

CHAPTER 14Decision MakingLEARNING OUTCOMESAfter completing this chapter, the student shouldbe able to understand:The difference between the rational approachand the bounded rationality approach todecision making.The limitations of using intuitive decisionmaking and the heuristics or biases approach.How framing heuristics affects escalation ofcommitment.The four basic styles of decision making.The Vroom-Yetton Decision-Making Methodand the related factors.

▶ OverviewManagers face different types of problems, bothwell-structured and poorly structured ones, and usedifferent types of decision-making models to solvethem. When confronting a well-structured problem,defined as one that is straightforward, repetitive,familiar, and easily defined, managers use a routineapproach that relies on an organization’s policiesand procedures. For example, if two employeesrequest the same vacation period, the manager,who must ensure adequate coverage in theworkplace, follows company policy by granting thevacation request to the employee with the mostseniority. However, middle and senior managersusually deal with poorly structured problems, thosethat are new and complex, for which information islimited and incomplete. This is especially true asnew legislation and payment models evolve rapidlyand health care systems consolidate, becominglarger and more multifaceted.In the context of behavioral decision making, thereare various means that an individual can use tochoose the optimal or most desired outcome.Individuals typically use the rational approach todecision making when there is enough time for an

orderly, thoughtful process. However, because ofconstraints on time, resources, and information andthe complexity of today’s health care organizations,managers are limited, or “bounded,” as to theirrational decision making. The bounded rationalityperspective takes into consideration that because ofthe complexity of problems, limited time, personalbiases, and other factors, managers will not be ableto weigh all possible alternatives to a problem andtherefore must sometimes rely on intuitive decisionmaking or the heuristics and biases approach.Rational ApproachThe rational approach to decision making, alsoreferred to as the economic rationality model,involves a systematic analysis of the problemfollowed by the choice and implementation of asolution in a logical, step-by-step sequence (Daft,2004). The rational model is considered the idealmethod of decision making, as illustrated in Figure14-1.

Figure 14-1 Steps in the Rational Approach to Decision Making

1. Monitor the External and InternalEnvironments: Managers need to firstmonitor the external (outside theorganization) environment then the internal(within the organization) environment forneeded changes to the status quo. Theseneeded changes can arise from reviewingfinancial statements, performanceevaluations, industry indices, competitors’activities, new regulations, and the like.2. Identify the Problem Requiring Action: Themanager responds to a needed change byidentifying important issues, such as where,when, who are the stakeholders affected andinvolved, and how current activities will beinfluenced.3. Determine Desired Outcomes of theDecision: The manager determines whatperformance outcomes need to be achievedby the decision.4. Analyze the Problem: The manager needs tofact find the causes of and/or issuessurrounding the problem. Additional data willbe generated in this process so theappropriate alternatives can be generated.5. Determine Possible Courses of Action:Before moving ahead with a decisive actionplan, the manager must have a clear

understanding of the various optionsavailable to achieve the desired outcomes.The manager should seek input fromstakeholders and evidenced-based researchfor varying ideas and suggestions.6. Evaluate Alternatives:. The managerassesses the merits of each alternative andthe probability that each alternative will reachthe desired outcomes.7. Choose the Best Course of Action: This stepis critical to the decision process. Themanager uses their analysis of the problem,outcomes, and alternatives to select thesingle best course of action for success.8. Implement the Selected Decision: Finally, themanager allocates the necessary resourcesand gives directions to ensure that theselected decision is carried out.9. Evaluate the Decision: Finally, the managerneeds to assess if the decision met thedesired outcomes and communicate theresults to others. Thereafter, the monitoringactivity (step 1) begins again.The rational model may be the ideal, but under mostcircumstances, managers do not have completeinformation about a problem and/or all the plausiblealternatives. In addition, managers are constrainedby limited time and resources, personal biases, and

other factors, which make rational decision makingunrealistic. Therefore, managers are bounded(limited) regarding their rational decision making.The concept of bounded rationality embraces therealism that evaluation of alternatives and decisionmaking are constrained by human actions (Forest &Mehier, 2001).Bounded Rationality ModelThe bounded rationality model of decision making,proposed by Simon (1957), recognizes thatindividuals have cognitive limitations that prohibitthe processing of all the necessary or optimalinformation for decision making; therefore, anindividual will limit their search for information beforemaking a decision. Dequech (2001, p. 913)explains the concept of bounded rationality in thefollowing manner:1. Individuals often pursue multiple objectives,which may be conflicting. The alternativesfrom which to choose in order to pursuethese objectives might have not been givento the decision maker, who must then adopt aprocess for generating alternatives.2. The limits in the decision maker’s mentalcapacity compared with the complexity of thedecision environment usually prevent thedecision maker from considering all the

alternatives. Those limits are also presentwhen the decision maker has to consider theconsequences of the alternatives, so thedecision maker employs some heuristicprocedure for that purpose.3. Finally, the decision maker adopts asatisfying strategy rather than an optimizingstrategy, searching for solutions that are“good enough,” given the realistic aspirationlevels.The expression “bounded rationality” is used todenote the type of rationality to which managersresort when the environment in which they operateis too complex relative to their cognitive limitations.Because of these limitations, managers may employthe use of intuitive and/or heuristic strategies fordecision making.IntuitionIntuitive decision making can be understood as acognitive “short-circuiting,” in which a decision isreached even though the reason for the decisioncannot be easily described (Hall, 2002). In otherwords, intuitive decision making involves usingone’s professional judgment based on pastexperiences rather than sequential logic or explicitreasoning (Daft, 2004). Agor (1985, 1986a, b)suggests that intuition is most useful to managers in

situations of uncertainty. Agor advocates reliance onintuition when a high level of uncertainty exists,when there is little precedent, when variables arenot scientifically predictable and analytical data areof little use, when facts are limited and do not clearlypoint the way to go, when several alternatives seemplausible, and when time is limited and there ispressure to come up with the right answer.There is some debate about the degree to which anindividual’s intuitive ability can be developed andimproved (Bennett, 1998). Some researchers arguethat intuitive abilities are closely related topersonality types (Myers, 1980). Others claim thatjob characteristics or situational factors encouragemanagers to develop and improve their intuitiveabilities (Agor, 1986a,b; Behling & Eckel, 1991;Wally & Baum, 1994). In top-level decision-makingenvironments, these abilities are certainly an assetand have been shown to be a benefit to seniormanagers (Agor, 1986a,b; Eisenhardt &Bourgeois, 1988; Hayashi, 2001; Simon, 1987).For example, Agor (1985, 1986a,b) conducted aseries of studies and found that senior managersalways score higher than middle- and lower-levelmanagers in their abilities to use intuition to makedecisions on the job. In Maidique’s (2011) study ofCEO decision making, he found that intuition was amajor or determining factor in 85% of the 36 key

decisions that were studied. Therefore, it is notsurprising that Peters and Waterman (1984) relatethat the 10 best-run companies in the United Statesencouraged the use of intuitive skills. In addition,business schools are designing courses to helpdevelop MBA students’ intuitive skills for decisionmaking (Agor, 1985, 1986b).Heuristics or Biases ApproachIn addition to using intuition to deal with theproblems of uncertainty and complexity, managersuse judgmental heuristics strategies to simplify theirdecision making. Heuristics are guidelines or “rulesof thumb” that help to make our world manageableby simplifying complex tasks (Kahneman, Slovic, &Tversky, 1982; Tversky & Kahneman, 1974).Heuristic processing strategies enable managers tocut through overwhelming data by applyingsimplifying assumptions to the information. The useof heuristics may result in accurate predictions, butit can also lead to an array of errors and biases.Tversky and Kahneman (1974) describe threecommonly used heuristics: (1) availability, (2)representativeness, and (3) anchoring andadjustment.Availability bias is an intuitive technique in which theperceived probability of an event is influenced bythe ease of recollection. More easily recalled events

are given a higher probability of reoccurring. Morefrequent events are often the most easily recalled,but the most easily recalled are not necessarily themost frequent (Hall, 2002). Ease of recall is alsoaffected by salience (i.e., the degree to which someinformation is perceived as being more relevant tothe decision being made) related to the emotionalstrength of a memory; memories associated withstrong emotions are recalled more easily. Forexample, performance appraisals of staff areaffected by the use of availability heuristics bymanagers while evaluating them. It is common tofind the most recent and vividly etched event—positive or negative—influencing the appraisal. (SeeCase Study 14-1.)CASE STUDY 14-1 Just Likethe OthersDr. Smith walked into the patient’s room afterquickly reviewing the chart. The patient was a42-year-old woman with a long history ofdiabetes. The patient was complaining ofneed to urinate frequently throughout the day,which is a sign of uncontrolled diabetes. WhenDr. Smith entered the room, he noticed thepatient was very obese and was wearingclothes that were quite worn with a few holes

here and there. “Oh great. Another low-income patient who doesn’t manage theirdiabetes. Ten bucks says this person is stilleating sugary foods and can’t get their insulinright. No wonder they have to urinate all thetime.” Dr. Smith typically counsels 4–5patients a week about managing theirdiabetes, and finds that his lower-incomepatients do not always seem to have thehealth literacy to really understand hisinstructions. Without asking many questions,Dr. Smith started lecturing the patient oneating better foods and doing a better job ofmanaging her insulin. When she protestedthat she was doing all of those things, he justreinforced the importance again.Six months later, Dr. Smith got a call fromhospital’s lawyer. The patient had a tumor inher pelvic region that was putting pressure onher bladder, increasing her urinary frequency.The cancer had progressed quickly, and hadmetastasized to her lungs. The lawyerinformed him that he was named in a lawsuitfrom the patient, claiming that he negligentlyrefused to listen to her concerns andmisdiagnosed in her, thus resulting hermetastatic cancer.

DiscussionDr. Smith used the availability heuristic whengiving his diagnosis. Symptoms ofmismanaged diabetes were very salient andaccessible to Dr. Smith, because he sawseveral cases per week, often among low-income patients. Dr. Smith also used therepresentativeness heuristic by comparing thepatient to former patients based on herappearance. Had Dr. Smith listened to thepatient and created a robust differentialdiagnosis in addition to relying on his previousexperience, he would have realized that thepatient’s symptoms could have been due toother causes such as a tumor.Representativeness bias is an intuitive techniquewhereby probabilities are evaluated according to thedegree to which the given sample matches, or isrepresentative of, a class of samples or populations.In the workplace, representativeness heuristics canbe traced as the reason behind many cases ofemployee discrimination. (See Case Study 14-1.)Anchoring and adjustment bias is an intuitivetechnique that is used when a series of estimates isused to obtain a proposed answer to a currentproblem. People create a preliminary solution on the

basis of initial information (anchoring) and thenmodify the answer when more information becomesavailable (adjustment). For example, when thesalary of a new employee is being set, theanchoring and adjustment heuristic is used. Theemployee’s starting salary is invariably set close tothe last paid salary without regard to what the newjob description may entail. In other words, the initialvalue significantly influences the process of theadjustment toward the new value, irrespective of therationality in the choice of the initial value. (SeeCase Study 14-2).CASE STUDY 14-2 HowMuch Am I Worth?Kim was really excited to start her new job.She had just graduated and was finally goingto work at a big hospital in town. When thehiring manager, John, was negotiating Kim’ssalary, he asked what her salary expectationswere. Because she had only ever workedstudent jobs, she wasn’t really sure what thesalary should be for this type of position. Shetried to look it up online, but it was hard to findaccurate information for this particular title.She knew her college friends who wereteachers were making about $35,000 a year,

so she said, “around $35,000.” John said thathe would start her at $37,000. “Wow!” ThoughtKim. “That’s pretty good for my first real job,and I got even more than I asked for, plusawesome benefits! I am so excited!” Johnthought to himself, “Wow! That was cheap.The last person I hired for that role started at$55,000.” After a few months, Kim becamefriends with the other employee who had thesame role, Sarah. In passing, Sarah casuallymentioned that she was a little disappointedwith her starting salary of $55,000 becauseshe was making $65,000 at her last job in adifferent industry. When Kim heard aboutSarah’s higher salary for doing the same job,she wasn’t so happy with the $37,000anymore. She made an appointment withJohn to discuss a raise. He replied, “I’m sorry,Kim, but HR will only let me go up a little bitfrom the starting salary without a differenttitle.”How was the anchoring and adjustmentheuristic used by Kim, Jim, and Sarah?.As Case Studies 14-1 and 14-2 illustrate, there aremany similarities between clinical decision makingand managerial decision making. Extensive

literature exists regarding the use of intuition andheuristics in medical decision making because ofthe high degree of uncertainty within the practice ofmedicine. As Sox et al. (1988, p. 17) point out,“[M]edicine is the art of making decisions withoutadequate information.” As such, decisions made byclinicians through the use of intuition or heuristicscan have a tremendous impact on health caremanagers. Clinicians make the decisions as to thecommitment of scarce resources to patients and theassociated care and treatment plans (Hall, 2002;Thompson, 2003). However, it is the responsibilityof health care managers to provide the resourcesfor clinicians to perform their work, and their healthsystems are judged on the clinical outcomes of thepatient populations they serve. Therefore, healthcare managers need to appreciate not only howintuition and heuristics play a part in their owndecision making but also how they affect thedecision making of clinicians because both affectthe achievement of organizational goals. (See CaseStudy 14-3.)CASE STUDY 14-3 CognitiveErrors in Clinical Decision MakingHeuristic processing strategies enableindividuals to cut through overwhelming data

by applying simplifying assumptions toinformation. Consider the following clinicalexamples illustrating commonly usedheuristics:Availability error occurs when cliniciansmisestimate the prior probability ofdisease because of recent experience.Experience often leads tooverestimation of probability whenthere is memory of a case that wasdramatic or that involved a patient whofared poorly or a lawsuit. For example,a clinician who recently missed thediagnosis of pulmonary embolism in ahealthy young woman who had vaguechest discomfort but no other findingsor apparent risk factors might thenoverestimate the risk in similar patientsand become more likely to do chest CTangiography for similar patients despitethe very small probability of disease.Experience can also lead tounderestimation. For example, a juniorresident who has seen only a fewpatients with chest pain, all of whomturned out to have benign causes, maybegin to do cursory evaluations of that

complaint even among populations inwhich disease prevalence is high.Representation error occurs whenclinicians judge the probability ofdisease based on how closely thepatient’s findings fit classicmanifestations of a disease withouttaking into account disease prevalence.For example, although several hours ofvague chest discomfort in a thin,athletic, healthy-appearing 60-year-oldman who has no known medicalproblems and who now looks and feelswell does not match the typical profileof a myocardial infarction (MI), it wouldbe unwise to dismiss that possibilitybecause MI is common among men ofthat age and has highly variablemanifestations. Conversely, a healthy20-year-old man with sudden onset ofsevere, sharp chest pain and back painmay be suspected of having adissecting thoracic aortic aneurysmbecause those clinical features arecommon in aortic dissection. Thecognitive error is not taking intoaccount the fact that aortic dissectionsare exceptionally rare in a 20-year-old,

otherwise healthy patient; that disordercan be dismissed out of hand andother, more likely causes (e.g.,pneumothorax, pleuritis) should beconsidered. Representation error isalso involved when clinicians fail torecognize that positive test results in apopulation where the tested disease israre are more likely to be false positivethan true positive.Anchoring errors occur when clinicianssteadfastly cling to an initial impressioneven as conflicting and contradictorydata accumulate. For example, aworking diagnosis of acute pancreatitisis quite reasonable in a 60-year-oldman who has epigastric pain andnausea, who is sitting forward clutchinghis abdomen, and who has a history ofseveral bouts of alcoholic pancreatitisthat he states have felt similar to whathe is currently feeling. However, if thepatient states that he has had noalcohol in many years and has normalblood levels of pancreatic enzymes,clinicians who simply dismiss or excuse(e.g., the patient is lying, his pancreasis burned out, the laboratory made a

mistake) these conflicting data arecommitting an anchoring error.Clinicians should regard conflictingdata as evidence of the need tocontinue to seek the true diagnosis(acute MI) rather than as anomalies tobe disregarded. There may be nosupporting evidence (i.e., for themisdiagnosis) in some cases in whichanchoring errors are committed.Modified from the Merck Manual of Diagnosis and Therapy, edited byRobert Porter. © 2013 by Merck Sharp & Dohme Corp., a subsidiaryof Merck & Co, Inc, Whitehouse Station, NJ. Available fromhttp://www.merckmanuals.com/professionalEscalation of Commitment andFraming HeuristicsIn addition to Tversky and Kahneman’s (1974)three commonly used heuristics, there is anotherbias that may cause low-quality decision making:escalation of commitment. Staw (1981) defines theproblem of escalation of commitment as whatoccurs when a manager continues to allocate moreresources to a losing proposition. One reasonescalation of commitment may occur is because amanager does not want to admit that they havemade a mistake (Staw & Ross, 1987). Research

finds that a manager who feels personallyresponsible for an initial decision that is failing theyare more likely to allocate additional resources thanis another person who was not responsible for theinitial decision (Staw, 1981). The expression“throwing good money after bad” describesescalation of commitment in a decision. Forexample, one of the main reasons for thebankruptcy of the Allegheny Health System inPennsylvania was the unwillingness of the topleaders of the organization to make midcoursecorrections in their grand plans on the basis of whatwas and was not working in hospitals and officepractices in Philadelphia and Pittsburgh (Bottles,2001). Examples from the public sector (Staw &Ross, 1987) include the city of Vancouver’scommitment to Expo ’86, Chicago’s Deep Tunnelproject, and the Washington Public Supply System.In the case of the World Exposition onTransportation and Communication, or Expo ’86, thefair was supposed to operate close to financialbreakeven. But as the plans moved forward, theprojected losses burgeoned. The plannerscontinued because politically it was too late to stop,owing to the interests of various stakeholders.British Columbia had to create a lottery to cope withthe $300 million deficit. The good news was that thefair did open as scheduled.

Another reason for escalation of commitment tooccur is known as framing heuristics. Framingheuristics involve a tendency to make a decision onthe basis of the form or manner in which informationis presented. For example, Levin, Schnittjer, andThee (1988) conducted a study in which one groupwas given a description of an experimental cancertreatment that was shown to have a 40% successrate; the other group was told that the procedurehad a 60% failure rate. Although both statementsare true, the way the researchers worded thestatements affected individuals’ opinion of thetreatment’s effectiveness and whether or not theindividual would recommend the treatment to afamily member. The participants were moreoptimistic about the treatment when its success ratewas presented and less optimistic when the failurerate was presented.Staw and Ross (1987) suggest that to avoidescalation of commitment, managers can (1)recognize that they may be biased towardescalation, (2) see escalation for what it is (i.e., anovercommitment to a strategy by defining failureambiguously or by ignoring other people’sconcerns), and (3) avoid overcommitment bylooking at the strategy from an outsider’sperspective.

Decision-Style ModelManagers have different styles when it comes tomaking decisions and solving problems. Rowe andBoulgarides (1983, 1998) developed a decision-style model that proposes that managers differalong two dimensions in the way they approachdecision making: value orientation and tolerance forambiguity. Value orientation reflects the extent towhich an individual focuses on either task andtechnical concerns or people and social concernswhen making decisions. Tolerance for ambiguityreflects the extent to which a person has a highneed for structure or control in their life.As illustrated in Figure 14-2, the decision-stylemodel encompasses four basic styles: directive,analytic, conceptual, and behavioral. Boulgaridesand Cohen (2001, pp. 59–60) describe the fourbasic styles as follows:Figure 14-2 Decision-Making Styles

Reproduced from Rowe, A. J., & Boulgarides, J. D. (1983).Decision styles: A perspective. Leadership & OrganizationDevelopment Journal, 4(4), 3–9.1. Directive: The decision maker who uses thisstyle has a low tolerance for ambiguity andlow cognitive complexity. The focus is ontechnical decisions, and this style is generallyautocratic. The decision maker may adoptthis style because of a high need for power.Because of the use of little information andfew alternatives, speed and satisfactorysolutions are typical. The decision makerstend to be focused and are frequentlyaggressive. Generally, they prefer structureand specific information, which is givenverbally. Their orientation is internal to theorganization and short range. They tend tooperate with tight controls. Although they areefficient, these decision makers have a highneed for security and status. They have thedrive that is required to achieve results, butthey also want to dominate others.2. Analytic: This decision maker has a muchgreater tolerance for ambiguity than thedirective-style manager and also has a morecognitively complex personality that leads tothe desire for more information and the

consideration of many alternatives. Becauseof the focus on technical decisions and theneed for control, the analytic style containsan autocratic bent. The analytic style istypified by the ability to cope with newsituations (but in a structured manner) andproblem solving. Position and ego areimportant to individuals who use an analyticdecision-making style. These individualsoften reach top positions in an organizationor start their own companies. They are notparticularly quick in their decision making,and they enjoy variety and prefer writtenreports. They also enjoy challenges andexamine every detail in a situation.3. Conceptual: Including both high cognitivecomplexity and people orientation, managerswith this decision-making style tend to usedata from multiple sources and to considermany alternatives. Like individuals using thebehavioral decision-making style, conceptual-style decision makers share goals withsubordinates in trusting and openrelationships. These individuals tend to beidealists who may emphasize ethics andvalues in their behavior. They generally arecreative and can readily understand complexrelationships. Their focus is long range with

high organizational commitment. They areachievement-oriented and value praise,recognition, and independence. They preferloose control over power and will frequentlyencourage the participation of those theylead. They may be characterized as thinkersrather than doers.4. Behavioral: Although low on the cognitivecomplexity scale, this leader has a deepconcern for the organization and thedevelopment of people. Behavioral-stylemanagers tend to be supportive and areconcerned with subordinates’ well-being.They provide counseling, are receptive tosuggestions, communicate easily, showwarmth, are empathetic, are persuasive, andare willing to compromise and accept alooser style of control. With low data input,this style tends toward a short-range focusand uses meetings primarily forcommunicating. These managers avoidconflict, seek acceptance, and tend to bemore people-oriented but sometimes areinsecure.Of the four decision-making styles, individuals havea tendency to resort to a single, dominant style (i.e.,default mode of decision making). However, with

training, managers can use all four styles effectivelyas different situations are presented.

▶ Vroom-Yetton Decision-Making ModelA decision-making method that is good under oneset of circumstances might not be considered sounder other conditions. A classic contingency modelfor decision making was first described by Vroomand Yetton (1973). Fifteen years later, Vroom andJago (1988) replaced the decision tree system ofthe original model with an expert system based onmathematics. You might see the model referred toas Vroom-Yetton, Vroom-Jago, or Vroom-Yetton-Jago (see Figure 14-3). The contingency model fordecision making suggests that individuals shouldconsider choosing from five types of decisionprocesses based on a number of factors. Two of thefive processes are autocratic (AI and AII), two areconsultative (CI and CII), and one is group-based(GII). This decision-making model can be used tochoose between individual and group decision-making strategies.

Figure 14-3 Vroom-Yetton Decision-Making ModelThe five decision processes as described by Vroomand Yetton (1973) are as follows:1. Autocratic I (AI): Completely autocratic. Yousolve the problem or make the decisionyourself, using the information available toyou at the present time.2. Autocratic II (AII): Request specificinformation. You obtain any necessaryinformation from team members orsubordinates and then decide on the solutionto the problem yourself. You may or may nottell subordinates the purpose of yourquestions or give information about theproblem or decision you are working on. The

input provided by subordinates is clearly inresponse to your request for specialinformation. They do not play a role in thedefinition of the problem or in generating orevaluating alternative solutions.3. Consultative I (CI): One-on-one discussion.You share the problem with the relevant teammembers or subordinates individually, gettingtheir ideas and suggestions without bringingthem together as a group. Then you makethe decision. This decision may or may notreflect your subordinates’ influence.4. Consultative II (CII): Group discussion. Youshare the problem with your team membersor subordinates in a group meeting. In thismeeting you obtain their ideas andsuggestions. Then you make a decision thatmay or may not reflect your subordinates’influence.5. Group (GII): Consensual group decisionmaking. You share the problem with yourteam members or subordinates as a group.Together, you generate and evaluatealternatives and attempt to reach agreement(i.e., consensus) on a solution. Your role ismuch like that of facilitator, coordinating thediscussion, keeping it focused on theproblem, and making sure that the critical

issues are discussed. You can provide thegroup with information or ideas that youhave, yet you do not try to pressure them toadopt your solution, and you are willing toaccept and implement any solution that hasthe support of the entire group.Many people find this decision making model helpfulwhen the following seven yes/no questions areanswered, as shown in Figure 14-3. Note, however,that, in some scenarios, you do not need to answerall of the questions as evident by the blank cell inthe table. The seven questions are answered inorder from 1 to 7 and followed across the table fromleft to right:1. Is there a quality requirement? Is the natureof the solution critical? Are there technical orrational grounds for selecting among possiblesolutions?2. Do I have enough information to make ahigh-quality decision?3. Is the problem structured? Are the alternativecourses of action and methods for theirevaluation known?4. Is acceptance of the decision bysubordinates critical to its implementation?5. If I were to make the decision by myself, is itreasonably certain that it would be accepted

by my subordinates?6. Do subordinates share the organizationalgoals to be obtained in solving this problem?7. Is conflict among subordinates likely inobtaining the preferred solution?For example, in the case in which the qualityrequirement (question 1) is low (e.g., the nature ofthe solution is not critical) and team commitment(question 2) is also not critical, the method suggeststhat you should make the decision on your own (i.e.,choose method AI). Alternatively, if teamcommitment is critical, you would consider question5 about the certainty of acceptance if you made thedecision on your own. If people are likely to acceptyour decision, the method suggests once againmaking the decision on your own (i.e., AI). However,if acceptance of your decision is not reasonablycertain, the method suggests a consensual groupmethod (i.e., GII) to help overcome this.Situational factors that may influence the modelinclude the following:When decision quality is important andfollowers have useful information, then AI andAII are not the best methods.When the leader sees decision quality asimportant but followers do not, then GII isinappropriate.

When decision quality is important, the problemis unstructured, and the leader lacksinformation or skill to make the decision alone,then GII is best.When decision acceptance is important andfollowers are unlikely to accept an autocraticdecision, then AI and AII are inappropriate.When decision acceptance is important butfollowers are likely to disagree with oneanother, then AI, AII, and CI are not appropriatebecause they do not give opportunity fordifferences to be resolved.When decision quality is not important butdecision acceptance is critical, then GII is thebest method.When decision quality is important, all agreewith this, and the decision is not likely to resultfrom an autocratic decision, then GII is best.The Vroom-Yetton model works best when there areclear and accessible opinions about the decisionquality importance and decision acceptance factors.However, these are not always known with anysignificant confidence.

▶ ConclusionIn this chapter, we have discussed the variousmethods used by managers in their decision-makingprocesses. The rational approach is used whenthere is sufficient time for an orderly, thoughtfulprocess. However, due to limited resources, such astime and information, managers may be bounded intheir rational decision making and will rely onintuitive or the heuristics and biases approach.

Discussion Questions 1. Explain the difference between the rationaland bounded rationality approaches todecision making. 2. Explain the limitations of using intuitive andthe heuristics or biases approach to decisionmaking. 3. Describe how framing heuristics affect amanager’s escalation of commitment. 4. Discuss the four basic styles of decisionmaking. 5. Explain the various situational factors thatmay influence the Vroom-Yetton decision-making model.

Exercise 14-1There are times when you have made gooddecisions. You knew it was a good decision at thetime, and when you looked back on it later, yourecognized that, yes, that was a good decision.Even now, you still think it was a good decision.There are also times when you have made poordecisions. You might have felt uneasy about it at thetime, and when you look back on it, you recognizethat it was a poor decision. Analyze the factors thatyou think contributed to both your good decisionsand your poor decisions.

Exercise 14-2You have 100 doses of a vaccine against a deadlystrain of influenza that is sweeping the country, withno prospect of obtaining more. Standing in line are100 schoolchildren and 100 elderly people. Theelderly people are more likely to die if they catch theflu than the schoolchildren are. But the elderlypeople have relatively fewer years left to live,whereas the schoolchildren have their whole livesahead of them. Which group do you vaccinate?Describe each step in your decision-makingprocess.

Exercise 14-3Project Implicit at Harvard has created a series oftests to help people better understand their ownimplicit biases so that they can become aware ofhow these biases could influence decisions andbehavior. Choose one of the tests at their website(https://implicit.harvard.edu/implicit/takeatest.html),and discuss what you learned about yourself fromthe results.

ReferencesAgor, W. H. (1985). Intuition as a brain skill in management.Public Personnel Management Journal, 14(1), 15–24.Agor, W. H. (1986a). How top executives use their intuition tomake important decisions. Business Horizons, 29(1), 49–53.Agor, W. H. (1986b). The logic of intuition: How top executivesmake important decisions. Organizational Dynamics, 14(3), 5–18.Behling, O., & Eckel, N. (1991). Making sense out of intuition.Academy of Management Executive, 5(1), 46–54.Bennett, R. H. (1998). The importance of tacit knowledge instrategic deliberations and decisions. Management Decision,36(9), 589–600.Bottles, K. (2001). The good leader—Management skills.Physician Executive, 27(2), 74–76.Boulgarides, J. D., & Cohen, W. A. (2001). Leadership style vs.leadership tactics. Journal of Applied Management andEntrepreneurship, 6(1), 59–73.Daft, R. L. (2004). Organization theory and design (8th ed.).Mason, OH: South-Western.Dequech, D. (2001). Bounded rationality, institutions, anduncertainty. Journal of Economic Issues, 35(4), 911–929.Eisenhardt, K., & Bourgeois, L. (1988). Politics of strategicdecision making in high velocity environments: Towards a mid-range theory. Academy of Management Journal, 31, 737–770.

Forest, J., & Mehier, C. (2001). John R. Commons and Herbert A.Simon on the concept of rationality. Journal of Economics,3(35), 591–605.Hall, K. H. (2002). Reviewing intuitive decision-making anduncertainty: The implications for medical education. MedicalEducation, 36, 216–224.Hayashi, A. M. (2001). When to trust your gut. Harvard BusinessReview, 79(2), 59–65.Kahneman, D., Slovic, P., & Tversky, A. (Eds.). (1982). Judgmentunder uncertainty: Heuristics and biases. Cambridge, UK:Cambridge University Press.Levin, I. P., Schnittjer, S. K., & Thee, S. L. (1988). Informationframing effects in social and personal decisions. Journal ofExperimental Social Psychology, 24, 520–529.Maidique, M. A. (2011). Decoding intuition for more effectivedecision-making. Harvard Business Review Blog Network.Available at: http://blogs.hbr.org/2011/08/decoding-intuition-for-more-ef/Myers, I. (1980). Introduction to type. Palo Alto, CA: ConsultingPsychologists, Inc.Peters, T. J., & Waterman, R. H., Jr. (1984). In search ofexcellence: Lessons from America’s best-run companies. NewYork, NY: Warner Books.Rowe, A. J., & Boulgarides, J. D. (1983). Decision styles: Aperspective. Leadership & Organization Development Journal,4(4), 3–9.Rowe, A. J., & Boulgarides, J. D. (1998). Managerial decisionmaking. New York, 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 ofintuition and emotion. Academy of Management Executive, 1,57–64.Sox, H. C., Marshal, A. B., Higgins, M. C., & Marton, K. I. (1988).Medical decision-making. New York, NY: Butterworths.Staw, B. M. (1981). The escalation of commitment to a course ofaction. Academy of Management Review, 6(4), 577–587.Staw, B. M., & Ross, P. (1987). Knowing when to pull the plug.Harvard Business Review, 65(2), 68–74.Thompson, C. (2003). Clinical experience as evidence inevidence-based practice. 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:Managing participation 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 structuraldeterminants of the pace of strategic decision making.Academy of Management Journal, 37, 932–956.

Other Suggested ReadingsAgor, W. H. (1984). Intuitive management: Integrating left andright brain management skills. Upper Saddle River, NJ:Prentice Hall.Ashford, B. E. (2001). Role transitions in organizational life: Anidentity-based perspective. Mahwah, NJ: Lawrence ErlbaumAssociates.Bates, B. (1975). Physician and nurse practitioners: Conflict andreward. Annals of Internal Medicine, 82, 702–706.Brett, J. F., Northcraft, G. B., & Pinkley, R. L. (1999). Stairways toheaven: An interlocking self-regulation model of negotiation.Academy of Management Review, 24(3), 435–451.Davis, M. H., Capobianco, S., & Kraus, L. (2004). Measuringconflict-related behaviors: Reliability and validity evidenceregarding the conflict dynamics profile. Educational andPsychological Measurement, 64(4), 707–731.Elangovan, A. R. (2002). Managerial intervention in disputes: Therole of cognitive biases and heuristics. Leadership &Organization Development Journal, 23(7), 390–399.Friedman, R. A., Tidd, S. T., Currall, S. C., & Tsai, J. C. (2002).What goes around comes around: The impact of personalconflict style on work conflict and stress. International Journalof Conflict Management, 11(1), 32–55.Gigerenzer, G. (2007). Gut feelings: The intelligence of theunconscious. New York, NY: Penguin Group.

Kahneman, D. (1991). Judgment and decision making: A personalview. Psychological Science, 2(3), 142–154.Kilmann, R. H., & Thomas, K. W. (1977). Developing a forced-choice measure of conflict-handling behavior: The modeinstrument. Education and Psychological Development, 37,309–325.Kolb, D. M., & Putman, L. L. (1992, May). The multiple faces ofconflict in organizations. Journal of Organizational Behavior,13, 311–324.McWilliams, C. (2003). Healthcare decision making for dementiapatients: 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 versuswhat we think we should do: An empirical investigation ofintrapersonal conflict. Journal of Behavioral Decision Making,15, 403–418.Shelton, C. D., & Darling, J. R. (2004). From chaos to order:Exploring new frontiers in conflict management. OrganizationDevelopment Journal, 22(3), 22–41.Thomas, K. W. (1992). Conflict and conflict management:Reflections and update. Journal of Organizational Behavior,13, 265–274.

CHAPTER 15Conflict Managementand Negotiation SkillsLEARNING OUTCOMESAfter completing this chapter, the student shouldbe able to 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 a natural part of human relationships. Assuch, it is inevitable and unavoidable. It is a part ofour everyday professional and personal lives;therefore, it is inherent in any type of work setting(Thomas, 1976). Although there are numerousdefinitions of conflict, Thomas (1992a, b) suggeststhat most definitions have three commoncomponents: (1) perceived incompatibility ofinterests, (2) some interdependence of the parties,and (3) some form of interaction. For example,Rahim (1985) defined conflict as an “interactivestate” manifested in disagreement or differences, orincompatibility, within or between individuals andgroups. For our discussions, we will define conflictas occurring when an individual or group feelsnegatively affected by another individual or group.No organization is exempt from conflict, and thehealth care setting is a particularly conflictualenvironment because of factors such as high stress,strong emotions, scarce resources, competition,downsizing, mergers, excessive regulations,diversity and cultural issues, and multiplestakeholders’ demands. These factors increaseconflict in organizations (Gardner, 1992; Johnson,

1994). Research has shown that both health careand non-health care managers spend an average of30% of their time dealing with conflict, and this isoften cited as one of the least enjoyable aspects oftheir leadership roles (McElhaney, 1996; Robbins,1990; Shelton & Darling, 2004; Thomas &Schmidt, 1976).It is important to note that conflict does notnecessarily lead to ineffectiveness. Conflict, likestress, can be either positive or negative. Positiveconflict can act as a stimulus for positive change.Positive or constructive conflict can lead to creativeproblem solving and alternatives, increasedmotivation and commitment, high-quality work, andpersonal satisfaction (i.e., functional outcomes)(Cosier & Dalton, 1990). However, negative orunconstructive conflict can be counterproductive foran organization by diverting efforts from goalattainment (i.e., dysfunctional outcomes). Negativeconflict may also affect the psychological well-beingof employees. Severe, unconstructive conflicts mayresult in employee resentment, tension, and anxiety,which may lead to low-quality work, personal stress,and possible sabotage. For example, it is estimatedthat over 65% of performance problems result fromstrained relationships and that conflict accounts forup to 50% of involuntary employee departures(Dana, 2000; Watson & Hoffman, 1996). Negative

conflict may create an organizational culture ofcompetition versus cooperation, thereby eliminatingthe sustainability of supportive and trustingrelationships, which are necessary for successfulorganizations (Baron & Richardson, 1990). Forexample, Forte (1997) points out that in clinicalenvironments, conflict among health careprofessionals can be counterproductive with respectto patients, resulting in increased mortality andmorbidity due to medical errors.Lewicki, Weiss, and Lewin (1992) identify sixmajor areas in conflict research: the micro-level(psychological) approach, the macro-level(sociological) approach, the economic-analysisapproach, the labor-relations approach, thebargaining and negotiation approach, and the third-party dispute approach. The micro-level approachincludes research on factors that affectintrapersonal and interpersonal conflict (i.e., withinand among individuals), whereas the macro-levelapproach focuses on factors that affect conflictamong and within groups, departments, andorganizations (i.e., intragroup, intergroup, andinterorganization). Economic analysis refers toeconomic rationality and how it applies to individualdecision making. The research areas of laborrelations, bargaining and negotiation, and third-partyresolution relate to studies that deal with the effects

of workplace and conflict resolutions and/or conflictmanagement.Using this framework, we first discuss the varioustypes and levels of conflict. Second, we examine thevarious methods to deal with conflict effectively,referred to as conflict resolution or conflictmanagement. This discussion includes individualdecision making and the negotiation skills that arenecessary for effective conflict management.

▶ Types of ConflictThere are four basic types of conflict: goal,cognitive, affective, and procedural (Kolb &Bartunek, 1992). Goal conflict occurs when two ormore desired or expected outcomes areincompatible. It may involve inconsistenciesbetween individual or group values and norms (e.g.,standards of behavior). Cognitive conflict occurswhen the ideas and thoughts within an individual orbetween individuals are incompatible. Affectiveconflict emerges when the feelings and emotionswithin an individual or between individuals areincompatible. Procedural conflict occurs whenpeople differ over the process to use for resolving aparticular matter. As illustrated in Case Study 15-1,the different types of conflict are not mutuallyexclusive.CASE STUDY 15-1 Who’s theBoss?“Dr. Jordan on line three for you, Mary.” WhenMary Jones pressed the blinking button, sheknew Dr. Jordan was not calling to set up theirnext tee time. As chief of surgery, Dr. Jordanhad full access to the board of directors, and

Mary, the chairperson of the board, noticed hetook full advantage of it. Lately, Dr. Jordan’scalls were mostly about Harriet Briggs, thehospital’s administrator. Today was nodifferent.“Mary, as chief of surgery, I have authorityover all issues that affect the quality of patientcare. When something or someone iscompromising that quality, it is my prerogative,not the prerogative of some layman [Dr.Jordan’s word for anyone not holding an MD]to do what I deem necessary to correct thesituation. Don’t you agree?”Mary mentally ran through job descriptionsand the hospital’s charter and she couldremember no clause that explicitly gave thechief of surgery this authority. Implicitlythough, his stance was probably correct. “I’llreserve comment on that, Alex, until you tellme the specific situation that has you thisupset.”The problem that concerned Dr. Jordaninvolved the nursing supervisor, Judith Brady,RN. Ms. Brady scheduled the hospital’ssurgical nurses according to her interpretationof established hospital policy. Surgeons werefrustrated with her attitude that maximum

utilization must be made of the hospital’soperating time for training purposes. Shetherefore scheduled in such a way that nurseswere often assigned to procedures they hadnot seen before. Surgeons complained thatthis scheduling method often added to thetime it took to perform an operation. Thiscaused problems because the operating roomwas run at full capacity. Surgeons already feltthey must hurry to complete a procedurebecause another procedure was scheduleddirectly following theirs. Having to waitbecause a nurse did not automatically knowwhat instrument is needed next onlyexacerbated this problem and did not permitthem sufficient time to complete a surgicalprocedure in the proper manner. The surgicalstaff were concerned that this schedulingsystem was impacting quality of care.Furthermore, some of the surgeons hadcomplained that Ms. Brady clearly favoredsome physicians over others and tended toassign more experienced nurses to theirprocedures.The situation came to crisis earlier in themorning when Dr. Jordan, following aconfrontation with Ms. Brady, told her she wasfired. Ms. Brady then made an appeal to

Harriet Briggs, the hospital administrator.Harriet overturned Ms. Brady’s dismissal andthen instructed Dr. Jordan that discharge ofnurses was the purview of the hospitaladministrator and only she had the authority todo so. Dr. Jordan vehemently disagreed. Theconversation ended with Dr. Jordan yelling,“This is clearly a medical problem, and I amsure the board of directors will agree with me.”Dr. Jordan then called Mary.After listening to Dr. Jordan, Mary decided tocall Harriet Briggs to get her side of the story.Harriet told Mary, “I cannot be responsible forimproving patient care if the board will notsupport me. I must be able to make decisionsand develop policies and procedures withoutworrying whether or not the board will alwaysside with the physicians. As you already know,Mary, I am legally responsible for the care thatpatients receive here at the hospital. Andanother thing, the next time Dr. Jordan tellsme that I should restrict my activities to fundraising, maintenance, and housekeeping, I willnot be responsible for my actions!”The severity of the problem was obvious, butthe answers were not. All Mary knew was sheneeded to fix the situation quickly.

Discuss the goal, cognitive, affective, andprocedural conflicts illustrated in this case.Friedman, R. (2002). Musical operating rooms: Mini-cases of healthcare disputes. International Journal of Conflict Management, 13(4),419–420. Reprinted with permission.

▶ Levels of ConflictThere are five levels of conflict: intrapersonalconflict (within a person), interpersonal conflict(between or among individuals), intragroup conflict(within a group), intergroup conflict (between oramong groups), and interorganizational conflict(between or among organizations).Intrapersonal ConflictIntrapersonal conflict occurs within the individualand may involve some form of goal or cognitive oraffective conflict. Intrapersonal goal conflict happenswhen several alternative courses of action areavailable and when the outcome, whether positiveor negative, is important to the individual (Locke,Smith, Erez, Chah, & Schaffer, 1994). Brehm andCohen (1962) identified three types of intrapersonalconflict that may develop, involving alternativecourses of action:Approach/Approach: The approach/approachtype occurs when an individual must choosebetween two or more alternatives, each ofwhich is expected to have a positive outcome.For example, Judy Lewis, a recent graduate ofa local university’s master of health services

administration (MHSA) program, has beenoffered job positions in two different health careorganizations. The first is a managed carecoordinator position with a national, publiclyheld laboratory company. The second is anetwork analyst position with a fast-growingthird-party administrator. The salary levels ofthe two positions are comparable.Avoidance/Avoidance: Theavoidance/avoidance type occurs when anindividual must choose between two or morealternatives, each of which is expected to resultin a negative outcome. For example, after JudyLewis accepted the position as the managedcare coordinator with the laboratory company,management announced that because of arecent merger, the company is in the process ofrightsizing. Two options were presented toJudy: retain her position by relocating to theorganization’s headquarters, which is 1000miles away from her hometown, or be laid off.Approach/Avoidance: The approach/avoidancetype occurs when an individual must choose analternative that is expected to have bothpositive and negative outcomes. Judy Lewischooses the relocation option. Although sherealizes that she will gain valuable experienceworking in the organization’s corporate

headquarters, where she will have opportunitiesfor advancement, she is unhappy about havingto leave her family, friends, and familiarsurroundings.Intrapersonal conflict may also be a consequence ofcognitive dissonance, which occurs whenindividuals recognize inconsistencies in their ownthoughts and behavior. Individuals seek consistencyamong their beliefs and/or opinions (i.e., cognitions),and when an inconsistency arises between one’sbeliefs or attitudes and one’s behavior (i.e.,dissonance), something must change to eliminate orlessen the conflict. When there is a discrepancybetween an individual’s attitude and behavior, theindividual’s attitude is likely to change toaccommodate their behavior, thereby reducing oreliminating the intrapersonal conflict (Brehm &Cohen, 1962).In the workplace, dissonance occurs most often inthe context of role conflict. The three types of roleconflict are (1) the person and the role, (2) intrarole,and (3) interrole. Person–role conflict occurs whenthe expectations associated with a work role areincompatible with the individual’s needs, values, orethics. For example, a pharmaceuticalrepresentative believes that making untested claimsabout a new drug is unethical, but whose work rolerequires them to do so. Intrarole conflict occurs

when an individual experiences differentexpectations from their role. For example, ahospital’s purchasing manager who reportsadministratively to the vice president of operationsand functionally to the medical director may faceconflicting expectations, as the former may,because of decreasing reimbursements, stress costefficiency by restricting choices of prosthesisdevices in the surgery department, whereas thelatter may emphasize having available whateverprostheses the surgeons prefer to use withoutregard to cost. Interrole conflict occurs when there isa clash between work and nonwork role demands.For example, if an individual must travel extensivelyor work excessive hours, it may conflict with theirfamily’s needs or their desire to spend timetogether.Interpersonal ConflictInterpersonal conflict is a natural outcome of humaninteraction. Interpersonal conflict involves two ormore individuals who believe that their attitudes,behaviors, or preferred goals are in opposition.Kottler (1996) relates that there are three majorsources of interpersonal conflict: (1) personalcharacteristics and issues, (2) interactionaldifficulties, and (3) differences around perspectivesand perceptions of the issues. Porter-O’Grady and

Epstein (2003, p. 36) summarize these componentsas follows:Personal Characteristics and Issues: As aresult of the diversity of today’s workplace, anextensive range of differences exists betweenpersons and cultures. These differences areembedded with a kind of emotional contentrelated to variations in beliefs, behaviors, roles,and relationships. Individuals function in thecontext of these diverse characteristics, furthervalidating differences others see in us.Interactional Difficulties: As we mature andsocialize, we learn effective communication andrelational skills. A lack of communication skills,combined with our personal and culturaldifferences, creates powerful deficits in ourability to relate to one another. Because of thisbroad-based inadequacy, relational conflictsregularly emerge.Perspective and Perceptive Differences: Whencombined with personal differences andcommunication inadequacies, dissimilarity inthe way people view issues and interactions isa common source of interpersonal conflict. Thissource of interpersonal conflict may includeerroneous perceptions based on incompleteinformation, disparate interpretations ofmeaning, or personal bias.

Many interpersonal conflicts involve goal conflict orrole ambiguity. Role ambiguity involves a lack ofclarity or understanding in terms of expectationsabout an individual’s work performance. Often, themisunderstanding is the result of perceptualdifferences regarding an issue or process. Unclearperformance expectations can easily intensifyinterpersonal conflicts and undermine sustainabilityof healthy relationships. Role ambiguity may causestress reactions, such as aggression, hostility, andwithdrawal behavior (Jackson & Schuler, 1985).Intragroup ConflictIntragroup conflict involves clashes among some orall of a group’s members, which often affect thegroup’s processes and effectiveness. Jehn andMannix (2001) suggest that there are three types ofintragroup conflict: (1) relationship, (2) task, and (3)process.Relationship conflict is an awareness ofinterpersonal incompatibilities. It includesaffective components such as feeling tensionand friction. Relationship conflict involvespersonal issues such as dislike among groupmembers and feelings such as annoyance,frustration, and irritation.Task conflict is an awareness of differences inviewpoints and opinions pertaining to a group

task. Like cognitive conflict, it pertains toconflict about ideas and differences of opinionabout the task. Task conflicts may coincide withanimated discussions and personal excitementbut, by definition, are devoid of the intenseinterpersonal negative emotions that arecommonly associated with relationship conflict.Process conflict is an awareness ofcontroversies about aspects of how taskaccomplishment will proceed. More specifically,process conflict pertains to issues of duty andresource delegation, such as who should dowhat and how much responsibility should beassigned to different people. For example,when group members disagree about whoseresponsibility it is to complete a specific duty,they are experiencing process conflict.Intergroup ConflictIntergroup conflict involves opposition and clashesbetween groups. Under extreme conditions ofcompetition and conflict, the groups developattitudes toward one another that are characterizedby a failure to communicate, distrust, and a self-interest focus (see Case Study 15-2). Nulty (1993)relates that there are four categories of intergroupconflict: (1) vertical conflict, (2) horizontal conflict,

(3) line–staff conflict, and (4) diversity-basedconflict.CASE STUDY 15-2 TurfBattlesAndrea Bevans, chief operating officer of HolyName Hospital, knew it was a matter of when,not if. The memo she had just read was thefirst salvo in what promised to be another turfbattle within the medical staff organization. Inthe memo, the hospital’s vascular surgeonsdemanded that radiologists not be allowed toperform balloon angioplasty. Bevans knewthat this treatment used a balloon at the end ofa catheter and that after the catheter had beenthreaded into an artery in the peripheralvascular system, the balloon was inflated tobreak up deposits that narrowed the arteries.The memo stated that vascular surgeons hadthe background, training, expertise, andproven outcomes using surgical skills and thatthey could best learn and apply the newtechniques, if those techniques wereappropriate at all. To allow radiologists to workinside the peripheral vascular system wouldviolate previously tried and testedrelationships and would cause other,

unspecified, disruptions. The memo endedwith a chilling, thinly veiled threat: “Should thehospital allow radiologists to perform balloonangioplasty, it may not be possible formembers of the surgical staff to be availableto treat untoward events, should they occur asthe result of a procedure done by radiologists.”Bevans reread the memo and mused aboutthe path of modern medicine. It was reachingthe point where many conditions were treatedwithout a scalpel. She thought fleetingly about“Bones,” the Star Trek physician, who hadonly to pass a device over a patient’s body tomake a diagnosis. “Is this where we’reheaded?” she thought. “But, enough ofscience fiction,” she said to herself. “How do Isolve yet another turf battle without too manycasualties, not the least of whom could beme?”Discuss the intergroup conflicts reflected inthis case.Reproduced from Darr, K. (1996). The developing crisis in medicalstaff organization. Hospital Topics, 74(4), 4–6. Reprinted withpermission.Vertical conflict occurs between employees atdifferent levels in an organization. For example,

when supervisors attempt to controlsubordinates, subordinates may resist becausethey believe that the control infringes too muchon their autonomy to perform their jobs. Verticalconflict may also arise because of poorcommunication, goal or value incompatibility, orrole ambiguity (Pondy, 1967).Horizontal conflict occurs between groups ofemployees at the same hierarchical level in anorganization. It occurs when each departmentor team strives only to achieve its own goals,disregarding the goals of other departmentsand teams, especially if those goals areincompatible (see Case Study 15-3; see alsoPondy, 1967).Line–staff conflict occurs over authorityrelationships. Most managers are responsiblefor the processes that create the organization’sservices or products. Staff managers oftenserve an advisory or control function thatrequires specialized technical knowledge. Linemanagers may feel that staff managers areintruding on their own areas of legitimateauthority. Staff personnel may specify themethods and partially control the resourcesused by line managers. Line managers oftenbelieve that their authority over employees isreduced by staff managers, although their

responsibility for the outcomes remainsunchanged (March & Simon, 1993).Diversity-based conflict relates to issues ofrace, gender, gender identity or expression,ethnicity, and religion. These conflicts mayencompass all five levels of conflict:intrapersonal, interpersonal, intragroup,intergroup, and interorganizational.CASE STUDY 15-3 TheManaged Care FactorCedars-Sinai is a 400-bed community hospitallocated in a major East Coast metropolitanarea. The hospital has a reputation as a high-quality, low-cost provider. The medical staff atCedars-Sinai comprises board-certifiedphysicians who are predominantly solopractitioners or are part of two- or three-physician practices. No single- ormultispecialty group practices are affiliatedwith Cedars-Sinai. Medical staff matters arehandled cautiously and conservatively by thehospital administration.Nine years ago a large West Coast healthmaintenance organization (HMO) establisheda presence on the East Coast and grewrapidly. Because of its fine reputation, Cedars-

Sinai has become a major provider of servicesfor the HMO, and many of the HMO’sphysician–employees have admittingprivileges. Almost 20% of Cedars-Sinai’sinpatient days come from the HMO.Following a review of the HMO’s utilizationpatterns, a West Coast consultant noted thelarge difference in hospital inpatient days per1000 enrollees between East and West Coastbranches of the HMO. The HMO’s clinicaldirector was asked to assess how many daysof care and, consequently, how manypremium dollars could be saved with variouslevels of progress toward the West Coastutilization patterns.Word of this study came to the attention ofCedars-Sinai’s chief executive officer (CEO),who was immediately alarmed by theimplications. He knew that if the HMO’sphysicians reduced the lengths of stay fortheir patients by moving utilization patternstoward the West Coast experience,shockwaves would run through the majority ofthe members of his medical staff—thevoluntary, fee-for-service physicians. Theconsequences of such a disparity in patient-day utilization patterns could be a decision by

the medical staff leadership not to reappointthe HMO’s physician–employees to themedical staff because the voluntary medicalstaff would judge that the lengths of stay wereinappropriately short and risked patientmorbidity and mortality.Discuss the horizontal conflict reflected in thiscase.Reproduced from Darr, K. (1996). The developing crisis in medicalstaff organization. Hospital Topics, 74(4), 4–6. Reprinted withpermission.Interorganizational ConflictInterorganizational conflict occurs betweenorganizations as a result of interdependence onmembership and divisional or system-wide success.For example, as Longest and Brooks (1998) pointout, health care organizations participate in a varietyof forms of organizational integration. The mostextensively integrated organizations are integrateddelivery systems (IDSs). As health care reformleads to increasing integration levels, seniormanagers become ever more involved ininterorganizational conflict. Integration that involvesextensive linking of providers at different points inthe patient care continuum—especially when IDSs

are linked with insurers or health plans and perhapswith suppliers in very highly integrated situations—brings into close interactive proximity what are oftenquite disparate organizations. Conflicts areunavoidable, and the knowledge and skills tomanage them effectively are imperative.Interpersonal and collaborative competence is, ofcourse, required of senior managers in all settings,but in an IDS, such competence becomes morecomplex overall, especially given the new dimensionof managing interorganizational conflict (Longest &Brooks, 1998).

▶ Conflict ManagementAs Winder (2003, p. 20) points out:Disagreements between people are an inherent andnormal part of life. These disagreements can stemfrom differences in perceptions, lifestyles, values,facts, motivations or procedures. Differing goals,expectations or methods can turn disagreements intoconflict, which can be damaging to both parties.Conflict may also be positive and beneficial in that itcan force clarification of policy or procedures, relievetensions, open communications and resolve problems.In its negative form, conflict can direct energy from realtasks, decrease productivity, reduce morale, preventcooperation, produce irresponsible behavior, breakdown communication, and increase tension and stress,all resulting in loss of valuable human resources.Understanding how conflict arises in the workplaceis helpful for anticipating situations that may becomeconflictual. However, individuals also need tounderstand how they themselves cope with orhandle these conflictual situations. Thomas andKilmann (1974), building on Blake and Mouton’s(1964) work in the area of leadership, identified fiveconflict-handling modes. Thomas and Kilmann

describe the five conflict-handling modes in twodimensions: (1) assertiveness (i.e., attempt tosatisfy one’s own concern) and (2) cooperativeness(i.e., attempt to satisfy others’ concerns). The fiveconflict-handling modes are (1) competition, (2)avoidance, (3) compromise, (4) accommodation,and (5) collaboration (see Figure 15-1).Figure 15-1 Thomas and Kilmann’s Two-Dimensional Taxonomyof Conflict-Handling Modes

Competition involves assertive and uncooperativebehaviors and reflects a win/lose approach toconflict. A dominating or competing person goes allout to win their objective and, as a result, oftenignores the needs, concerns, and expectations ofthe other party (Rahim, Garrett, & Buntzman,1992). When dealing with conflict betweensubordinates or departments, competition-stylemanagers use coercive powers such as demotion,dismissal, negative performance evaluations, orother punishments to gain compliance (Winder,2003). When conflict occurs between peers, acompetition-style manager will try to get their ownway by appealing to their supervisor in an attempt touse the supervisor to force the decision on theirpeer (Blake & Mouton, 1984b).Competition-style management is appropriate insome situations, such as when the issues involvedin a conflict are trivial or when emergencies requirequick action. It is also appropriate when unpopularcourses of action must be implemented for long-term organizational effectiveness and survival (e.g.,cost cutting, dismissal of employees for poorperformance). This style is also appropriate forimplementing strategies and policies that have beenformulated by higher-level management (Dewine,Nicotera, & Perry, 1991; Rahim et al., 1992).

Collaboration involves highly assertive andcooperative behaviors and reflects a win/winapproach to conflict. A collaboration-style managerattempts to find a solution that maximizes theoutcomes of all parties involved. Managers who usethe collaborating style see conflict as a means to amore creative solution that would be fully acceptableto everyone involved (Winder, 2003). This styleinvolves openness, exchange of information, andexamination of differences to reach an effectivesolution acceptable to all parties. Rahim et al.(1992) suggest that when issues are complex, thecollaboration conflict-handling mode emphasizesthe use of skills and information possessed bydifferent employees to arrive at creative alternativesand solutions. This style may be appropriate fordealing with the strategic issues relating toobjectives and policies, long-range planning, andthe like. However, as Winder (2003) points out, thisstyle requires sufficient interdependence and parityin power among individuals that they feel free tointeract candidly, regardless of their formal status assuperior or subordinate. In addition, this stylerequires expending extra time and energy;therefore, sufficient organizational support must beavailable to resolve disputes through collaboration(Winder, 2003).

Compromising is the middle ground, in whichmanagers display both assertive and cooperativebehaviors. It involves give-and-take, whereby eachparty gives up something to reach a mutuallyacceptable agreement. According to Rahim et al.(1992), it may mean splitting the difference,exchanging concessions, or seeking a middle-ground position. Compromising may be appropriatewhen the goals of the conflicting parties aremutually exclusive or when two parties that areequally powerful (e.g., labor and management) havereached a deadlock in their negotiation.According to Winder (2003), heavy reliance on thecompromising style may be dysfunctional because itcan create several problems if used too early intrying to resolve conflict. First, the parties involvedmay be encouraged to compromise on the statedissues rather than on the real issues. The firstissues that are raised in a conflict often are not thereal ones, so premature compromise may preventfull diagnosis or exploration of the real issues.Second, accepting an initial position as presented iseasier than searching for alternatives that are moreacceptable to everyone involved. Third, compromisemay be inappropriate for all or part of the situationbecause it may not be the best decision available.Compared with the collaborating style, thecompromising style does not maximize optimal

outcomes for all involved parties. Compromiseachieves only partial satisfaction for each person.Kabanoff (1991) points out that this style is likely tobe appropriate when agreement enables each partyto be better off or at least not worse off than if noagreement were reached, achieving a total win/winagreement is not possible, and conflicting goals oropposing interests block agreement on one party’sproposal.Accommodating involves cooperative andunassertive behaviors and is the opposite ofcompeting. Accommodations may represent anunselfish act, a long-term strategy to encouragecooperation by others, or a submission to thewishes of others (Winder, 2003). This style isassociated with attempting to play down differencesand emphasizing commonalities to satisfy theconcern of the other party. An obliging personneglects their own concern to satisfy the concern ofthe other party; thus, accommodating-stylemanagers may be perceived as weak andsubmissive because they try to reduce tensions andstress by reassurance and support (Rahim et al.,1992; Winder, 2003).According to Lee (1990), accommodating isgenerally ineffective if used as a dominant style, butit may be effective on a short-term basis whenindividuals are in a potentially explosive emotional

conflict situation and smoothing is used to defuse it,when keeping harmony and avoiding disruption areespecially important in the short run, and when theconflicts are based primarily on the personalities ofthe individuals and cannot be easily resolved. Inaddition, this style is useful when an individualbelieves that they might be wrong or the other partyis right and the issue is much more important to theother. It can be used as a strategy when a party iswilling to give up something with the hope of gettingsomething in exchange from the other party whenneeded (Rahim et al., 1992).Avoiding involves unassertive and uncooperativebehaviors and is the opposite of collaborating. It isassociated with withdrawal, buck-passing, orsidestepping situations (Rahim et al., 1992). Thisapproach often reflects a decision to let the conflictwork itself out, or it may reflect an aversion totension and frustration. Because ignoring importantissues often frustrates others, consistent use of theavoidance mode of handling conflict usually resultsin increasing frustration for others. When unresolvedconflicts affect goal accomplishment, the avoidingstyle will lead to negative results for the organization(Winder, 2003).Conflict Negotiation Models

Rubin and Brown (1975) define negotiation as theprocess by which two or more parties decide whateach will give and take in an exchange. Since the1960s, there has been extensive research in thefield of conflict resolution or conflict management.From this research, three major negotiation modelshave been developed: (1) distributive, (2)integrative, and (3) interactive. Each of thesemodels is associated with different goals andindicators of success, and each may beappropriately applied in different contexts (Winder,2003).Distributive ModelThe distributive model originated in the field of labornegotiations (Lewicki et al., 1992; Stevens, 1963;Walton & McKersie, 1965) and can be describedas a set of behaviors for dividing scarce resources.Distributive negotiation is often referred to as hardbargaining or a win/lose, zero-sum approach. Thenegotiators are viewed as adversaries that reachagreement through a series of concessions with thegoal of obtaining the greater “piece of the pie.”Tactics that are used in the distributive negotiationmodel are withholding information, guardedcommunications, power positioning, limitedexpressions of trust, use of threats, and distortedstatements and demands (Walton & McKersie,

1965). Brett and Shapiro (1998) referred todistributive negotiations as a tug-of-war with eachparty trying to tug the other to its own side. Thewinner wins when the opponent’s strength gives outand the opponent is pulled across the midline. Theresult is an agreement that favors one side morethan the other.Winder (2003) outlines the four win/lose strategiespracticed by negotiators in using the distributiveapproach. The first negotiating strategy is the “Iwant it all” tactic. This tactic involves makingextreme offers and then granting concessionsgrudgingly if at all. The party using this tactic hopesto wear down the resolve of the other party bypressuring the other to make significantconcessions and forcing the other into a position ofnonreciprocation. The second negotiating strategy is“time warp.” The time-warp tactic communicates anarbitrary deadline for acceptance of the offer. Forexample, the party using this tactic will relate to theother party that an offer is good only until a certaindate and time. If not accepted by the arbitrarily setdeadline, the offer will be withdrawn. The thirdnegotiating strategy is the “good cop, bad cop”scenario. In this scenario, one party attempts tosway the other by alternating sympathetic behaviorand threatening behavior. The fourth negotiatingstrategy is the ultimatum tactic, which is designed to

try to force one party to submit to the will of theother. In this negotiation approach, “take it or leaveit” offers are presented, and one party overtly triesto force acceptance of demands; one party isunwilling to make any concessions, and the otherparty is expected to make all of the concessions(Fisher, Ury, & Patton, 1991).Integrative ModelThe integrative negotiation model, like thedistributive model, evolved primarily in the field oflabor negotiations (Follett, 1940, 1942; Lewicki etal., 1992; Walton & McKersie, 1965). It is currentlyone of the most frequently used models of conflictresolution because of its collaborative versusconfrontational approach.Integrative negotiation is a cooperative, interest-based, agreement-oriented approach to dealing withconflict that is viewed as a win/win or mutual-gaindispute. Integrative negotiation is a process bywhich parties attempt to explore options to achievemutual gains rather than unilateral gains. Partiesrecognize and define a problem, search for possiblesolutions to it, evaluate the solutions, and select onethat maximizes joint gains (Lewicki et al., 1992).Filley (1975), building on the work of Walton andMcKersie (1965), developed an integrative

decision-making model. Filley’s six-step approach isas follows:1. Create an environment that promotesequality, cooperation, communication, andinformation sharing.2. Review and adjust perceptions.3. Review and adjust attitudes (i.e., createprocesses that maximize information sharingand clear the air of past hostilities andnegative attitudes).4. Define the problem.5. Search for alternatives.6. Achieve consensus.The concept of integrative negotiation is based on avalue system that stresses interpersonal trust,cooperation, a willingness to share informationcombined with open communication, and a searchfor mutually acceptable outcomes (Lewicki et al.,1992). This model looks beyond the existingresources and aims to expand the alternatives andincrease the available payoffs to both partiesthrough joint problem solving (Winder, 2003).Fisher and Ury (1981) and Fisher et al. (1991)define integrative negotiation as “principlednegotiation.” They suggest that negotiations shouldbe grounded in substantive concerns when theparticipants do the following:

Separate the people from the problem. In otherwords, separate the issues that are in conflictfrom the personal relationships. Negotiatorsshould be hard on the issues but do so in acooperative relationship with the other party.Focus on interest or need rather than position.In other words, do not allow individual egos tonegate the negotiation process. This requirestrust, respect, and open communication by bothparties.Identify the best alternative to a negotiatedagreement (BATNA) for both parties. Byidentifying BATNAs, the parties’ goal will be toachieve better outcomes than their BATNAthrough negotiations.Invent options or alternatives that providemutual gain. Brainstorming, before and duringmeetings, can assist in developing creativealternatives.Insist on using only objective criteria to judgesolutions. When negotiations are based onobjective rather than subjective criteria,discussions focus on equitable solutions, notfalse assumptions.The integrative-conflict model encourages equitablesolutions to problems. Negotiators are viewed aspartners who cooperate in searching for a fairagreement that meets the interests of both sides

and seeks to maximize the gain for all the partiesinvolved (Winder, 2003). (see Case Study 15-4).CASE STUDY 15-4 Creatinga Win/Win SituationA hospital anesthesiology department isdeeply financially troubled. Departmentleaders approach senior hospitaladministrators seeking additional funds.Department leaders say that without fundingthey will lose staff and be forced to closeoperating rooms. The administrators take theposition that if they provide funding to theanesthesiology department, every departmentwill demand it. Furthermore, theanesthesiology department has enjoyed theprivilege of having an exclusive contract. Ifrooms are closed, the hospital may entertainlooking at other anesthesiology practices. Thesenior vice president for medical affairs (i.e.,VPMA) is called in to mediate. A meeting isset up to negotiate a solution.Applying Fisher’s Principled Negotiations,How Should the VPMA Proceed?The first component of principled negotiationis to attack the problem over which the partiesare negotiating. The further apart the

positions, the more likely emotions willobscure the objective merits of the problem.Most negotiations are as much about emotionas they are money. The negotiation processwill deteriorate rapidly if both sides firmly settleinto their respective positions. If theanesthesiology group and hospitaladministration settle into their respectivepositions of closing rooms and denying theanesthesia group their exclusive contract, thenegotiation soon will become a series ofpersonal attacks.The first step is for the VPMA to acknowledgethat negotiation is an emotional undertaking.As mediator, they should encourage bothparties to consider what they would bethinking if they were on the other side of thetable. The point is to get both parties toaddress the problem and not to reactimmediately to emotional outbursts.Relationship building and the “spirit of thedeal” are important factors to keep in mind.The way to accomplish this relationshipbuilding is simple. Lay down the ground rulesso that each party agrees to show the samedegree of honesty, respect, and fairness that itwould demand from others.

The ultimate objective of any negotiation is tosatisfy the underlying interests of each side inthe best way possible. As mediator, the VPMAmust get each party to recognize theimportance of each other’s interests.What are the interests of each group in thisexample? For the anesthesiologists, it may beincreasing salaries to retain current staff andrecruit new staff, while not having to workunreasonable or unsafe amounts of time toachieve this goal. For the hospital, it may bemaintaining or even increasing operating roomtime to retain and attract high-volumesurgeons.The point is that each side has multipleinterests. Positions such as “We will closedown an operating room” obscure theunderlying interests. Both parties must becautioned to recognize and avoid anypreconceived perceptions they may haveabout the other party.For example, not all anesthesiology groupsseeking stipends are greedy. Not all hospitaladministrators are clueless to clinical issues.No attempt should be made to discard anysolutions until there has been a discussion ofthe problem and interests at hand.

With the interests articulated and understood,the VPMA should begin to look at options,looking first for shared or common interests. Inthis example, it is a common interest for boththe anesthesiology group and hospital to keepthe operating rooms open and running, sinceboth derive revenue from the cases (i.e.,common ground).Unfortunately, it may be difficult or impossibleto find common ground in many situations. Asa result, capitalizing on differences may holdthe key to developing options for achievingagreement. For example, the hospital maystate that in order to provide a stipend, theanesthesiology group must be willing toexpand operating room coverage in theevenings. The anesthesiology group mayclaim it does not have the staff to expandcoverage and there is no need for expansion.Could there be a solution in thedisagreement? If both sides agree to look atboth decreasing room turnover time and moreaccurate posting of procedure times bysurgeons on the basis of historical data, theinterest of the hospital in providing time forhigh-volume surgeons, and theanesthesiologists’ interest in not expanding

evening coverage, might be achieved.Remember that agreement often can bebased on disagreement.Once the parties begin looking at options, theproblem can be discussed on the basis ofobjective criteria. The VPMA must have bothparties prepare objective data to present priorto negotiating a solution. The anesthesiologygroup should be prepared to havebenchmarks as to current salaries, workload,and operating room staffing models. Thehospital should know how other institutionshandle stipends, the legal implications, andobjective criteria used to judge performance.Tarantino, D. P. (2004). The role of the physician executive innegotiation. Physician Executive, 30(5), 71–73. Reprinted withpermission.Interactive ModelWhen negotiations become locked into a win/losesituation, a third party may be invited to assist inresolving the issues (Schwarz, 1994). Interactiveproblem solving is a form of third-party consultationor informal mediation. Third-party facilitators can bemediators, arbitrators, or consultants. Depending onthe situation, a third-party facilitator may have high

or low control of either the conflict-resolutionprocess and/or the outcomes. For example, the thirdparty in intraorganizational conflicts is most oftenthe person in the hierarchy to whom the contestingparties report (Lewicki et al., 1992). In thissituation, the mediator/supervisor would have highcontrol of both the conflict-resolution process andthe outcomes. Mediators usually have high controlof the conflict-resolution process and low control ofthe outcomes (as demonstrated by the VPMA inCase Study 15-4), whereas arbitrators have lowcontrol of the conflict-resolution process and highcontrol of the outcomes.In general, interactive negotiation is designed tofacilitate a deeper analysis of the problems andissues that are forcing the conflict. According toWinder (2003), interactive negotiation usuallybegins with an analysis of the needs of each of theparties and a discussion of the constraints faced byeach side that make it difficult to reach a mutuallybeneficial solution to the conflict. After the analyticaldialogue, the parties engage in joint problem solvingrather than a fight to be won. Interactive negotiationis less focused on directly helping parties reachbinding agreements (excluding arbitration) and moredevoted to improving the process of communication,increasing perspectives and understanding,enabling the parties to reframe their substantive

goals and priorities, and engaging in more creativeproblem solving. Other goals include improving theopenness and accuracy of communication,improving intergroup expectancies and attitudes,reducing misperceptions and destructive patterns ofinteraction, inducing mutual positive motivations forcreative problem solving, and ultimately building asustainable working relationship between the parties(Winder, 2003).

▶ Benefits of Skilled ConflictResolution and NegotiationManagers need to understand and appreciate thatnegotiation is not a zero-sum game. Managers whodemonstrate effective conflict-resolution skills areoften seen as competent, effective leaders (Gross& Guerrero, 2000; Stamato, 2004). A study byEckerd College’s Management DevelopmentInstitute (2003) found a significant link between aperson’s ability to resolve conflict effectively andtheir perceived effectiveness as a leader andsuitability for promotion. The sample for the studyconsisted of 172 employees (90 male and 82female) from five different types of organizations.Approximately one-half of the participants weremiddle-level managers or higher in theirorganization; all of them participated in a programfocusing on workplace conflict. The study revealed astrong correlation between certain conflict-resolutionbehaviors and perceived effectiveness as a leaderand promotion potential. Employees who wereperceived as being good at creating solutions,expressing emotions, and reaching out wereconsidered more effective. By contrast, destructivebehaviors, such as winning at all costs, displaying

anger, demeaning others, and retaliating, werefound to be the worst behaviors in terms of careeradvancement and leadership. Avoidance behaviorswere found to be particularly problematic for would-be negotiators because individuals who areuncomfortable with negotiating or who perceivethemselves to be unskilled or ineffective innegotiating often avoid conflict and thus fail tomanage differences effectively. Of particularsignificance is the study’s finding that negotiationskills are an important aspect of leadership.

▶ ConclusionIn this chapter, we discussed the positive andnegative outcomes of conflict and pointed out thatconflicts originate from a variety of sources. We canpredict with 100% certainty that managers will dealwith conflict and negotiation in the course of theirwork. Conflict-handling behavior can be learned,and managers should adapt their behavior to thesituation to be resolved. Collaborative behavior isstrongly desired as a way to manage conflict andreflects positively on the individuals who use thisapproach.

Discussion Questions 1. 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 15-5 Health Care SystemVersus InsuranceUAB to No Longer Accept UnitedHealthCare After Negotiations FailAt the end of the month, UnitedHealth careinsurance will not be accepted at most UABHealth System entities after the twocompanies failed to reach a contractagreement.The end of UAB entities accepting United isJuly 31, and approximately 25,000policyholders will be affected.“UnitedHealth care forced us in this position,”said UAB Health System CEO Will Ferniany.“We haven’t had these kinds of problems withany other provider but United.”Entities like UAB Hospital, The Kirklin Clinic,all other UAB Medicine primary care, specialtycare and urgent care clinics, UA HealthServices Foundation, UAB Callahan EyeHospital, Medical West and Baptist Health inMontgomery are some of the UAB providers

who won’t be accepting the insurance plansafter July 31. The change also includes allservices provided by UAB doctors, regardlessof where the service is provided.The emergency departments at UAB hospitalswill remain open to United customers, officialssaid, and some United policyholders whohave an open benefit plan may also beexempt from additional charges when thechange goes into effect.Last month, the UAB Health System sent out40,000 letters to patients who went to a UABentity in the past two years with Unitedinsurance to notify them they may soon haveto pay out-of-pocket costs if no agreement isreached.UAB currently accepts Medicare, Medicaid,Blue Cross Blue Shield of Alabama and VIVAHealth (an affiliate of the UAB Health System).The change won’t affect supplemental plans,arrangements with Medicare or PEEHIPpolicies.“We recognize and appreciate that some ofthe services UAB Health System provides areunique and more costly. We reimburse themaccordingly for these types of services,” a

spokesperson from United said. “However,UAB Hospital charges significantly more thanother hospitals even for common services andtests.”The university said it is opposed to the tier twodesignation which would make some ofUnited’s policyholders pay more to come toUAB, while United would pay less. In somecases, the extra out-of-pocket costs would beapplied even if the patient had no choice butto come to UAB Hospital because of theseverity of their illness or the services needed.“UAB is demanding that they be designated aTier 1 provider despite the fact that they don’tmeet the criteria because of their egregiouslyhigh costs,” a spokesperson from United said.“If we agreed to this demand, it wouldundercut employers’ ability to designcompetitive benefit plans that reward theiremployees for choosing quality, cost-effectivecare providers.” United said it would continueto pay the contracted rate no matter whatUAB’s tier designation is.In their negotiations, Ferniany said Unitedbelieved UAB’s costs should mirror smaller,less comprehensive hospitals. These

demands ignore the complexity of the servicesUAB offers, he said.UAB is the only Trauma I center in Alabamarecognized by the American College ofSurgeons, which causes the system to treatsome of the state’s most critical patients. Thehospital also serves as a public safety net toother hospitals in the state that cannot providethe same level of care as UAB, Ferniany said.Its charity costs are more than $70 million ayear.“We are also opposed to a program that onlylooks at price and not quality of care,”Ferniany said. He added the tier system isn’tfair to UAB, because many patients must go toa UAB entity for various reasons related totheir condition or illness. He asked if UAB isthe only place someone can go, why shouldthey have to pay more?He also said United shouldn’t punish UAB forbeing a teaching hospital, but recognize thatAlabama would have far fewer doctors withoutthe residents who train there. Other insurancecompanies realize that, Ferniany said.United is one of the most profitable insurancecompanies, according to data, and generates

more cash profit than all other national publiclytraded health plans in the country combined.The company had $9 billion in earnings in2018—profits that come at the expense of itspolicyholders and health care providers,Ferniany said.This is not the first time UAB could not reachan agreement with United. The two could notreach a deal in 2005, and United was notaccepted at the university from 2006 to 2011.Raheel Farough, vice president of UAB HealthSystem Managed Care, and Ferniany calledthe lack of partnership a sad and unfortunatesituation, but maintain that UAB will not acceptsomething that puts profits ahead of patientcare.“The things they’re asking for… are just notthings we can accept,” Ferniany said. “This isvery, very worrisome to these people. This isnot a good thing.”Farough added that United’s policies canharm patients, as the company will only payfor what they deem is medically necessary,regardless of what’s best for the individual.United has not been able to renew contractswith hospitals across Alabama and the

country, according to information from UAB.South Alabama Medical Center and Universityof Colorado Hospital/CU Medicine were two ofthose hospitals, citing reasons including“frequent difficulty in obtaining authorizationfor services needed by patients” that wereoften not paid for. The hospitals alsomentioned United’s refusing to pay healthcare providers after initially approving care.The two are still committed to discussions ofan agreement. “I’m planning to bereasonable,” Ferniany said. “They’ve notprovided us anything close to reasonable.”United responded Friday: “Despite repeatedefforts to reach a compromise, UAB hasdecided to put Alabama residents square inthe middle of this dispute. This is unfortunateand completely avoidable. We hope UAB willreconsider so we can continue working towarda new agreement that will ensure ourmembers have continued access to UAB at amore affordable cost.”1. What level of conflict is represented inthis case?2. What type of negotiation style did UABuse in this case?

3. What type of negotiation style didUnitedHealthcare use in this case?4. Who are the winners and losers in thisconflict?Reproduced from Auglair, H. (2019). UAB to no longer acceptUnitedHealth care after negotiations fail. Al.com. Availablefrom https://www.al.com/news/birmingham/2019/07/uab-to-no-longer-accept-united-healthcare-after-negotiations-fail.htmlCase Study 15-6 Musical OperatingRoomsDr. John Wilkins sat staring at the phonemessage in front of him. Dr. Peter Mikelson,chief of orthopedics, had called again wantingto discuss the current system used toschedule operating room times. As chief ofmedicine, technically, Dr. Wilkins had thepower to dictate who would use the operatingresources and when. Up to now he had beenreluctant to use that power, relying instead onscheduling administrators to handle theschedule for operating room use. Perhaps thetime had come to review that system andimplement changes if necessary.Mercy Hospital, a not-for-profit hospitallocated in the Northeast, employed 1000

doctors in 30 different departments. Thefacility had an outstanding reputation as ateaching hospital. About 40% of its doctorswere full-time faculty, while the remaining 60%were volunteer staff (those doctors who, whilenot employees of the hospital, worked withresidents and had access to hospitalresources). The hospital currently had 25operating rooms located throughout thehospital. Operating rooms were not assignedto any particular department, but doctors triedto use the rooms closest in proximity to theirdepartment wing. In some more extremecases, it was simply understood that theoperating rooms in certain wings were to beused only by certain departments.Dr. Wilkins decided to have some informaldiscussions with different department chairs togauge how dire the situation really was. Hisfirst stop was with Dr. Steve Daly, chief ofurology. “You know, John,” Dr. Daly explained,“I understand urology is not a high-profileglamour specialty, but I am having a verydifficult time attracting both volunteer staff andthe best residents because of the trouble Ihave scheduling procedures. We have 20doctors in three different departments sharingfour operating rooms. I know to you this may

sound like an inability on my part to plan, butlet me put this in terms that may meansomething to you. The operating room iswhere we make our money. If my doctors andI can’t easily schedule time in the OR, wecan’t continue to build the department. I havealready seen a decline in the number ofreferrals from primary care physicians. If thiskeeps up, this hospital will have a hard timemaintaining this specialty at a competitivelevel.”Next on Dr. Wilkins’s list was Dr. Jack Palmer,chief of neurosurgery. Jack Palmer was a bitof a legend in the region. This was due to acombination of the high-profile nature of hisspecialty, his long tenure at the hospital, andhis impressive client list, which included manyof the people who sat on Mercy Hospital’sboard of directors as well as their families andfriends. As John walked through thedepartment, he noticed that all three of theORs in the Neurosurgery wing were not inuse. When he mentioned this to thedepartment secretary, she replied that thiswas always the case on Friday mornings. Foras long as she could remember, Neurosurgeryheld a weekly teaching conference from 7:00to 12:00 every Friday. The secretary then

informed John that Jack could not free up anytime to speak with him, but she did relay themessage that all was fine in Neurosurgery asfar as OR time.Dr. Wilkins next spent some time with Dr.Sheehan, chief of ophthalmology. Afterreviewing the OR schedule for the next month,Dr. Wilkins was astounded at the number ofprocedures Dr. Sheehan and members of herdepartment were scheduled to perform. Dr.Sheehan explained, “Well, John, I’ve actuallyput a little cushion in there to make sure Ihave the time I need. At the beginning of themonth I sign up those surgeries I am sure wewill perform as well as some ‘phantom’patients. That way, if surgery runs overbecause I’m teaching the procedure to aresident, or if a patient shows up in a conditionunder which I cannot operate, I can easilyreschedule them. Patients get quicklyrescheduled, doctors’ office hours aren’tdisrupted, and everyone is happy. The nameof the game is customer service. Peter [Dr.Mikelson] is new and will learn the system likeeveryone else did. I’m feeling particularlycharitable today. Send Peter my way and we’llsee if we can’t negotiate for some of myscheduled time.”

Dr. Wilkins spoke with Dr. Mikelson last. Dr.Mikelson said, “John, I know I’m the new kidon the block, but this system is simplyunacceptable. Six months ago when I tookthis position, you and the board made it veryclear to me the importance of building thepractice. I’ve done as much as I can, but mycapacity analysis shows that if my growthcontinues, I’ll need four operating roomsinstead of the one I am currently allocated.The bottom line is the bottom line, and youand I both know the money Orthopedicsbrings into the hospital. If I have to beg andplead with Susan Sheehan every time anunexpected change in my schedule pops upor rely on the grapevine to figure out when theOR is available, I can’t keep my patientshappy. The game has changed, John.Unhappy patients simply go elsewhere forsurgery.”Dr. Wilkins knew Dr. Mikelson was right. Howwould he fix the situation in a way that madeeveryone happy, including patients, doctors,administrators, and the board of directors?What was the proper criteria to use: longevity,political clout, fiscal impact? How was hegoing to allow for emergency surgeries? Howmuch control did he really want to take away

from the physicians in scheduling theirprocedures?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 atmanaging the conflict? What should theyhave done? Would you do what they did?Why or why not?4. Imagine that you are Dr. Wilkins, who hasbeen asked to resolve this dispute. Whatsource of leverage do you have? Whatoptions are possible? What impact wouldeach option have? What are your overallgoals?Reproduced from Friedman, R. (2002). Musical operatingrooms: Mini-cases of health care disputes. InternationalJournal of Conflict Management, 13(4), 421–422. © EmeraldGroup Publishing Limited all rights reserved.Case Study 15-7 What Went Wrong?Tim Hardwood, CEO of Community HealthSystem, hung up the phone with a heavy sigh.He had just received the news from MaryMartin, vice president of human resources,that negotiations had stalled between thehealth system and the service employees’

union. Mary had told him, “As of now, the2,000 service employees at our threehospitals are without a contract andthreatening to strike. But don’t worry, Tim. Itold the union negotiators that the healthsystem is prepared to handle a strike.”“A strike!” Tim thought. “The media will have afield day with this! What went wrong?”Jim Brentward, one of the union negotiators,sat across the table from Mary Martin. Jim toldMary that his members understood thatCommunity Health System was havingfinancial difficulties because of the currentstate of the industry with decreasingreimbursements and increasing regulations,but the union members were not pleased withthe organization’s proposed offer for salaryincreases and benefits package over the next4 years. Jim said, “Unless the health systemsigns a contract by 5:00 P.M. Friday withacceptable salary and benefit increases,members of the union are threatening tostrike.” He continued, “The union plans to holdan informational picket on Thursday, andalthough the union doesn’t want to strike, it’s astrong possibility. After the informational

picket, we will hold a strike vote and see whatour members have to say about the situation.”Mary was shocked by Jim’s comments. Shesimply could not believe that CommunityHealth’s service employees would threaten tostrike! Because of her position as vicepresident of human resources, Mary knew thatthe service employees represented by Jim’sunion were at the bottom end of the healthcare system’s pay scale. These employeesincluded patient transporters, housekeeping,and cafeteria workers. Mary also knew thatthe union benefits paid to members during astrike equaled only 50% of the employee’sweekly salary. Mary felt confident thatbecause they had too much to lose financially,the employees would never vote to strike. Inaddition, she knew that Community HealthSystem was considering outsourcing itsdietary departments to Thomson Health careFood Services. If the employees did strike,although Mary considered that very unlikely,dietary services would continue withoutinterruption. Knowing this inside information,Mary decided that she wasn’t going to let Jimand the other union negotiators bully her.Mary told Jim that the health care system

would not give in to the union’s demands andwas prepared for a strike.Explain to Tim Hardwood what went wrong. Ifyou were hired as the mediator, how wouldyou go about resolving the situation to achievea win/win agreement?Case Study 15-8 Healthy ConflictResolution“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 ahospital-owned multispecialty group.“But, Dr. Jones,” Cindy says, while whippingoff her telephone headset and turning awayfrom the open patient registration window,“you are double booked for most of theafternoon because you canceled your clinictwice this month already. Many of thesepatients have been waiting more than threemonths to see you!”Jones glances furtively at the waiting room,and already half turned and heading towardthe clinic exit, says, “I’m sure you will be ableto smooth things over. Just tell them that I gotcalled to an emergency.”

Cindy has a suspicion that, because theweather is nice, Jones is taking off with acouple of colleagues to go sailing or play around of golf. After all, he always sports a darntan, comes to clinic late, and often leavesearly. Cindy does not relish having to call andreschedule these patients, some of whomhave already been rescheduled at least oncein the past couple of months.Cindy decides enough is enough. She callsher manager and requests a meeting as soonas possible. Her manager can sense thatCindy is upset and offers to have someonecover for Cindy so that they can talk privately.Cindy tells the manager about the situationwith Jones that happens “all the time,” andhow she is “sick of it,” and will not “workanother day under these conditions.” Aftercalming Cindy down, the manager promises tobring the matter up with the chief of thedepartment.To make a long story shorter, suffice it to saythat this conflict continues to mushroom toinvolve several more individuals (the chiefmedical officer, the executive director of theclinic, the director of human resources, andthe union representative) before Jones is ever

made aware that Cindy has filed a formalcomplaint about him. When he is finallyconfronted, in a meeting with the chief medicalofficer and the director of human resources,he is caught completely off guard.After all, the incident happened several weeksago, and Cindy did not mention anything tohim about it. They have continued to worktogether, in his opinion, as if nothing werewrong. He is also surprised to find out thatCindy has been keeping a tally of the numberof times that he has canceled his clinic, leftearly, or started clinic late.Jones goes from astonishment to red-facedanger in a few minutes. It is clear to all that therelationship between Cindy and the doctor isirreparable. Jones is labeled as a disruptivephysician. Cindy is not welcome in anydepartment because the other physicians arefearful of being targeted. Cindy eventuallyresigns, and Jones feels betrayed andunappreciated by his staff and his employer.If you were the manager in this case, howwould you have handled the situation?Reproduced from Pierce, K. P. (2009, January/February).Healthy conflict resolution. Physician Executive, 35(1), 60–61.

Case Study 15-9 Conflict-HandlingStylesFor each of the five scenarios that followdetermine the most appropriate conflict-handling style(s).Scenario OneA radiologist on the staff of a large communityhospital was stopped after a staff meeting by acolleague in internal medicine. On Monday ofthe previous week, the internist referred anelderly man with chronic, productive cough forchest X-ray, with a clinical diagnosis ofbronchitis. On Thursday morning, the internistreceived the radiologist’s written X-ray reportwith a diagnosis of “probable bronchogeniccarcinoma.” The internist expressed hisdismay that the radiologist had not called himmuch earlier with a verbal report. Visiblyupset, the internist raised his voice, but did notuse abusive language.How should the radiologist handle this conflictwith the internist?Scenario TwoThe Family and Community Medicine Divisionof a large-staff model HMO serves apopulation that is ethnically diverse. Thesenior management team of the HMO,

spurred by repeated complaints fromrepresentatives of one racial group, hasencouraged the division, all of whosephysicians are White, to diversify. SeveralBlack and Hispanic physicians with strongcredentials apply for the open positions, butnone are hired. Weeks later, a young femalefamily physician learns from severalcolleagues that the division director hasidentified her as racist and the obstructionist torecruiting. The comments attributed to her arenot only false but are also typical ofdiscriminatory statements that she has heardthe division chief utter. The rumors about her“behavior” have circulated widely in thedivision.How should the young female family physicianhandle this conflict with the division chief?Scenario ThreeA manager who reports to the vice presidentfor clinical affairs (VPCA) of a tertiary-carehospital hired a young woman to supervisedevelopment of a large community outreachprogram. During the first four months of heremployment, several behavioral problemscame to the VPCA’s attention: (1) complaintsfrom community physicians that the

coordinator criticizes other physicians inpublic; (2) concerns from two communityleaders that the coordinator is not truthful; and(3) complaints about written reports about theproject that label and blame others,sometimes in language that is disrespectful.The VPCA spoke several times to themanager about these problems. The managerreported other dissatisfactions with thecoordinator’s performance, but he showed nosign of dealing with the behavior. Two morecomplaints come in, one from an influentialcommunity leader.How should the VPCA handle this conflict withthe manager?Scenario FourThe medical school in an academic healthcenter recently implemented a problem-basedcurriculum, dramatically reducing the numberof lectures given and substituting small-grouplearning that focuses on actual patient cases.Both clinical and basic science faculty arefeeling stretched in their new roles. In thepast, dental students took the basic course inmicroanatomy with medical students. The corelectures are still given, but at different timesthat do not match with the dental-curriculum

schedule. The anatomists insist that they don’thave time to teach another course specificallyfor dental students. The dean has informedthe chair of the Department of Anatomy andCell Biology that some educational revenueswill be redirected to the dental school if thefaculty do not meet this need.How should the dean handle this conflict withthe chair of the Department of Anatomy andCell Biology?Scenario FiveThe partners in a medical group practice areinformed by the clinic manager that onephysician member of the group has beenrepeatedly upcoding procedures for a specificdiagnosis. This issue first came to light 6months ago. At that time the partners met withhim, clarified the Medicare guidelines, andoutlined the threat to the practice fornoncompliance. He argued with their view, butultimately agreed to code appropriately. Therewere no infractions for several months, butnow he has submitted several erroneouscodes. One member of the office staff hasasked whether Medicare would consider thisbehavior “fraudulent.”

How should the partners handle the situationwith the other physician partner?Aschenbrener-Siders, C. A. (1999). Managing low-to-mid intensityconflict in the health care setting. Physician Executive, 25(5), 44–50.Reprinted with permission.

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PART VGroups and TeamsPeople are social beings and have a need foraffiliation or achieving a sense of belonging. Groupshelp to satisfy this need. In Chapter 16, we examinegroup dynamics. “Group dynamics” is a termcreated by Kurt Lewin and used to describe thesubfield of organizational behavior that attempts tounderstand the nature of groups, how they develop,and how they interact with the members of thegroups, with other groups, and with theirenvironments. In Chapter 17, we discuss thevarious types of groups and their related functions.Chapter 18 examines the use of teams in today’scomplex health service organizations. Health caredelivery “takes a village.” Few tasks can beperformed from start to finish by one person. Tocomplete a task requires resources from manyindividuals. Today, we see the widespread use ofinterdisciplinary teams to deliver effective andefficient health care.

CHAPTER 16Overview of GroupDynamicsLEARNING OUTCOMESAfter completing this chapter, the student shouldunderstand:The importance of group dynamics.The characteristics that define a group.The meaning of group interaction andmethods to measure it.What motivates individuals to join and remainin groups.The various roles that members assume ingroups and the importance of these roles.The meaning of group norms and how theyare formed and sustained.The factors that contribute to or inhibit groupcohesiveness.The impact of conformity on groupperformance.

The impact of groupthink on group decisionmaking.

▶ OverviewHuman beings are social animals. Although we areborn into and leave the world in a singular manner,we spend the majority of our time working,worshiping, learning, and playing in groups.Because we spend so much of our time in groups,there is great interest in understanding the innerworkings of groups and their members. Thisresearch is referred to as the study of groupdynamics, which is the attempt to understand thebehavior in which people interact with, influence,and are influenced by others within groups.Why is understanding group dynamics important tomanagers? It is important to the success of anorganization. More and more organizations aremoving toward a stronger emphasis on theiremployees working in groups and/or teams. A studyby Blackburn and Rosen (1993) found that FederalExpress had 4000 employee teams, Motorola used2200 problem-solving teams, and at any given time75% of Xerox’s employees serve on some type oftask force or on advisory teams. When individualstransition from a staff role to a management role,their objective moves from being an individualperformer to accomplishing work through others. It

is increasingly rare for managers to workindependently. For example, it is estimated that, onaverage, managers spend 50%–80% of theirworking day in one sort of group or another. In thehealth care setting, this estimate is not surprising.Health care managers, both clinical andadministrative, participate in numerous work groupsand teams on a daily basis, such as operating roomteams, disease management teams, patient safetycommittees, biomedical ethics committees, patientcare teams, trauma teams, and emergency-preparedness and disaster-management teams.The movement toward accountable careorganizations and patient-centered medical homeswill increase the importance of teams in health care(Taplin, Foster, & Shortell, 2013). Additionally, ashealth care systems expand geographically andintegrate vertically, more managers may findthemselves working on virtual teams with peoplethey may have never met face to face. Therefore, tobe able to manage groups effectively, managersneed to understand the variables involved relating togroups: formation and development, structure, andinterrelationships with individuals, other groups, andorganizations (Turner, 2000).Our discussion of groups is divided into threesections. We define what a group is, discuss whyindividuals join groups, and then examine the

interactions and behavior of members within agroup. Although the terms “groups” and “teams” areoften used interchangeably, there are differences.The concept of groups is broader than the conceptof teams; therefore, not every group is a team.Katzenbach and Smith (1993) point out that teamsare a special form of groups that have highlydefined tasks and roles and demonstrate high groupcommitment. Because of these characteristics, wediscuss the nature of teams separately.

▶ What Is a Group?Social scientists usually define a group using fourcharacteristics: (1) two or more people in socialinteraction, (2) a stable structure, (3) commoninterests or goals, and (4) the individuals perceivingthemselves as a group. For example, two patientswaiting to be treated in a hospital’s emergencydepartment are not a group. This collection of twoindividuals is not a group because (1) there is nointeraction between the two patients, nor are theyattempting to influence each other; (2) patients in anemergency department constantly change, so astable environment does not exist for futureinteractions; (3) although patients may have similargoals (e.g., restoring their healthy status, alleviationof pain), they are not working in a coordinated effortto achieve a common goal; and (4) these patientsdo not perceive themselves as a group, only asindividuals occupying space in the same location atthe same time. However, a group exists whenvolunteer members of the local chapter of theAmerican Heart Association meet to plan the nextfundraising event or when a multidisciplinary groupof clinicians convenes for the purpose of developingevidence-based guidelines for patients admitted to

the hospital with congestive heart failure. Thesegroups represent collections of individuals with acommon interest or goal in a stable environment(although members may join and leave the group atvarious times) wherein members interact with oneanother with the intent of influencing each other.One important factor relating to group dynamics isunderstanding the interactions that occur between agroup’s members.

▶ Group InteractionTubbs (2001) defines group interaction as theprocess by which members of a group exchangeverbal and nonverbal messages in an attempt toinfluence one another. Therefore, interactionincludes talking, listening, nonverbal gestures, texts,emails, and any other behavior to which peopleassign meaning. By observing these interactions,we can better understand the dynamics within agroup. On a formal level, researchers may use asociogram to record their observations of theinteractions between members of a group (seeFigure 16-1).

Figure 16-1 A Typical SociogramA sociogram is a pictorial method of mapping outand recording the contributions of members to agroup interaction. In the example shown in Figure16-1, the number of inputs is recorded as lines inthe circles, each of which represents a participant inthe interaction. The arrows show the direction of thecontributions made, and their thickness indicatesthe intensity of the traffic. An arrow pointing outwardindicates a contribution made to the group as awhole rather than to an individual member (such aswhen an individual addresses the group in general).However, a sociogram is limited to documenting thedirection and intensity of communication; it does notinclude the content of what was communicated bythe members in their attempt to influence oneanother. Other assessment tools, such as Bales’sInteraction Process Analysis, can provide insightinto the content of the members’ communication(see Figure 16-2).

Figure 16-2 Bales’s Interaction Process AnalysisReproduced from Bales, R. F. (1950). Interaction processanalysis: A method for the study of small groups. Chicago:

University of Chicago Press.As Sprott (1958) noted, Bales’s Interaction ProcessAnalysis includes 12 categories of interactions;these interactions are classified as relating to eitheremotion or task. The emotional responses are eitherpositive (items 1–3) or negative (items 10–12). Taskresponses are either giving information (items 4–6)or asking for information (items 7–9). The 12categories are also grouped into pairs, as noted inTable 16-1. The interactions of these 12 categoriesgreatly influence the roles assumed by membersand group norms.Table 16-1 Bales’s Interaction Process Analysis: TwelveCategories PairedItemsDescriptionExample1 and12OrientationHow well do the group members cohere?Bales gives the example of a man who makesan offensive remark directed at anothermember (item 12); however, the laughter thatfollows is classified under item 2.2 and11EmotionalresponseonlyBales gives the example of a member sighingheavily and examining his fingernails.3 and10Acceptanceor rejectionThis is where decisions are made. If positive,the member may show understanding, passiveacceptance, and complies with the decision. Ifnegative, the member may show

disagreement, passive rejection, and withoutassistance.4 and9ControlAsking for suggestions such as “I think weshould do this” or “How do you think we oughtto tackle this?” By asking for suggestions, amember is getting the others to committhemselves. By committing themselves,members limit their future choices. This is amethod of bringing other members undercontrol, which may or may not lead toresentment.5 and8Opinion“Have we done that?” “We ought to make surethat we do this.” Any comments that involvesummarizing the issues.6 and7OrientationSetting out the problem and giving factualinformation.Bales, R. F. (1950). Interaction process analysis: A method forthe study of small groups. Chicago: University of Chicago Press.Reprinted with permission.

▶ Why Do People JoinGroups?Individuals join groups for many reasons, and manyof these reasons are explained by Maslow’sHierarchy of Needs. Individuals join groups tosatisfy their need for belonging (i.e., the need tohave close contact with others and to be acceptedby them) in addition to social and affection needs.Groups can satisfy an individual’s need for safety byreducing the sense of powerlessness and anxiety,which may be experienced in ambiguous orthreatening situations. Members may join becausegroup affiliation can be an important part of anindividual’s self-esteem as well as social identity.People need to have a positive opinion ofthemselves, which they gain in part fromacceptance by others in a group and evidence thatother group members share their views and values.Furthermore, a group can help members to achievestated goals that they could not have achievedalone as individuals.Group membership can satisfy a number of needsfor an individual, in addition to the membercontributing to other members and the groupachieving objectives. However, deciding whether to

join a group or to continue membership in a groupposes an approach–avoidance conflict. To resolvethe conflict, an individual will perform a cost–benefitanalysis of the relationship. Members will continuewith their association as long as the rewards(satisfaction of needs) outweigh or are equal to thecosts of being a member, such as required time toparticipate and financial commitment. This cost–benefit analysis is analogous to Adams EquityTheory of Motivation.

▶ Roles of Group MembersFunctional Role Theory, as introduced by Benneand Sheats (1948), identified the functional rolesthat they saw individual group members assumingin small group interactions. The three roles identifiedwere task, maintenance, and individual (sometimescalled “self-centered”) roles (see Exhibit 16-1).Task-oriented roles focus on goal accomplishment,maintenance roles focus on relationships, andindividual roles focus on individual needs (such asneeds for power or recognition), which may in thelong run be harmful to the group’s overall success.Benne and Sheats’s task and maintenance roles aresimilar to the two communication patterns—task-oriented and socioemotional—that Bales (1950,1953, 1970, 1999) identified in his research ongroup members’ interactions. Bales’s task rolerelates to a member’s activities that help the groupaccomplish its goals (e.g., concern for production),and the member’s socioemotional role is describedas the activities that the member performs topromote harmonious relations within the group (e.g.,concern for people) (refer to Figure 16-2).Exhibit 16-1 Benne and Sheats’s

Functional Roles of Group MembersTask Roles—Groups have members who playroles relating to job completion:Initiator–contributor: Generates newideas.Information-seeker: Asks for informationabout the task.Opinion-seeker: Asks for the input fromthe group about its values.Information-giver: Offers facts orgeneralization to the group.Opinion-giver: States their beliefs abouta group issue.Elaborator: Explains ideas within thegroup and offers examples to clarifyideas.Coordinator: Shows the relationshipsbetween ideas.Orienter: Shifts the direction of thegroup’s discussion.Evaluator-critic: Measures group’sactions against some objective standard.Energizer: Stimulates the group to ahigher level of activity.Procedural-technician: Performslogistical functions for the group.

Recorder: Keeps a record of groupactions.Maintenance Roles—Groups also havemembers who play certain social roles:Encourager: Praises the ideas of others.Harmonizer: Mediates differencesbetween group members.Compromiser: Moves group to anotherposition that is favored by all groupmembers.Gatekeeper/expediter: Keepscommunication channels open.Standard setter: Suggests standards orcriteria for the group to achieve.Group observer: Keeps records of groupactivities and uses this information tooffer feedback to the group.Follower: Goes along with the group andaccepts the group’s ideas.Individual Roles—Member roles that can becounterproductive to the accomplishment of thegroup’s task or goals:Aggressor: Attacks other groupmembers, deflates the status of others,and shows other aggressive behavior.

Blocker: Resists movement by thegroup.Recognition seeker: Calls attention tothemselves.Self-confessor: Seeks to disclose non-group-related feelings or opinions.Dominator: Asserts control over thegroup by manipulating the other groupmembers.Help seeker: Tries to gain the sympathyof the group.Benne, K., & Sheats, P. (1948). Functional roles of group members.Journal of Social Issues, 4, 41–49. Reprinted with permission.Members may assume different roles depending onthe needs of the individual or the group. Bales foundthat some members engaged in more task andsocioemotional activities than others and, as aresult, were offered leadership status in the group.However, Bales also found that the person whoengaged in the most task activities was not thesame person who performed the mostsocioemotional activities. Therefore, two leadersemerged: the task leader, who was rated as havingthe best ideas, offering the most guidance, andbeing most influential in forming the group’sopinions, and the socioemotional leader, who wasthe best liked. The usual explanation for the

emergence of the second leader is that a taskleader’s sense of purpose gives rise to activities(e.g., unpopular orders, sharp criticism) that hurtgroup members’ feelings. The second leaderemerged to smooth things over and restoreharmony to the group.Belbin (1981, 1993, 2004) studied the performanceof a team and how performance was directlyaffected by the roles that members play. Belbindeveloped the Team Role Theory, which proposesthat for optimal operation of a management team,nine (originally eight) personality-related team rolesneeded to be fulfilled. The roles arechairman/coordinator, shaper, plant, teamworker,completer/finisher, company worker/implementator,resource investigator, monitor/evaluator, andspecialist. Belbin’s nine roles can be categorized astask/task-oriented, maintenance/socioemotionalpositive, or individual/socioemotional negativeaccording to Benne and Sheats’s Functional RoleTheory and Bales’s Interaction Analysis (see Table16-2). All groups need task leadership as well asattention to detail and a concern for people in orderto be effective. Understanding the various members’roles is important for comprehending theinteractions that either push a group toward orhinder the group from meeting its goals, includingmember satisfaction with the interactions. The

role(s) that a member assumes and the resultinginteractions greatly influence the group’s norms.Table 16-2 Comparison of Members’ Roles

▶ Group NormsEvery group has a set of norms, which is an impliedcode of conduct about what is acceptable andunacceptable member behavior. Norms can bewritten or unwritten; positive, negative, or neutral;and applied to all members of the group or only tocertain members. In addition, groups will apply“punishment” or sanctions to members whosebehavior deviates from the group’s norms. Normscan dictate the performance level of groups (e.g.,high- or low-productivity work groups), theappearance of group members (e.g., bankers weardark suits), or the social arrangement within thegroup (the chair of the committee sits at the head ofthe conference table).Most organizations have formal rules of conduct,which are delineated in their policies andprocedures manuals. For example, a hospital wouldhave written policies on clinical research protocols,infection-control procedures for handling blood andother body fluids, the proper attire to be worn inoperating room suites, and processes to ensure thatthe correct patient (and correct body part) isoperated on (see Exhibit 16-2).

Exhibit 16-2 Surgical ChecklistThe implementation of a surgical checklist thatguides the surgical team through a series oftasks and communications before, during, andafter the surgery represents an example ofwritten formal rules of conduct. Research bythe World Health Organization found thatimplementing such a checklist reducedpostoperative complications and death rates byover 30% (Haynes et al., 2009).

WHO Surgical Safety Checklist, Retrieved fromhttps://www.who.int/patientsafety/topics/safe-surgery/checklist/en/However, in most instances, group norms (i.e.,acceptable behavior of group members) areunwritten and learned by members through theirinteractions 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 asnormal methods of weight control. The most popularmembers of the group binged and purged at the rateestablished by the norms of the group, and thosewho did not binge and purge when they first joinedthe group were more likely to take up the practicethe longer they were members of the group. Thisalignment of behavior within a group is part of anindividual’s socialization process. This process ofsocialization explains how unwritten norms becomethe “standards” for the group, as members begin tointernalize the group’s norms as their own behaviorstandards. As such, norms do not just maintainorder within the group; they also maintain the groupitself (Youngreen & Moore, 2008).Since most group norms are unwritten, they areusually not easily identified until violated. Whengroup norms are violated, members of the group willattempt to convince the “deviant” to conform to thegroup’s standards of behavior. If the use ofpersuasion is not successful, the group may punishthe member by withdrawing any “special” status thatthe member may hold, or the group maypsychologically reject (e.g., ignore) the member.The final consequence for a member who refuses toconform would be dismissal from the group.Through this process, members learn the range or

boundaries of acceptable behavior within a group.For example, Feldman (1984) describes the normsabout productivity that frequently develop amongfactory workers. A person produces 50 widgets andis praised by their coworkers; a person produces 60widgets and is sharply teased by coworkers; aperson produces 70 widgets and is ostracized bycoworkers. If the group norm is that producing 50widgets allows for an acceptable pace of work, thegroup member who produces 70 widgets may eithermake the rest of the group look lazy or causemanagement to raise the target number of widgetsto be produced, resulting in an uncomfortably fastpace of work. Not all behavior deviations will beenforced, only those violations that have somesignificant effect on the group meeting its goals (seeTable 16-3). Norms are powerful forces not only dinaffecting the behavior of group members, but also indetermining the degree of cohesiveness andconformity of the group.Table 16-3 Why Norms Are EnforcedFour Conditions UnderWhich Group Norms AreMost Likely To BeEnforcedExampleIf norms facilitate groupsurvivalGroup members do not disclose certainproject details so that their work cannot

be replicated by another group.If norms simplify or makepredictable what behavioris expected of groupmembersEmployees are expected to be presentat the office during the same hours eachday so that clients always know whereto find team members.If norms help the group toavoid embarrassinginterpersonal problemsMembers do not discuss politics at workso that members with strongly heldbeliefs do not create conflict or ostracizeother members.If norms express thecentral values of the groupand clarify what isdistinctive about thegroup’s identityLong white coats are worn by physiciansso that patients know which careprovider is their doctor and to symbolizea high level of training and expertise.“The Development and Enforcement of Group Norms,” by D. C.Feldman, 1984. The Academy of Management Review, 9, pp.47–53.

▶ CohesivenessThe degree of cohesiveness (e.g., camaraderie) ofa group is determined by various factors, which mayinclude members’ dependence and physicallocation/proximity. The more significant factors tendto be (1) the size of the group, (2) experience ofsuccess by the group, (3) group status, and (4)outside threats to the group.Size of the GroupResearchers have determined that the size of thegroup has a direct impact on the cohesiveness of agroup. When there are too many members, itbecomes too difficult for members to interact. Luft(1984, p. 23) concluded that “cohesion tends to beweaker and morale tends to be lower in largegroups than in comparable smaller ones.” What isthe acceptable group size? Kameda, Stasson,David, Parks, and Zimmerman (1992) suggest thatthe optimum group size appears to be fivemembers. Five-member groups are small enoughfor meaningful interaction yet large enough togenerate an adequate number of ideas (Tubbs,2001). Small groups may also avoid the problem ofsocial loafing.

Social LoafingDiffusion of responsibility refers to the phenomenonby which an individual feels less responsible for atask when they are part of a group. For example,people are more likely to call for an ambulancewhen they see a car wreck if there are no other carson the road. However, if the car wreck occurs in themiddle of a busy highway with lots of other carsaround, people are more likely to assume thatsomebody else in traffic will make the call. Perhapsyou ignore the full trashcan, hoping that yourroommate will take care of it. A specificconsequence of diffusion of responsibility thatoccurs in working groups is called social loafing.Social loafing refers to the decreased effort ofindividual members in a group when the size of thegroup increases (Tubbs, 2001). Ringelmann(1913) identified this social phenomenon when henoticed that as more and more people were addedto a group pulling on a rope, the total force exertedby the group rose but the average force exerted byeach group member declined. The reason is thatsome members’ performance became mediocrebecause they assumed that other members wouldpick up the slack. Karau and Williams (1993) foundthat social loafing occurs across work populationsand tasks. However, the researchers noted that ifthe participants’ dominant culture emphasized

collectivism versus individualism as described byHofstede’s four dimensions of national culture(Hofstede, 1984), the degree of social loafingdecreased.Subsequent studies revealed that when anindividual’s contribution is identified and the personis held directly accountable for and rewarded fortheir behavior, social loafing may be eliminated(Kerr, 1983; Kerr & Bruun, 1981; Shepperd, 1993;Szymanski & Harkins, 1987). Beyerlein,Freedman, McGee, and Moran (2003) stress thatpersonal accountability by each group member fortheir role and responsibilities is required to achievean effective collaborative team. When accountabilityis lacking, members will usually act in support oftheir own self-serving interests. For example,members will sometimes hold back if they believethat other members of their group are not expendingequal efforts toward accomplishing the task.Experience of SuccessPrior success of a group in reaching its goals has adirect impact on the degree of cohesiveness. Noone wants to stay on a losing team. When a groupfails to attain its goals, members display a lack ofunity by infighting, finger pointing, and, finally,disassociation.

Group StatusCohesiveness is more prominent when admissioninto the group is more difficult to obtain because ofvarious barriers or high criteria, such as educationlevels. This perception of status, whether real or not,creates a feeling of being in the “in-group” for theindividuals who were able to overcome the barriersfor admission into the group—for example, aphysicians’ group.Outside Threats to the GroupThe cohesiveness of a group will increase if itsmembers perceive that an external force mayprevent the group from reaching its goals. Membersof the group will unite to display a unified front to theopposing force. In addition, cohesive groups willunite against nonconforming members who threatenthe esprit de corps of the group. Therefore,cohesive groups exert pressure on members of thegroup to conform.Managers should assist their subordinates’development into cohesive work groups becauseresearch has shown that cohesive unitsdemonstrate a higher level of productivity than lesscohesive groups do. However, managers need to beaware that group norms may mediate therelationship between cohesiveness andperformance. On the one hand, if norms support

performance-related activities, then cohesiveness islikely to improve performance. On the other hand, ifnorms support limited output or engagement inirrelevant tasks, cohesiveness may undermineperformance (Berkowitz, 1954).In conclusion, group cohesiveness is a product ofsocial identification. According to Hogg andAbrams (1990), the more positive a member feelsabout their group, the more motivated the person isto promote in-group solidarity, cooperation, andsupport. In turn, the more cohesive a group is, themore likely it is that its members will interact sociallyand influence one another (Turner, 1987). Becauseof these interactions, we find that more cohesivegroups have a tendency to eventually pressure theirmembers toward a higher degree of conformity, anda high degree of conformity can lower theperformance level of the group.

▶ ConformityStrong group norms and high degrees of groupcohesiveness can hamper the performance of agroup because of conformity pressures. Conformityinvolves the changing of an individual’s perceptionsor behaviors to match the attitudes or behaviors ofothers. This “normative social influence” occurswhen we conform to what we believe to be thenorms of the group in order to be accepted by itsmembers.One of the earliest studies in the conformity areawas Sherif’s (1936) experiment that involved theautokinetic effect. Sherif pointed a light in a darkspace that, although stationary, appeared to move.Subjects were asked, both as individuals and asmembers of a group, to estimate the amount ofmovement they observed. When in groups, thesubjects changed their original estimates to moreclosely fit the answers of the other members. Thisexperiment demonstrated the individual’s urge toconform.Asch (1952) also conducted conformity studies. InAsch’s experiments, eight people were seatedaround a table. Seven of them were actually theexperimenters or confederates. However, the eighth

person, the subject, was unaware of this situation.The group was shown two cards; each cardcontained different lengths of vertical lines (i.e., notwo lines matched in length on either card). Theparticipants were asked to say which of the linesmatched the length of another. One after another,the participants announced their decisions. Theconfederates had been told to give an incorrectresponse. The eighth subject sat in the next to lastseat so that all but one of the other participants hadgiven an obviously incorrect answer before thesubject gave their answer. Even though the correctanswer was obvious (i.e., no two lines matched inlength on either card), Asch found that one-third ofthe subjects conformed to the majority, one-thirdnever conformed, and the remaining one-third gaveconforming responses at least once. Thisexperiment was designed to create pressure onsubjects to conform to others, which in fact they did.Although Asch’s experiment has been criticized forbeing unrealistic (i.e., in the real world, individualswould be making decisions on subjects morecomplex and more important than the length of aline), it did confirm that “humans have the tendencyto conform to the goals and ideas of a small groupand tend to be unwilling to go against the groupeven if they know the group is wrong” (Asch, 1960).

Not all people conform. There is evidence that thosewho do not conform tend to have a healthy level ofself-esteem and to have mature social relationshipsas well as being fairly flexible and open-minded intheir thinking. For example, Crutchfield (1955) andTuddenham (1958) found that there is a correlationbetween high intelligence and other personalitytraits and low conformity. Another important aspectof conformity is that it may lead to “groupthink.”

▶ GroupthinkStrong conformity pressures reflect members’attempts to maintain harmony within the group.However, conformity may hamper a group’sperformance by decreasing innovation andincreasing faulty decision making. Janis (1982)referred to this situation as “groupthink.” Groupthinkrefers to conditions under which efforts to maintaingroup harmony undermine critical thought and leadto poor decisions (Janis, 1982; Janis & Mann,1977). Janis, as cited by Tubbs (2001, p. 236),identified eight symptoms of groupthink:Type I: Overestimation of the group—its powerand morality1. An illusion of invulnerability, shared bymost or all of the members, which createsexcessive optimism and encouragestaking extreme risks.2. An unquestioned belief in the group’sinherent morality, inclining the membersto ignore the ethical or moralconsequences of their decisions.Type II: Closed-mindedness1. Collective efforts to rationalize in order todiscount warnings or other information

that might lead the members toreconsider their assumptions before theyrecommit themselves to their past policydecisions.2. Stereotyped views of enemy leaders astoo evil to warrant genuine attempts tonegotiate or as too weak and stupid tocounter whatever risky attempts are madeto defeat their purposes.Type III: Pressures toward uniformity1. Self-censorship of deviation from theapparent group consensus, reflectingeach member’s inclination to minimize tothemselves the importance of their doubtsand counterarguments.2. A shared illusion of unanimity concerningjudgments conforming to the majority view(partly resulting from self-censorship ofdeviations, augmented by the falseassumption that silence means consent).3. Direct pressure on any member whoexpresses strong arguments against anyof the group’s stereotypes, illusions, orcommitments, making clear that this typeof dissent is contrary to what is expectedof all loyal members.4. The emergence of self-appointedmindguards—members who protect the

group from adverse information that mightshatter its shared complacency about theeffectiveness and morality of its decisions.Was groupthink the downfall of HealthSouth? (SeeExhibit 16-3.) Many former senior managers ofHealthSouth, a nationwide provider of rehabilitativeservices headquartered in Birmingham, Alabama,were indicted and in some cases found guilty offraudulently and systemically inflating thecompany’s earnings and assets by approximately$4 billion during the 1990s.Exhibit 16-3 Five HealthSouth OfficersCharged with Conspiracy to Commit Wireand Securities FraudCount 1 of the Information alleges that aconspiracy existed from in or about 1994 untilthe present between AYERS, EDWARDS,MORGAN, AND VALENTINE and with Owens,Smith, Harris, and others to devise a scheme toinflate artificially HealthSouth’s publiclyreported earnings and the value of its assets,and to falsify reports of HealthSouth’s financialcondition. It was part of the conspiracy thatOwens, Smith, Harris, and others wouldprovide the Chief Executive Officer (CEO) withmonthly and quarterly preliminary reports

showing HealthSouth’s true and actual financialresults. After reviewing these reports, Owens,Smith, Harris, and others would direct thatHealthSouth’s accounting staff find ways toensure that HealthSouth’s “earnings per share”number met or exceeded Wall Street analystexpectations. After Owens, Smith, Harris, andothers issued instructions as to the desiredearnings per share number, HealthSouth’saccounting staff would meet to discuss ways toinflate artificially HealthSouth’s earnings tomeet 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 discussways by which members of the accounting staffwould falsify HealthSouth’s books to fill the“gap” or “hole” and meet the desired earnings.The fraudulent postings used to fill the “hole”were referred to as the “dirt.” Owens, Smith,Harris, and others would and did direct one ormore of the defendants, also members of theaccounting staff, to make false entries inHealthSouth’s books and records for thepurpose of artificially inflating HealthSouth’srevenue and earnings. Owens, Smith, Harris,and others would direct one or more of thedefendants to make corresponding false entries

in HealthSouth’s books and records for thepurpose of artificially inflating the value of itsassets, including, but not limited to, falseentries made to (a) Property, Plant andEquipment (“PP&E”) accounts; (b) cashaccounts; (c) inventory accounts; and (d)intangible asset [goodwill]. When eventsrequired that financial records and reportsrelated to units of HealthSouth were called forby auditors, purchasers, and others, Owens,Smith, Harris, and others would direct one ormore of the defendants to generate recordsand reports that would black out the falseentries. Owens, Smith, and one or more of thedefendants would, for the purpose of deceivingauditors, manufacture false documents for thepurpose of supporting false record entries. Oneor more of the defendants would and didchange codes on accounts to deceive auditors.Reproduced from the U.S. Department of Justice’s Press Releasedated April 3, 2003.Managers must be careful because group memberssometimes desire to maintain their close teamrelationships—or, in the HealthSouth case, “thefamily relationship”—at all costs. When groupmembers operate in a groupthink mode, it mayaffect their decision making. For example, consider

a health care provider who has proposed a newmedical procedure for joint replacements. Someteam members are initially resistant because of hightraining demands, even though the new procedurewould establish best practices. To preserveharmony in the group, other staff members go alongwith the resisting members. In this case, the teamhas succumbed to group thinking instead of criticalthinking.Many researchers studied the culture of the NationalAeronautics and Space Administration (NASA) afterthe Challenger disaster and found evidence of thistype of groupthink. Engineers did not voice theirconcerns and criticism because of the strong teamspirit and camaraderie at NASA. In other words, it iswhen groups display a high degree of cohesivenessthat it is especially important to be on guard againstgroupthink.Suggested safeguards against groupthink include(1) soliciting outside expert opinions during thedecision-making process, (2) appointing a devil’sadvocate to challenge majority views, (3)hypothesizing alternative scenarios of a rival’sintention, and (4) reconsidering decisions after awaiting period. Many researchers have questionedthe effectiveness of these safeguards. For example,Bennis (1976) argues that a devil’s advocate will be

ignored if the group perceives the member as onlyrole-playing.

▶ ConclusionMany factors influence our behavior. Groupdynamics is a complex subject that attempts toprovide us with some understanding of howindividuals interact with one another and how thoseinteractions become visible in our resultingbehavior. Burton and Dimbleby (1996) developeda model, using interpersonal communication as thefoundation, to help us understand the complexity ofgroup dynamics (see Figure 16-3).

Figure 16-3 The Interface of Me and ThemReproduced from Burton, G., & Dimbleby, R. (1996). Betweenourselves: An introduction to interpersonal communications (2nded.). London: Edward Arnold.The figure is titled “The Interface of Me and Them.”Since group dynamics is the attempt to understandhow people interact with and influence others withingroups, the title is most appropriate. Whenexamining the model, you will notice that the bottom

half is concerned with “me” and the top halfrepresents “them.” The process begins with anindividual’s needs or motivation, which triggers the“whole of self.” The triangle represents the variousinteractions we have with our groups that are filteredthrough our self-concept, which, taken together,form our personal roles. We then communicate ourrole and receive feedback from both ourselves (did Iplay the role correctly?) and others (did they confirmmy behavior was correct?) to restart the process ofredefining who we are as an individual (personalrole). Although the model may appear somewhatcomplex, it only starts to explain the complexity ofhuman behavior.

Discussion Questions 1. Define the study of group dynamics anddiscuss why it is important to today’smanagers. 2. Describe the four characteristics that define agroup and provide examples of nongroupsand groups. 3. Explain what is meant by “group interaction.” 4. Discuss how group interactions can bemeasured. 5. Discuss why people join groups and whatsustains their membership. 6. Explain the importance of the various rolesthat members assume in groups. 7. Discuss how group norms are formed andsustained within groups. 8. Explain how group cohesiveness isdeveloped and sustained. 9. Discuss why conformity can inhibit a group’sperformance.10. Explain what behavior is displayed by agroup that is engaging in groupthink.

Exercise 16-1Form small groups of four to five individuals anddiscuss the following statement:Often employees do not act or react as individuals butas members of groups.When discussing this statement, the groupmembers should share experiences of working ingroups. Can you recall an instance in which yougave in because of the pressure to conform? Haveyou experienced a nonconformist in one of yourgroups? How did you or other members of yourgroup react to “deviant” behavior in your group?

Exercise 16-2Form small groups of four to five individuals. Usingthe worksheet “Be the Best We Can Be TeamNorms,” discuss how the answers to the questionscan assist the group with developing team norms sothat each member understands their expectedbehaviors.Be the Best We Can Be Team Norms1. When I am upset with someone I will:2. One way I can avoid making prematureassumptions is:3. When a member of the group is notcontributing, we will:4. One thing I think we could do to resolvedifferences among us as a team could be:5. One thing important to me about how wecommunicate (e-mail, text, F2F, how quicklyshould people respond, etc.) is:6. When someone comes to complain to meabout so-and-so on our team I/we will:7. One way I’d like to be recognized orappreciated is:8. One thing our group could do when we forgetour Team Commitments and want to get

back on track could be:Reprinted with permission from Nance Guilmartin: author, The Powerof Pause: How to Be More Effective in a Demanding, 24/7 World.

Exercise 16-3Analyze the level of group cohesiveness in one ofthe groups to which you belong.

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Luft, J. (1984). Group processes: An introduction to groupdynamics (3rd ed.). Palo Alto, CA: National Press.Ringelmann, M. (1913). Recherches sur les moteurs animes:Travail de l’homme [Research on animate sources of power:The work of man]. Annales de l’Institut National Agronomique,2e serie-tome XIL 1–40.Shepperd, J. A. (1993). Productivity loss in performance groups:A motivation analysis. Psychological Bulletin, 113, 67–81.Sherif, M. (1936). The psychology of social norms. New York, NY:Octagon Books.Sprott, W. J. H. (1958). Human groups. Harmondsworth, England:Penguin Books.Szymanski, K., & Harkins, S. G. (1987). Social loafing and self-evaluation with a social standard. Journal of Personality andSocial Psychology, 53, 891–987.Taplin, S. H., Foster, M. K., & Shortell, S. M. (2013).Organizational leadership for building effective health careteams. Annuals of Family Practice, 11(3), 279–281.Tubbs, S. L. (2001). A systems approach to small groupinteraction. New York, NY: McGraw-Hill Book Company.Tuddenham, R. (1958). The influences of a distorted norm uponindividual judgments. Journal of Psychology, 46, 227–241.Turner, J. (1987). Rediscovering the social group. New York, NY:Basil Blackwell.Turner, M. E. (2000). Groups at work: Theory and research.Mahwah, NJ: Lawrence Erlbaum Associates.

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CHAPTER 17GroupsLEARNING OUTCOMESAfter completing this chapter, the student shouldbe able to understand the:Importance of a group’s size.Three broad categories of groups.Difference between informal and formalgroups.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, and decision-making processesof groups. The optimum size for a group is fivemembers. However, we will find groups with fewerthan five members and groups with more. When agroup has fewer than five members, problems mayarise relating to an inability to make decisions andlower levels of creativity (Tubbs, 2001). If the groupbecomes too large, subgroups may form, distractingfrom the main group’s purpose, and a majority of thegroup’s time may end up being used for functioningpurposes (e.g., organizing members, assigningroles) rather than the required task (Tubbs, 2001).All these situations can cause frustration among themembers and stifle the group’s ability to reach itsgoal.

▶ Types of GroupsGroups can be categorized into three broad groups:primary, secondary, and reference. In theworkplace, groups operate under an informal orformal structure.Primary GroupsPrimary groups include one’s family and closefriends and/or peers. Social psychologists tend tosee primary groups as those that (1) involve regularcontact between members of the group, whetherthrough direct face-to-face interaction, technology,or other means, and (2) are fairly small (20members or less) (Blackler & Shimmin, 1984). Inaddition, primary groups (1) involve cooperation, (2)share common goals, (3) are familiar with allmembers, and (4) have an understanding of therole(s) of each member.Primary groups have a powerful influence on amember’s self-concept as well as the developmentof the individual’s perceptions and attitudes. Duringan individual’s childhood and adolescent years, thefamily unit has a strong impact on the developmentof the individual’s personality and future behaviors,both socially and in the workplace.

Secondary GroupsSecondary groups comprise the larger circle ofpeople we associate with. During the adult years,associations with work and professional groups willinfluence an individual’s attitudes and perceptionsthrough various interactions with these differentgroups. For example, Jane Kerry, RN, is a memberof a family group, a member of a group of close-knitfriends that meet for dinner once a month (friendsJane has known from high school), the president ofher local bridge club, a member of Glen HavenHospital’s neonatal intensive care unit nursing staff,and a member of the hospital’s quality improvementcommittee. Jane is also a member of larger groups:She is a member of the hospital’s pediatricdepartment, a member of the hospital’s nursingstaff, and a member of the community in which thehospital is situated. In addition, she is a member ofthe American Nurses Association. Some of thesegroup memberships may be short term, and othersmay be long term. No matter what the time frame,each group will influence Jane’s behavior.Reference Groups“Reference group” is a term coined by HerbertHyman (1942, 1968) to designate a group that anindividual uses as a point of reference indetermining their judgments, preferences, and

behaviors. A person uses a reference group as ananchor point for evaluating their own beliefs andattitudes. Even though an individual may or may notbe a member and may or may not aspire to be amember of a reference group, the group can havegreat influence on the person’s values, opinions,attitudes, and behavior patterns. For example, onemight say, “I’m not like those people” or “I am likethose people.” A reference group’s influence on anindividual may be positive or negative. An individualmay pattern their beliefs and behavior to becongruent with or opposite to those of the group.Churches, labor unions, and political parties areexamples of reference groups that can be positiveor negative for specific individuals. The size of areference group can range from a single individual(e.g., a movie star, athlete, or supermodel) to alarge aggregate of persons, such as a political partyor a religious institution.

▶ Informal or Formal GroupStructureIn the workplace, two types of groups can be found:informal groups and formal groups.Informal GroupsThe informal group (also referred to as a clique) isorganized on the basis of the members’ commoninterests or goals. Membership is voluntary and notpart of the organization’s official structure. Althoughinformal groups usually have a short life cycle, theycan have a significant effect on the organization’scurrent and future operations. Informal groups caninfluence attitudes, perceptions, group norms, andcommunication networks.For example, a small group of nurses at a largecommunity hospital were unhappy about their workenvironment and met daily during lunch to discussthe situation. A recent change in the hospital’ssenior management was causing a high level ofuncertainty among the clinical staff. The nurses alsofelt overworked as a result of the well-recognizednursing shortage. Their wages and benefits hadbeen stagnant, with no salary market adjustmentsfor the past 3 years. Furthermore, whenever the

nurses approached management about thesematters, they perceived their concerns as falling ondeaf ears, since no changes were ever made. Thisinformal group of nurses decided to contact a laborunion. The union began an organizing effort in thehospital shortly thereafter, holding an aggressivecampaign over a 6-week period. There wastremendous peer pressure, as some of the well-respected members of the nursing staff becameactive leaders for unionization, although they hadnot been among the initial organizing group. Theelection was held, and the union was voted in bytwo-thirds of the nursing staff. In the weeks thatfollowed, the clinical nursing staff remarked thatthey were surprised by the union’s victory; they hadonly wanted to scare management into makingchanges to their work environment.Many cliques in the workplace can exist harmlessly,but managers need to be aware that some informalgroups can be a powerful force within theirorganization. With an understanding of theirinfluence, managers can use informal groups toinitiate positive changes. Researchers have foundthat groups with informal leadership were in someinstances more productive than groups withoutinformal leaders. This occurs because informationoften spreads more easily through informal leadersthan through formal channels (Marion,

Christiansen, Klar, Schreiber, & Erdener, 2016).For example, the administrator of a free-standingoutpatient surgical center wanted to begin a cross-training program of the clinical staff to improve theorganization’s performance. The administrator knewthat staff would resist this “new” concept because oftheir past failures to implement change. Havinglearned from their past mistakes, they enlisted thesupport of a group of nurses who had developedinto a close-knit group. This was also the nursinggroup to which other clinical staff members lookedfor guidance on patient care issues. Theadministrator secured the support of the informalgroup by showing how the change would improvethe quality of care for the patients (e.g., a moreknowledgeable workforce), patient satisfaction (e.g.,shorter wait time for procedures to be performed),and job security (e.g., an increase in theorganization’s financial stability). Because of thesupport of this group of nurses, the change wassuccessfully implemented with minimum resistancefrom staff. Furthermore, the good outcomes that theadministrator predicted would occur did happen.These outcomes positively reinforced therelationship between the informal nursing group andmanagement.Informal groups meet the needs of individuals andtherefore have a strong influence on the members’

behaviors. If managers are aware of these groups,they can be enlisted to assist the organization inachieving its goals (see Case Study 17-1). Thereare several ways that managers can incorporateinformal leaders into the change process (AmericanNurse Today, 2013):CASE STUDY 17-1 UsingInformal Groups to PromoteOrganizational GoalsThe clinic’s chief executive officer (CEO) wasknown for consistently seeking, listening to,and incorporating the views of others. Whileshe worked effectively through the formalhierarchy, she also regularly sought the viewsof both physician and employee influenceleaders. These influence leaders were part ofa group that met to provide input, shape ideas,and take accurate information forth to thosewho looked to them for the inside scoop. Theirrole in helping to sell others on new directionswas clearly recognized.For example, when it came time to consideraffiliating the clinic with another health careorganization, influence leaders made sitevisits and came back to share their feelingswith a broad cross-section of the organization.

Many who listened to them would have beenmore skeptical if the information presentedhad come from the lips of the CEO.Peters, L. H., & O’Connor, E. J. (2001). Informal leadership support:An often overlooked competitive advantage. Physician Executives,27 (3), 35–39. Reprinted with permission.Keep informal leaders informed and encouragethem to ask questions and challengeassumptions.Give frequent feedback and share results.Get buy-in from employees on which informalleaders should be involved in helping to leadthe change.Incorporate the feedback provided by theinformal leader and ask for suggestions.Distribute various elements of the change orproject to different formal leaders to avoid oneperson dominating the process.Formal GroupsFormal groups are created by an organization;therefore, they are part of the organization’s formalstructure. These groups can be a long-term team(e.g., a functional or command group) or a short-term team (e.g., an ad hoc committee).

A functional or command group is specified andoutlined in an entity’s organizational chart. Forfunctional groups, members are grouped by similartasks, such as financial and administrative services,ancillary services, human resources andorganizational development, and nursing services(see Figure 17-1). For command groups, membersare formed into subgroups under the leader’slegitimate power position in the organization. Forexample, all laboratory technicians report to themanager of laboratory services. The manager formsa group of laboratory technicians to discuss theimplementation issues of providing clinical supportfor the hospital’s new outpatient clinic.

Figure 17-1 Organizational Chart for ABC Hospital and HealthSystem

Task groups include two (a dyad) or more peoplewho are focused on an identified target, a project, ora specific issue or goal. Task groups may be eithershort term or long term and may be evaluated onthe basis of their identified objectives. In contrast tofunctional or command groups, members of taskgroups can be from various functional areas andlevels of organizational authority, depending on thespecialized knowledge, experience, or authority thatmay be required by the group. For example, theCEO of a local hospital forms a multidisciplinarytask force to address the organization’s disasterpreparedness procedures. Members of this groupwould include all functional areas of the hospital,including administration, patient care, informationtechnology, and physical plant. Task groups can bepermanent groups, which may be used for policymaking or coordination of activities. Permanentgroups can exist for spans of time ranging from 1year or indefinitely. Ad hoc groups are generallyestablished to deal with a specific issue or problem.These latter groups may exist for a very shortperiod, such as from 1 month up to 1 year,depending on resolution of problems, tasks, andissues.

▶ Group DevelopmentGroups go through five sequential stages ofdevelopment. Some groups, on the basis of theirleadership or members’ prior experiences, canmove through these stages more quickly thanothers. Because of the same factors, some groupsmay never experience all five stages. The fivestages of development are as follows:1. Forming: During the forming stage, memberstry to determine the appropriate behaviorsand core values of the group. They focus onexchanging functional information, taskdefinition, and boundary development. Theybegin to establish tasks and determine howthey might meet objectives. During this initialstage, members must gain an understandingof the reason or purpose for joining the groupand must find a social niche in the group.2. Storming: The second stage of groupdevelopment is characterized by high levelsof emotion because members are trying tofind their group identity and exert theirindividuality. At this stage, members areclaiming their social power within the group,and a hierarchy is established as people

question authority, react to what is supposedto be accomplished, and jockey for powerwithin the group. Intermember criticism,scapegoating, and judgments mayaccompany this struggle for control.3. Norming: In the third stage, the developmentof cohesion and structure occurs when thegroup’s standards, key values, and roles areaccepted. The gradual development ofcohesion occurs after the conflict in thesecond stage. In this third stage, the rules forbehavior are explicitly and implicitly defined.There is a greater degree of order and astrong sense of group membership.4. Performing: In the fourth stage, membershave found their role(s) within the group, andtheir energy is focused on the task. Thegroup works through the problems itconfronts it, and when the task is nearcompletion, the group moves to the finalphase.5. Adjourning: Adjourning is the final stage ofgroup development, representing thedissolution or termination of membership inthe group.

▶ Group Decision MakingGroup decision making is the process of arriving ata judgment based on the feedback of multipleindividuals. Such decision making is a keycomponent of the functioning of an organizationbecause organizational performance involves morethan just individual action. Therefore, managersneed to understand the ways in which the groupprocess affects group decision making.Group decision making usually takes longer than anindividual decision (Nour & Yen, 1992). However,research confirms that groups produce more andbetter solutions to problems than do averageindividuals working alone, and the choices thatgroups make will be more accurate and creative(Robbins, 2003). This is due to the higher levels ofcommunication, coordination, and collaboration thatoccur within groups during the decision-makingprocess (Nour & Yen, 1992).Four factors play an important part in the quality of agroup’s decision. First, the group should be diverse;that is, members should have differences inexperiences, individual knowledge, talents, skills,culture, and age (Butterfield & Bailey, 1996).Second, the members need to feel that they are in a

safe environment so that they can express theirideas freely; this will help the group to avoidconformity and groupthink. This concept is oftencalled psychological safety. Third, the degree oftask interdependence must be high; if the task is toosimple, members can solve the problem individuallywith no assistance from other members. Fourth, thegroup must have the potency for success; that is,the members believe that the group can be effective(Shea & Guzzo, 1987).

▶ Rational Decision-MakingProcessesPeterson (1997) and Burn (2004) provide a seven-stage model that illustrates the process by whichgroups make decisions (see Figure 17-2):

Figure 17-2 Group Decision Process ModelStage 1—Problem Definition: The betterinformed the group members are, the betterthey are at formulating the problem or issue athand. Clarity about the problem is necessaryfor a high-quality decision.Stage 2—Identify Alternatives: Groupssometimes limit and restrict options on thebasis of the ideas and perceptions of only a fewmembers. Inclusivity and careful review of allavailable options expand problem-solvingalternatives. Members sometimes believe thatthey have to choose the first alternative for thesake of time or that they do not have access toall of the relevant information.Stage 3—Gather Information: Informationneeds to be gathered about all possibleconsequences on the basis of the identifiedalternatives. Groups often neglect to take thetime to gather all of the relevant information anddo not develop a process by which all memberscan contribute to gathering information.Stage 4—Evaluate Alternatives: The groupmust objectively analyze all of the availablealternatives and potential consequences. Thechallenges that emerge during this stageinclude developing processes to ensure that all

information is reviewed, that higher-statusmembers do not dominate, and that decisionsare not made for any member’s personal gain.Group members could choose the first availablealternative that meets minimal standards andconvince themselves and others that it is themost appropriate. Therefore, rational andobjective criteria are needed to prevent flaweddecisions.Stage 5—Make the Decision: The method bywhich the group chooses to make the decisionis extremely important. Some members may tryto control and bolster their own ideas withoutsupportive evidence. Lower-status membersmight vote with higher-status members whenthe vote is by a show of hands; the vote mightchange drastically if there is a secret ballot.Stage 6—Implementation: The challenges atthis stage involve the resolution of all of thetasks necessary to fully implement the decision,including identification of all of the neededresources.Stage 7—Evaluate the Outcome: Afterimplementation, a step that is often disregardedis evaluation of the outcome. Have processesbeen developed so that the decision group canmeasure the success or relevance of theoutcome? Did the decision meet the goals and

objectives? This critical inquiry is essential tolearning from the experience.The collective information processing of a grouptakes time to develop. This may be due to membersnot being aware of the information resources of thegroup or members being hesitant to provideinformation to the group. Some groups providestructured techniques so that every memberparticipates equally and positive interaction isencouraged. These strategies includebrainstorming, the nominal group technique, and theDelphi technique.BrainstormingBrainstorming involves taking a designated amountof time (usually 5–7 minutes) to generate as manyideas as possible with no discussion of theirfeasibility or practicality. The originator of thistechnique (Osborn, 1957) believed that members’tendencies to judge and criticize other people’sofferings deter members from freely expressingcreative ideas. Osborn hypothesized that the moreideas a group developed, the greater the chancethat the ideas would be of high quality. However,research does not support Osborn’s hypothesis.Brainstorming groups do not produce more orhigher-quality ideas than those that are generatedindividually (Mullen, Johnson, & Salas, 1991).

Some factors that may reduce the performance ofbrainstorming groups include social loafing,apprehension about being judged by others, and thetendency for introverted people to withdraw when inthe company of extroverted members, who maycompete and try to dominate the brainstormingprocess. People also have a difficult time thinkingand listening to others at the same time. Dennis(1996) contends that computer-basedbrainstorming, a technique in which group membersinteract electronically, often anonymously andsimultaneously, eradicates the interpersonalpressure. The advantages are that they are lesslikely to forget what they are sharing as they type;the written record of all contributions can be madeavailable for all and at any time; and because of theanonymity, lower-status members do not feel thepressure of the evaluation of their contribution byother members. Computerized group supportsystems may also reduce the potential forgroupthink.Nominal Group TechniqueThe nominal group technique is a brainstormingtechnique that is implemented on an individual andnonverbal basis. The information obtained is thenpooled. This technique is efficient because it doesnot require a great deal of leadership training, and

the group can communicate without the risksinvolved in verbal communication. A typical five-stepprocess begins with a period of silence, duringwhich group members write down their ideasindependently. This is followed by a round-robinrecording of ideas. Third, the leader calls on eachmember to share one idea at a time and writes eachidea down in view of the total group. Fourth, there isgroup discussion of each idea on the list, and allideas are clarified and evaluated. Fifth, theparticipants identify and privately rank their ideas inorder of preference, and then they vote, the vote isrecorded, the voting pattern is discussed, and thehighest-ranked idea is discussed. The nominalgroup technique has been used extensively inbusiness and government because of its efficiencyand its capacity to limit emotional arguments.The Delphi TechniqueThe Delphi technique is intended to help with thechallenge faced by group members who may lackthe experience to understand that the informationthey hold is needed to generate and evaluateoptions or alternatives. This technique uses a seriesof written communications to collect and synthesizethe opinions of a group of experts into a decision. Acarefully devised letter is sent to several expertsthat defines the problem and asks the experts for

advice on a possible solution. The leader collectsand collates the responses for each of the expertsand sends them back to the experts for commentaryand additional solutions. The leader collects theletters and analyzes them for consensus. If a clearconsensus emerges, a decision can be made. If not,the process is repeated until consensus is achieved.This process can be time consuming, and the sameresult may be achieved through a face-to-facemeeting of experts.

▶ Irrational Decision-MakingProcessesThe “Garbage Can” Decision-MakingProcessUnlike the rational decision-making model describedearlier, in which groups follow a step-by-stepprocess to arrive at the best solution to a problem,the “garbage can” model of decision making is aprocess that does not begin with a problem and endwith a solution. In this process, many types ofindependently generated problems and solutionsare placed in a “garbage can” (see Figure 17-3).Managers and other participants then searchthrough the “garbage can” looking for interesting,suitable, or important “problems” and “solutions”(Cohen, March, & Olsen, 1972; Lovata, 1987;Schmid, Dodd, & Tropman, 1987). Although the“garbage can” decision-making approach is not veryefficient, the process is appropriate for groupdecision making in organizations in which thetechnologies are not clear, the involvement ofparticipants fluctuates in terms of the amount of timeand effort given, and choices are inconsistent andnot well defined (Cohen et al., 1972; Lovata, 1987;Schmid et al., 1987).

Figure 17-2 Illustration of Independent Streams of Events in the“Garbage Can” Model of Decision MakingReproduced from Daft, R. L. (2004). Organization theory anddesign (8th ed.). Mason, OH: Thomson South-Western.The “garbage can” model is often referred to aspolitical or antirational because it disconnectsproblems, solutions, and decision makers from oneanother. Cohen et al. (1972) relate that specificdecisions (i.e., choices) do not follow an orderly

process from problem to solution but are outcomesof several relatively independent streams of eventswithin the organization:1. Problems identified in organizations usuallyrequire attention because there areperformance gaps.2. Solutions are ideas that have been identifiedto solve one or more problems, which areindependent and distinct from the problemsthat they might be used to solve (e.g., insome cases, solutions are answers lookingfor a problem).3. Participants come and go, and levels ofparticipation vary for each problem and eachsolution depending on the demands onparticipants’ time or on other situationalfactors.4. Choices are made only when thecombination of problems, solutions, andparticipants allows the decision to happen(i.e., when they are in alignment).Consequently, the alignment of the problems,solutions, and individuals often occurs after theopportunity to make a decision about a problem haspassed, or it may occur even before the problemhas been discovered (Cohen et al., 1972). The“garbage can” model provides a real-world

representation of the nonrational manner in whichdecisions are often made in an organization. In abroad sense, the model provides some clue tounderstanding “how organizations survive whenthey do not know what they are doing” (Cohen etal., 1972).

▶ ConclusionGroups remain the context for most of our socialand work activities. The powerful impact that groupshave on people and the powerful influence thatpeople have on groups merit our ongoing attention.

Discussion Questions 1. Discuss why the size of a group is importantto performance. 2. Explain the different broad categories ofgroups. 3. Describe the difference between informalgroups and formal groups. 4. Discuss the various task groups within anorganization and their purposes. 5. Explain the five stages of groupdevelopment. 6. Discuss the factors that may hinder theeffectiveness of a group decision-makingprocess. 7. Explain the seven stages of group decisionmaking. 8. Describe the various methods for groupdecision making.

Exercise 17-1Analyze the last poor decision made by a group ofwhich you were a member. What do you thinkcontributed to the group’s poor decision? Did thegroup think of alternative possibilities? Did the groupmove too quickly through any of the developmentstages? If so, did this cause lack of cooperation orpoor communication?

Exercise 17-2Form small groups of four or five individuals and,within 10 minutes, brainstorm as many solutions aspossible that address the following situation:A small nonprofit organization for which you serve as amember of the board of directors needs to raise$500,000 in order to support its programming needs.After the exercise has been completed, personallyreflect on the group interactions. Did you notice anyfactors that might have reduced the performance ofthe group (e.g., social loafing, apprehension ofbeing criticized by others, dominant behavior by oneor more members)?

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Marion, R., Christiansen, J., Klar, H. W., Schreiber, C., & Erdener,M. A. (2016). Informal leadership, interaction, cliques andproductive capacity in organizations: A collectivist analysis.The Leadership Quarterly, 27(2), 242–260.Mullen, B., Johnson, C., & Salas, E. (1991). Productivity loss inbrainstorming groups: A meta-analytic integration. Basic andApplied Social Psychology, 12, 3–23.Nour, M. A., & Yen, D. C. (1992). Group decision supportsystems, toward a conceptual foundation. Information andManagement, 23(1), 55–64.Osborn, A. F. (1957). Applied imagination. New York, NY:Scribner.Peterson, R. S. (1997). A directive leadership style in groupdecision making can be both virtue and vice: Evidence fromelite and experimental groups. Journal of Personality andSocial Psychology, 72(5), 1107–1121.Robbins, S. P. (2003). Organizational behavior (10th ed.). UpperSaddle River, NJ: Prentice Hall.Schmid, H., Dodd, P., & Tropman, J. E. (1987). Board decisionmaking in human service organizations. Human SystemsManagement, 7(2), 155–161.Shea, G. P., & Guzzo, R. A. (1987). Group effectiveness: Whatreally matters? Sloane Management Review, 8(3), 25–31.Tubbs, S. L. (2001). A systems approach to small groupinteraction. New York, NY: McGraw Hill Book Company.

CHAPTER 18Work Teams and TeamBuildingLEARNING OUTCOMESAfter completing this chapter, the student shouldbe able to understand the:Difference between stable teams and teamingVarious types of teams.Differences between a virtual team andconventional types of teams.Various approaches for building teamperformance.Various organizational barriers to effectiveteam building.Common characteristics of successful teams.

▶ OverviewWhat is the difference between groups and teams?Does a group of people who happen to be throwntogether in a surgical suite or primary care officeconstitute a team? No—not all groups meet thedefinition of a team (see Case Study 18-1).CASE STUDY 18-1Halloween in the Trauma UnitDr. Andrea Martinelli, a trauma surgeon,loathed working in the trauma surgery unit onHalloween, on any holiday involving fireworks,or after a big win for the local college footballteam. Drunk drivers, burn victims, andshooting victims seemed to roll in at anunstoppable pace. Although Dr. Martinelliusually worked the day shift, she was requiredto take some night shifts. She checked in forher Halloween night shift at 6 P.M., andimmediately the action got started. “Dr.Martinelli, you’ve got a patient prepped andready in Room 6. Major car accident, and he’sbleeding out.” As she walked into the room,Dr. Martinelli thought, “ Who will I be workingwith this time?” She entered a room that was

frenetically busy with nurses, residents, asurgery fellow, two nursing students, a scrubtech, an anesthesiologist, and a nurseanesthetist, and she realized that she didn’tknow any of them. This was a large hospital,and because of different shift schedules andturnover, she almost never worked with thesame configuration of people. She could tellthat the patient was crashing and she neededto act fast. “Okay, everyone, I’m Dr. Martinelli.Let’s get started.”In general, groups are much broader than teams.Teams are special groups that have highly definedtasks and roles and demonstrate high groupcommitment (Katzenbach & Smith, 1993). Webegin this chapter with a discussion of teams. Wethen examine the various types of teams, theircharacteristics, and the factors that either promoteor hinder the effectiveness of teams in theworkplace.Teams are very popular in the workplace. Accordingto Lawler (1999), almost every organization usessome form of problem-solving team, the mostcommon being the self-managing work teams thatare common in a high majority of Fortune 1000companies. As teams become more of the norm in

the workplace, managers need to understand thecomplexity of teams in terms of their work design,the composition of the members, and the factorsthat enable teams to achieve high levels ofperformance and effectiveness.

▶ Teams and TeamingA team can be defined as a small group of peoplewho are committed to a common purpose, possesscomplementary skills, and have agreed on specificperformance goals for which the team membershold themselves mutually accountable (Katzenbach& Smith, 1993) (see Case Study 18-2). On thebasis of this definition, a team (1) should becomposed of a small number of members(preferably an odd number, such as five or seven) toencourage consensus without discord, (2) musthave specific goals, and (3) must contain memberswith mutual accountability, requiringinterdependence and collaboration of efforts(Gordon, 2002).CASE STUDY 18-2 KaiserPermanente Facilities UseTeamSTEPPS to ImproveObstetrics and Other Patient CareA Well-Functioning Care TeamAs a result of implementing AHRQ’sTeamSTEPPS to improve teamwork andcommunication, Kaiser Permanente in®

Northern California has reduced the dosage oflabor-inducing drugs by approximately 15percent, without increasing C-section rates,from 2015 to 2017. Kaiser trained its staff at16 medical centers and a skilled nursingfacility across the State. As a result, perinatalteams have successfully used TeamSTEPPSstrategies to standardize and reduce variationin dosing of labor-inducing drugs.TeamSTEPPS is an evidence-based,customizable program aimed at optimizingperformance among teams of health careprofessionals, enabling them to respondquickly and effectively to whatever situationsarise. It was developed by AHRQ incollaboration with the Department of Defenseand first launched in 2006.Initially, Kaiser’s main focus was to trainteams for three new hospitals prior to theiropening and to “build TeamSTEPPS expertiseat the regional risk management and patientsafety department in Oakland to support thenew teams,” explained Celia Ryan, M.S.H.A.,R.N., executive director of risk and patientsafety. Officials were so pleased with theresults that they expanded TeamSTEPPSimplementation to training teams in

emergency departments, operating rooms,and inpatient units in all of Kaiser’s NorthernCalifornia hospitals.In total, 45 Kaiser teams have completedTeamSTEPPS “train the trainer” programssince 2014. Staff have been trained across awide variety of units, including emergencydepartments, intensive care, coronary care,cardiac catheterization laboratories, neonatalintensive care, medical/surgery/telemetry,interventional radiology, environmentalservices, perioperative (including pre-operative, operating room, and post-anesthesia care), perinatal (labor and delivery,nursery, and mother/baby), and skilled nursingunits.The perinatal teams at Kaiser commonly usethe following TeamSTEPPS strategies—Huddle—An ad hoc meeting/planningsession used to reinforce plans that arealready in place. This allows for on-the-spot assessment and reassessment.Huddles are held daily withmultidisciplinary teams comprised ofobstetricians, certified nurse midwives,residents, registered nurses,anesthesiologists, and pediatric

specialists who review the patient’sstatus, any concerns about hercondition or treatment, and fetalmonitoring.Debrief—An after-action review and/orinformation-sharing session intended toimprove team performance andeffectiveness. Debriefs help identifyand resolve concerns and addresstimely acquisition of additional staffassistance when needed.SBAR—An acronym that stands forSituation, Background, Assessment,and Recommendation. This techniquefacilitates prompt and effectivecommunications among staff. A “babySBAR” is used to ensure situationalawareness between the obstetricianand neonatal teams to establish thedelivery approach and anticipatepotential resuscitation needs.“During times of high volume, huddles haveimproved workflows and situationalawareness,” said Paul Preston, M.D., staffanesthesiologist and safety educator for ThePermanente Medical Group. “Debriefs havealso been critically useful—specifically post-delivery and for real-time learning—and have

contributed to improvements in the obstetricshemorrhage team response and C-sectiondecision-to-incision time,” he noted.Kaiser Permanente Facilities Use TeamSTEPPS to ImproveObstetrics and Other Patient Care, United States Department ofHealth and Human Services. Retrieved fromhttps://www.ahrq.gov/news/newsroom/case-studies/201716.htmlMany of the groups that we see in health care donot fit neatly into the given definitions of either agroup or a team. Recall that one of the definingelements of a group is a stable structure. Accordingto this formal definition, a variety of strangers whoare quickly assembled in an operating room, as inCase Study 18-1, does not qualify as a group.Health care is filled with examples of people comingtogether quickly for a specific purpose and thendisbanding to form new configurations. Thesechanges can occur daily, even hourly. For example,an anesthesiologist overseeing four surgical roomswill be working with four different combinations ofnurses, surgeons, technicians, residents, andstudents at any point during the day. Depending onthe number of operating rooms in a hospital andstaff turnover, it may be weeks or months before aparticular configuration is repeated. Similarly, anoncologist, a doctor of internal medicine, a radiationoncologist, and a surgeon from another hospital

may convene to determine the best path forward fora cancer patient. Then, for the next patient, thatoncologist may be working with a completelydifferent set of specialists. So what shall we callsuch a collection of people? A group? A team?Amy Edmondson (2012) of Harvard BusinessSchool calls this phenomenon “teaming,” which shedefines as “teamwork on the fly.” She argues thatstable teams of people who work together over timecan be highly effective, such as a basketball teamthat practices thousands of hours together and winsa national championship. However, the currentreality is that health care teams are often more likeplayers in a game of pickup basketball in the park.Edmondson suggests that when companies facecomplex and uncertain tasks that need rapidresolution, stable teams are insufficient. Teamingcan be highly effective because it allows the rightexperts from different fields and disciplines to beassembled to accomplish a complex task. Withindustry changes and reforms, evolving diseasesand treatments, and the explosion of new scientificknowledge, it is no surprise that health care is filledwith examples of teaming.

▶ Types of TeamsCohen and Bailey (1997), after an extensiveliterature review, determined that teams can beorganized into the following four categories: (1) workteams, (2) parallel teams, (3) project teams, and (4)management teams.Work teams are continuing work units that areresponsible for producing goods or providingservices. Traditional work teams are directed bymanagers who make most of the decisionsabout what is done, how it is done, and whodoes it. However, an alternative form of workteam with a variety of labels—self-managing,autonomous, semiautonomous, self-directing,empowered—is gaining favor. Self-managingwork teams involve employees, not managers,deciding how to carry out tasks, allocating thework within the team, and making decisions.Examples include primary care teams, surgicalteams, and emergency department teams(Taplin, Foster, & Shortell, 2013).Parallel teams draw members from differentwork units or jobs to perform functions that theregular organization is not equipped to performwell. They exist in parallel with the formal

organizational structure. They generally havelimited authority and can makerecommendations only to individuals higher upin the organizational hierarchy. Parallel teamsare used for problem-solving and improvement-oriented activities. Examples include qualityimprovement teams, employee involvementgroups, quality circles, and patient satisfactiontask forces.Project teams are time limited and produceone-time outputs. Examples include a newelectronic health record implementation team ora new facility design and construction team.Typically, project team tasks are nonrepetitiveand involve considerable application ofknowledge, judgment, and expertise. The workthat a project team performs may representeither an incremental improvement over anexisting concept or a radically different newidea. Project teams often draw their membersfrom different disciplines and functional units sothat specialized expertise can be applied to theproject at hand. For example, a new drug-development team of a pharmaceuticalcompany would draw its members fromresearch and development, marketing, finance,and manufacturing. When a project iscompleted, the members either return to their

functional units or move on to the next project.Cross-functional project teams enhance projectsuccess as a result of their capacity to handlemultiple activities simultaneously rather thansequentially. This saves time and is importantto organizations that are concerned with rapiddevelopment of new services and/or productsowing to competition.Management teams coordinate and providedirection to the subunits for which they areresponsible, laterally integrating interdependentsubunits across key business processes. Themanagement team is responsible for the overallperformance of a business unit. Its authoritystems from the hierarchical rank of itsmembers. It is composed of the managers whoare responsible for each subunit, such as vicepresidents of nursing, compliance and security,finance, and medical affairs. At the top of theorganization, the executive management teamestablishes and manages the organization’sstrategic direction and performance. The use oftop management teams is expanding inresponse to the turbulence and complexity ofthe current health care environment.Management teams can help organizations toachieve competitive advantage by applyingcollective expertise, integrating disparate

efforts, and sharing responsibility for thesuccess of the organization.

▶ Virtual TeamsThe virtual team has emerged along with technologyadvances. Unlike conventional teams, a virtual teamworks across space, time, and organizationalboundaries through various communicationtechnologies (Lipnack & Stamps, 1997). Roebuckand Britt (2002) note that the primary differencebetween a conventional team and a virtual team isthe dimension of physical space or distancebetween team members. In virtual teams,employees can be located anywhere in the world.Virtual teams rarely meet face to face and aresupported by technology to collaborate (Lurey,1998). Often, these teams are set up as temporarystructures that exist to accomplish a particular task,or they may be more permanent teams that addressongoing organizational issues (Roebuck & Britt,2002). Virtual teams are on the rise. As of 2018,70% of workers globally work remotely at least oneday per week (Browne, 2018). These numbers maybe lower in health care than in other industriesbecause much of the work in health care requiresbeing in the same location as the patient. However,as virtual teams become more common, managers

must be able to understand how to facilitate theirperformance and cohesion.Organizations can benefit from virtual teamsthrough access to previously unavailable expertiseenhanced through cross-functional interaction andthe use of systems that improve the quality of thevirtual team’s work (Lipnack & Stamps, 1997). Byusing virtual teams, organizations can assign theright person to the job, regardless of where theperson lives. However, the dimension of physicaldistance between members does affect the way inwhich team members interact. Roebuck and Britts(2002) advise that for a virtual team to besuccessful, members must be firmly committed tothe team’s purpose and to each team member.They must want their collaborative work to besuccessful and be willing to go the extra mile. Forexample, Rush University Medical Center inChicago implemented a pilot program known asVirtual Integrated Practice, in which primary carephysician practices recruit and organize their ownoffsite interdisciplinary teams consisting of socialworkers, dietitians, pharmacists, and other healthcare providers to manage and coordinate care forgeriatric patients with chronic disease. These teamscollaborate virtually, using email, phone, and fax toplan and deliver coordinated patient care. Acomparison of four practices using the virtual

integrated practice model to four similar practicesthat provided the usual care found that the virtualintegrated practice program reduced emergencydepartment visits, enhanced patient satisfaction andunderstanding of their medical condition(s) andmedications, increased physician knowledge, andboosted referrals to interdisciplinary team members(Rothschild & Lapidos, 2009).One issue that managers must consider whencreating virtual teams is the possibility of socialisolation. Social interaction with one’s team at workcan be a positive experience for employees. Theworkplace is often a place where people makefriends, with 76% of Americans reporting that theyhave met at least one friend through work. However,a 2019 survey found that 30% of millennials reportalways or often feeling lonely, and 22% reporthaving no friends (Ballard, 2019). Therefore,managers must consider the well-being of virtualteam members who may not benefit from socialinteraction in a traditional work setting.

▶ Building TeamPerformanceTeamwork does not always come naturally to healthcare professionals; health care cultures too oftenemphasize autonomy and working withinprofessional boundaries (Bartunek, 2011). Yet alack of effective teamwork and communicationamong and between teams of caregivers can haveserious consequences for patients’ safety. Todeliver safe and effective care, staff members inhigh-risk areas such as emergency departments,intensive care units, labor and delivery units, andoperating rooms must work as cohesive, high-functioning teams. A highly cohesive team will bemore cooperative and effective in achieving thegoals that they set for themselves (Oxford Centre,2011). Daft and Marcic (2009) relate that membersof a highly cohesive team focus on the process, notthe person; are respectful of one another; are fullycommitted to team decisions; and hold eachmember accountable to the team.Katzenbach and Smith (1993) developed the teamperformance curve to illustrate how small groupsmay develop into high-performing teams (seeFigure 18-1). Katzenbach and Smith (1993, p. 85)

found that, “unlike teams, working groups rely onthe sum of ‘individual bests’ for their performance.They pursue no collective work products requiringjoint efforts. By choosing the team path instead ofthe working group, people commit to take the risksof conflict, joint work-products, and collective actionnecessary to build a common purpose, set goals,approach, and mutual accountability. People whocall themselves teams but take no such risks are atbest pseudoteams.”Figure 18-1 The Team Performance Curve

Katzenbach, J. R., & Smith, D. K. (1993). The wisdom of teams:Creating the high-performance organization (p. 84). Boston, MA:Harvard Business School Press. McKinsey & Company. Used withpermission.Although there is no guaranteed “how-to” recipe,Katzenbach and Smith (1993, pp. 119–127) listeight approaches to building team performance.These steps are most appropriately applied tostable or semistable teams:1. Establish Urgency and Direction: All teammembers need to believe that the team hasurgent and worthwhile purposes, and theywant to know what the expectations are. Thebest team charters are clear enough toindicate performance expectations butflexible enough to allow teams to shape theirown purpose, goals, and approach.2. Select Members on the Basis of Skills andSkill Potential, Not Personality: Teams musthave the complementary skills needed to dotheir jobs. Three categories of skills arerelevant: (1) technical and functional, (2)problem-solving, and (3) interpersonal. Thekey issue for potential teams is striking theright balance between members who alreadypossess the needed skill levels and memberswhose skill levels will develop after the team

gets started. Margerison and McCann(1989) have performed extensive researchon the “people” side of successful team-building. On the basis of studiesincorporating over 5000 managers, theydeveloped the Team Management Wheel,which assists managers in selecting the rightbalance for their teams regarding roles(advisers, explorers, organizers, andcontrollers) and linking skills (e.g., the mainrole of the team leader) (see Exhibit 18-1and Figure 18-2).3. Pay Attention to First Meetings and Actions:Initial impressions always mean a great deal.When potential teams first gather, everyonealertly monitors the signals given by others toconfirm, suspend, or dispel assumptions andconcerns they have going in. They payattention to the people in authority: the teamleader and any executive who set up,oversee, or otherwise influence the team.What leaders do is more important than whatthey say.4. Set Some Clear Rules of Behavior: All realteams develop rules of conduct to help themachieve their purpose and performancegoals. The most critical early rules pertain toattendance (“no interruptions to take phone

calls”), discussion (“no sacred cows”),confidentiality (“the only things to leave thisroom are what we agree will leave thisroom”), analytic approach (“facts arefriendly”), end-product orientation (“everyonegets assignments and does them”),constructive confrontation (“no fingerpointing”), and often the most important:contributions (“everyone does real work”).5. Set and Seize upon a Few ImmediatePerformance-Oriented Tasks and Goals:Most teams trace their advancement to keyperformance-oriented events that forge theminto a cohesive group. Potential teams canset such events in motion by immediatelyestablishing a few challenging yet achievablegoals that can be reached early on.6. Challenge the Group Regularly with FreshFacts and Information: New informationcauses a potential team to redefine andenrich its understanding of the performancechallenge, thereby helping the team to shapea common purpose, set clear goals, andimprove on its common approach.7. Spend Lots of Time Together: Commonsense tells us that teams must spend a lot oftime together, especially at the beginning.The time spent together must include both

scheduled and unscheduled time. Creativeinsights and personal bonding requireimpromptu and casual interactions, which arejust as important as time spent analyzingspreadsheets, interviewing customers, andso on. These meetings or interactions neednot be always face to face. Use of technologyis encouraged.8. Exploit the Power of Positive Feedback,Recognition, and Reward: Positivereinforcement works well in a team context.There are many ways to recognize andreward team performance, of which directcompensation is only one. Ultimately, thesatisfaction in the team’s performancebecomes the most cherished reward. Untilthe goal is reached, however, team leadersmust find other ways to recognize andreinforce individual and team contributionsand commitment.Exhibit 18-1 The Team ManagementWheelThe Margerison–McCann Team ManagementWheel defines members’ roles and is based onthe following eight characteristics:

1. Reporter–Advisors: Those who prefer workinvolving gathering and sharing ofinformation. Supporters, helpers, collectorsof information, knowledgeable, flexible.2. Creator–Inventors: Those who prefer workthat generates and encouragesexperiments with new ideas. Imaginative,creative, enjoy complexity, future-oriented.3. Explorer–Promoters: Those who preferwork that involves investigation andpresentation of new opportunities.Persuaders, influential and outgoing, easilybored.4. Assessor–Developers: Those who preferwork that involves planning to ensure thatideas and opportunities are feasible inpractice. Analytical and objective, ideadevelopers, experimenters.5. Thruster–Organizers: Those who preferwork that allows them to arrange andorganize the way work is done. Results-oriented, analytical, organizers, andimplementers.6. Concluder–Producers: Those who preferwork that can be implementedsystematically to produce regular outputs.Practical, production-oriented, like

schedules and plans, value effectiveefficiency.7. Controller–Inspectors: Those who preferwork involving controlling and auditingprocedures and systems. Controller, detail-oriented, inspectors of standards andprocedures, low need for personalinteraction.8. Upholder–Maintainers: Those who preferwork that involves upholding andconserving processes and procedures.Conservative, loyal, supportive, strongsense of right and wrong, motivation basedon purpose.The hub of the Team Management Wheel isthe Linker, and that is often the main role of theteam leader, although it is important for all teammembers to contribute to this activity. TheLinker circle can be expanded into a full-rangeteam leadership model that describes threelevels of Linking that should be practiced, tovarying degrees, by everyone in anorganization.At the first level of Linking are the skillsarranged around the outside of the model.These skills are the People Linking Skills. Theycreate the atmosphere in which the team

works, by promoting harmony and trust. Thus,everyone in a team has a responsibility toimplement this level of leadership.Active ListeningCommunicationTeam RelationshipsProblem Solving and CounselingParticipative Decision MakingInterface ManagementInside the People Linking Skills are the TaskLinking Skills. These skills create a solid coreor foundation on which the work of the teamrelies. They promote confidence and stability.Work AllocationTeam DevelopmentDelegationObjectives SettingQuality StandardsThese skills tend to apply more to people onthe second rung of the leadership ladder—those in more senior positions in a team,responsible for guiding others. This guidingmay be done in either a supportive or adirective way but should not violate the firstlevel of People Linking Skills. The challenge isto find the balance at which the six People

Linking Skills and five Task Linking Skills cancoexist.At the core of the Linking Skills Wheel are thetwo Leadership Linking Skills of Motivation andStrategy. Leadership Linking is the third step onthe leadership ladder and applies to leaderswho have organizational responsibility forstrategy. They need to implement these twoskills along with the People and Task LinkingSkills to achieve the status of the LinkerLeader, a term that is used to describesomeone who is effective at implementing allthree levels described in the Linking SkillsWheel.

Figure 18-2 The Linking Skills WheelMargerison, C., & McCann, D. Team Management Systems(TMS). Reprinted with permission.Recall that teaming usually involves a group ofpeople who come together (often quickly) to solve acomplex problem and then disband. Therefore,

some of the steps listed by Katzenbach and Smithmight not be possible when teaming takes place,such as spending lots of time together. Edmondson(2012) suggests behaviors that are necessary forsuccessful teaming (Table 18-1).Table 18-1 Behaviors of Successful TeamingBehaviorsofSuccessfulTeamingDescriptionHealth CareExamplesEmphasizingpurposeDefine the purpose of theproject or task and how italigns with shared values.Clinicians can uniteunder their sharedvalue of doing what isbest for the patient.BuildingpsychologicalsafetyCreate an environment inwhich it is expected thatpeople can speak up anddisagree without beingpunished. Exhibit curiosity,ask thoughtful questions, anddemonstrate “situationalhumility,” which isacknowledging that theproject is complex and wedon’t know all the answers.The concept of sharedgovernance in healthcare means that eachmember of the careteam has sharedresponsibility indecision making forthe patient (versus theoutdated “Just do whatthe doctor says”mentality).EmbracingfailureCreate an environment inwhich members know thatfailures are expected to occurand it is okay to admit failureand ask for additional help.A nonjudgmentalmortality and morbidity(M&M) conference canbe held to openlydiscuss clinical errors

and develop solutions.Puttingconflict toworkEncouraging members todevelop curiosity and inquireabout different viewpointsinstead of focusing onwinning other people over toa certain point of view.Doctors and nursescan listen to eachother with a spirit ofcuriosity to avoidprofessional clashes.Modified from Edmondson, A. C. (2012). Teamwork on the fly.Harvard Business Review, 90 (4), 72–80.

▶ Common Characteristics ofSuccessful TeamsHackman (2011) has studied teams for many years,and he has identified six enabling conditions foreffectiveness. The team must (1) be real, (2) have acompelling purpose, (3) consist of the rightmembers, (4) establish and follow clear norms ofconduct, (5) work in a highly supportive context, and(6) receive well-timed team coaching. Elaine Biech,as cited by Gordon (2002, p. 184), outlines the 10most commonly mentioned characteristics forsuccessful teams:Clear Goals: Clear goals allow everyone tounderstand the function and purpose of theteam.Defined Roles: Defined roles allow teammembers to understand why they are on theteam and enable clear individual- and team-based goal setting.Open and Clear Communication: Effectivecommunication is considered the mostimportant aspect of team building. It hinges oneffective listening.Effective Decision Making: Effective decisionmaking is critical, and for a decision to be

effective, the team must be in agreement withthe decision and must have reached agreementthrough a consensus-finding process.Balanced Participation: Balanced participationensures that all members are fully engaged inthe efforts of the team. Participation is alsodirectly linked to leader behaviors. Effectiveteam leaders should not see their role asauthoritarian and should strive to be seen asthe team’s mentor or coach.Valuing Diversity: The team must recognizeeach member’s expertise and value variety ofknowledge, skills, perspectives, and abilities. Inthe world of teams, diversity consists of morethan just race or gender.Managed Conflict: Managed conflict requiresthat all team members feel safe to freely statetheir points of view without fear of reprisal. Forteams, managed conflict is almost akin tobrainstorming, in that conflict allows the team toopenly discuss ideas and decide on commongoals.Positive Atmosphere: A positive atmosphererequires a climate of trust. One way ofdeveloping trust is to allow team members tocome together in a positive atmosphere.Allowing team members to become comfortablewith one another will generate a positive

atmosphere, leading to enhanced creativity andproblem solving.Cooperative Relationships: Cooperativerelationships are a must, and team membersshould recognize that they need one another’sknowledge and skill to complete the giventask(s).Participative Leadership: Participativeleadership includes having good leadership rolemodels as well as leaders who are willing toshare responsibility and recognition with theteam.Reflection and appreciative inquiry can be added toBiech’s list of successful team characteristics.Teams should be encouraged to allocate time forreflection and debriefing on the results of theiractions and decisions. Appreciative inquiry can helpwith this process by encouraging honestcommunication and analysis by the group (Drew &Coulson-Thomas, 1996). Appreciative inquiryencourages members to identify and reflect onperiods of excellence and achievement. By lookingat the past, members can develop a vision of whatthey want to accomplish in the future. They build onwhat worked best to reach their goal.

▶ Barriers to EffectiveTeamworkThe barriers to effective teamwork fall into fourcategories: (1) lack of management support, (2) lackof resources, (3) lack of leadership, and (4) lack oftraining (see Table 18-2). If these barriers exist inan organization, the likelihood that groups would begiven the opportunity to develop into high-performing teams is limited. Teams needmanagement support, proper leadership, adequateresources, and training to reach their full potential.Table 18-2 Barriers to Effective TeamworkCategoryDescriptionManagementLack of sufficient support and commitment from seniormanagementManagementPressure for short-term resultsManagementandleadershipPolitical meddling and power politicsManagementandleadershipLack of trust among team members and withleadership (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 skillsLeadershipandresourcesFailure to recognize and reward group effortsResourcesInsufficient release time from other duties for teammembersTrainingInadequate training and skills developmentTrainingLack of project management skillsDrew, S., & Coulson-Thomas, C. (1996). Transformationthrough teamwork: The path to the new organization?Management Decision, 34(1), 7. Reprinted with permission.Dunphy’s (1996) research supports the idea thatteams contribute significantly to the productivity andefficiency of organizations. In today’s environment,hospitals and other health care providers areseeking innovative ways to reduce medical errorsand costs while increasing quality of care andcustomer and employee satisfaction. Effective, high-performing teams can help accomplish these goals.However, team building is a process that takes timeand resources. Management needs to invest todayto reach tomorrow’s goals.

▶ ConclusionIn conclusion, Messmer (2004, pp. 13–14) providesan excellent guide to assist managers in thecoordination of activities for building an effectiveteam (see Exhibit 18-2).Exhibit 18-2 Building Effective Teams: AChecklist for Managers1. Begin by creating an action plan thatspecifies the group’s mission, the types ofexpertise required to achieve thisobjective, and how team members willwork together. Critical questions to answerinclude:How long will the group need to beactive?What are the different components ofthe project and the deadlines forcompleting them?Is the team responsible for generatingand implementing its suggestions?Will the group operate independently,or will any of its activities overlap with

those managed by full-timeemployees currently not on the team?2. Be sure you have researched how theproject impacts the department orcompany so you can convey itsimportance at the first team meeting. Also,create a handout (e.g., a timeline) andgather supporting materials that can beused for reference.3. When selecting the team members, besure to evaluate their interpersonal andcommunication skills as well as theirindividual professional abilities andexpertise. A hospital’s accountant withsolid analytical skills may have theknowledge you need to assess theorganization’s operations, but if they lackthe ability to explain their analysiseffectively to colleagues outsideaccounting or finance, you’ll need to eitherhelp them develop those skills or appointsomeone with a persuasivecommunication style to co-present.4. Ask others in your company forrecommendations of people who would beappropriate for the project. Always checkwith each individual’s manager beforemaking a final selection to ensure that a

potential team member can commit thenecessary time and effort to the initiative.5. In addition to identifying employees whomeet specific project needs, you may alsowant to select a coordinator. This personwould periodically collect, organize, anddistribute status reports to everyone in thegroup.6. After team members have been identified,plan an initial meeting to review the actionplan you drafted. Encourage feedbackfrom participants so they feel moreconnected to the project and upcomingassignments. You may also want toestablish protocols for certain practicessuch as conflict resolution and expenditureapprovals to help preventmisunderstandings and encourage moreeffective collaboration. Once finalguidelines and expectations have beenagreed upon, distribute a revised actionplan to everyone involved.7. As team leader, you must walk a fine linebetween coaching and micromanaging.When participants come to you withproblems or challenges, encourage themto develop their own solutions, and rewardthose who take reasonable risks to make

improvements. Sometimes the difficultiesencountered during a project can spurinnovative ideas that are transferable toother groups or the company as a whole.8. Evaluate the team’s progress periodicallyto make sure everyone is contributing. Ifan individual’s regular work demands areaffecting their ability to complete projectrequirements, you may need to select asubstitute participant who has thenecessary time. Also pay attention to thelevel of interaction during group meetings.Sometimes a few people will speak upmore than others. While you want to avoiddiscouraging their input, make sure thatquieter team members don’t feelintimidated. An administrative professionalshould be just as comfortable as afinancial executive when sharing ideas thatmight help the team. You may need tosolicit comments from certain employeesto prompt their participation.9. Providing motivation should be an ongoingpriority. Even when things aren’t goingsmoothly, do your best to keep the moodupbeat and positive. Try to begin eachmeeting with a summary ofaccomplishments before you address

problems. Also take time to acknowledgeand celebrate project milestones. You willhelp to maintain productivity and generateongoing enthusiasm for the initiative.10. In your role as leader, you play a pivotalrole in helping the team get results. Yourstrategy should include carefulconsideration of potential participants andsufficient direction and motivation once theteam is formed. The right approach willencourage more effective collaborationamong participants while maximizing theteam’s contribution to the organization.Messmer, M. (2004). Project Teams That Get Results. StrategicFinance, 85(8), 13–14. Reprinted with permission.

Discussion Questions 1. Explain why teams and groups are not thesame. 2. Describe the various types of teams that areused in today’s organizations. 3. Explain the difference between a traditionalwork team and a self-managing work team. 4. Discuss the positive and negative issues ofusing a virtual team rather than aconventional-type team. 5. Explain the difference between a workinggroup and a high-performing team. 6. Explain the various approaches managerscan use to build team performance. 7. Discuss the various organizational barriers toteam effectiveness. 8. Are there other characteristics of asuccessful team that can be added to Biech’slist?

Exercise 18-1List and describe the types of teams that are mostcommonly found in your organization. What are thepurposes of the teams?

Exercise 18-2List the teams of which you are a member. Selectone of these teams to analyze. Is it a high-performing team? If so, why is it? If not, why isn’t it?What changes need to be made to increase theprobability that it could become a high-performingteam?

Exercise 18-3Using recent news headlines, describe an exampleof teaming in which a group of people cametogether briefly to solve a complex problem.

ReferencesBallard, J. (2019). Millennials are the loneliest generation.YouGov. Available fromhttps://today.yougov.com/topics/lifestyle/articles-reports/2019/07/30/loneliness-friendship-new-friends-poll-surveyBartunek, J. M. (2011). Intergroup relationships and qualityimprovement in healthcare. BMJ Quality and Safety, 20(Suppl.1), i62–i66.Browne, R. (2018). 70% of people globally work remotely at leastonce a week, study says. CNBC. Available fromhttps://www.cnbc.com/2018/05/30/70-percent-of-people-globally-work-remotely-at-least-once-a-week-iwg-study.htmlCohen, S. G., & Bailey, D. E. (1997). What makes team work:Group effectiveness research from the shop floor to theexecutive suite. Journal of Management, 23(3), 239–390.Daft, R., & Marcic, D. (2009). Understanding management (6thed.). Mason, OH: Southwestern Cengage Learning.Drew, S., & Coulson-Thomas, C. (1996). Transformation throughteamwork: The path to the new organization? ManagementDecision, 34(1), 7.Dunphy, D. (1996). Organizational change in corporate settings.Human Relations, 49(5), 541–552.Edmondson, A. C. (2012). Teamwork on the fly. Harvard BusinessReview, 90(4), 72–80.

Gordon, J. (2002). A perspective on team building. Journal ofAmerican Academy of Business, Cambridge, 2(1), 185–188.Hackman, J. R. (2011). Collaborative intelligence: Using teams tosolve hard problems. San Francisco, CA: Berrett-KoehlerPublishers.Katzenbach, J. R., & Smith, D. K. (1993). The wisdom of teams:Creating the high-performance organization. Boston, MA:Harvard Business School Press/McKinsey & Co.Lawler, E. E., III. (1999). Employee involvement makes adifference. Journal of Quality and Participation, 22(5), 18–20.Lipnack, J., & Stamps, J. (1997). Virtual teams reaching acrossspace, time and organizations with technology. New York, NY:John Wiley & Sons.Lurey, J. (1998). A study of best practices in designing andsupporting effective virtual teams. Los Angeles, CA: CaliforniaSchool of Professional Psychology.Margerison, C., & McCann, D. (1989). Managing high-performance teams. Training & Development Journal, 43(11),52–60.Messmer, M. (2004). Project teams that get results. StrategicFinance, 85(8), 13–14.Oxford Centre for Staff and Learning Development. (2011).Characteristics of a group-cohesiveness. Available fromhttps://www.brookes.ac.uk/services/ocsld/resources/small-group/sgt107.htmlRoebuck, D. B., & Britt, A. C. (2002). Virtual teaming has come tostay—Guidelines and strategies for success. SouthernBusiness Review, 28(1), 29–39.

Rothschild, S. K., & Lapidos, S. (2009). Virtual teams thatcoordinate care for chronically ill geriatric patients reduceemergency department visits and improve medicationcompliance, referral patterns, and patient outcomes. AHRQHealth Care Innovations Exchange. Available fromhttps://innovations.ahrq.gov/profiles/virtual-teams-coordinate-care-chronically-ill-geriatric-patients-reduce-emergency. Last accessed December 18, 2019.Taplin, S. H., Foster, M. K., & Shortell, S. M. (2013).Organizational leadership for building effective health careteams. Annals of Family Medicine, 11(3), 279–281.

Other Suggested ReadingsBeich, E. (Ed.). (2001). The Pfeiffer book of successful teambuilding: Best of the annuals. San Francisco, CA: Jossey-Bass/Pfeiffer.Wise, H., Beckhard, R., Rubin, I., & Kyte, A. L. (1974). Makinghealth teams work. Cambridge, MA: Ballinger Publishing Co.

PART VIManagingOrganizational ChangeIn Part VI, we discuss planned organizationalchange and how to manage it. To manageorganizational change, a leader needs to apply allthe theories and concepts that have been discussedthroughout this textbook. To be successful, theleader, or change agent, must use their knowledgeof motivation, leadership, group dynamics, teambuilding, and conflict management in addition tocommunication and negotiation skills. In Chapter19, we explain the role of organization developmentin planned change management. In Chapter 20, wedescribe the concepts and theories related tochange management and explore how health careorganizations are accomplishing change.

CHAPTER 19OrganizationDevelopmentLEARNING OUTCOMESAfter completing this chapter, the student shouldbe able to:Understand the role that organizationdevelopment (OD) plays in an organization’splanned changes.Appreciate the function and responsibilities ofthe OD professional.Understand the components of the ActionResearch Model.Identify and understand the OD process.Understand the interventions that are used inthe OD process.

▶ OverviewHealth care has been a dynamic industry in recentyears. New reimbursement models, escalatingcosts, and changing regulations have resulted in anenvironment fraught with survival struggles. Rapidchanges in technology, epidemic levels of clinicianburnout, and consolidation among health caresystems and insurers have created a challengingenvironment. These issues have caused healthsystems to be in a flux of constant change. Healthcare organizations need the necessary strategies tosuccessfully implement changes, sometimesrapidly, to ensure sustainability and survival. Manyorganizations have turned to experts in the field oforganization development (OD) to assist withchange initiatives and to help ensure the long-termviability of the organization.OD has extensive roots dating back to the early1900s. Frederick Taylor and his theory of scientificmanagement were extremely influential because thetheory advocates exploring ways to increaseworkers’ productivity. The Hawthorne Studies,conducted between 1924 and 1933, also played animportant role in paving the way for understandingorganizational behavior–oriented change processes

(Ott, 1996). As the nation progressed through theIndustrial Age, the Great Depression, and two worldwars, the emphasis on the way employees wereviewed changed as employee motivation becamebetter understood. The popularity of labor unions,especially in health care, contributed toorganizations’ motivation for designing a betterworking environment. The result of more than acentury of research and practice has beenorganizations that understand the need to change inorder to remain competitive but also recognize thatan emphasis on employee satisfaction is critical formeeting organizational goals. The relationshipbetween needing change and striving to understandhow employees will react to change is the focus ofthe field of OD. Meaningful change is a centraldeliverable of the OD profession (Hanson, Moir, &Wolf, 2011).

▶ Organization DevelopmentMany things that occur in an organization involvesome type of change; however, not all of these areOD initiatives. For example, expanding a service,such as an emergency department (ED), requireslong-term planning, a needs assessmentdetermined by increasing volumes or changingmarket conditions, a thorough cost–benefit analysis,and a strategic plan. However, this type of changemay be successfully implemented without an ODintervention. Why? Although the expansion of theservice directly affects the functioning of the EDstaff as well as various other functional units withinthe hospital, the organization’s culture will mostprobably not be affected by this change initiative.Most employees will likely understand and probablywelcome the expansion; therefore, behavioralscience intervention is not needed. One of thecomponents of OD that is fundamental to thedefinition of the field is the behavioral scienceapplication. If the ED expansion requires a culturechange for the hospital, then the interrelationshipbetween the expansion and the culture shift mayrequire the expertise of an OD professional.

Cummings and Worley (2009) describe threefeatures of OD that differentiate it from other changeinitiatives: (1) It applies to an entire system; (2) itinvolves the impact of behavioral science on thechange process; and (3) it includes planned changebased on diagnosis, intervention, and redirecting ifnecessary.First, OD applies to an entire system, which mayinclude the whole organization or a single division,but OD does not involve change directed at a singleperson or a single unit. For example, theintroduction of a new magnetic resonance imaging(MRI) scanner into the newly expanded ED mayrequire training for the radiologic technologists whowill be using the new machine, but this training istargeted to new technology and to the specificindividuals who will be working with the newequipment. Therefore, OD would not be involved inthis implementation. However, an implementation ofa new electronic health record (EHR) system thatwill be used across the organization would involveOD.The second feature of OD, outlined by Cummingsand Worley (2009), is the impact of behavioralscience on the change process. Practitioners in thefield of OD recognize the interrelationship of groupdynamics, group processes, and culture on thechange initiative, and great efforts are made to

ensure that this relationship is cultivated throughoutthe change process to ensure the success of theinitiative. In addition, OD practitioners understandthe psychological and sociological components ofchange and work to assist the organization todevelop a greater understanding of these dynamics.The importance of the behavioral science approachcannot be overstated. Since OD involves changewithin an organization, the members of thatorganization will be directly affected by anychanges. If a change initiative is implementedwithout an understanding of how the people in theorganization will react and respond to this change,the change is likely to be difficult at best andcompletely unsuccessful at worst. The behavioralscience component will help the leadership of theorganization to understand the psychology ofchange, key phases in a successful change, and theimportance of critical mass, as well as barriers to beprepared to overcome any anticipated time frames.The third feature of OD is that planned change isbased on diagnosis, intervention, and redirecting ifthe change efforts are not progressing as planned.Cummings and Worley (2009) state that OD isfocused on improving organizational effectivenessand utilizes a variety of process change techniques.Five components of OD work toward achieving the

goals of improving organizational effectivenessthrough process change techniques:OD is supported by multidisciplinary theoriesOD views organizations as open systemsOD recognizes that if one part of theorganization is affected by change, effects willbe felt in another part of the organizationOD is based on action research, which is acontinuous examination of the progress of theinterventionsOD is based on data (see Case Study 19-1).CASE STUDY 19-1 Doctor’sHospital’s Organizational ChangeDoctor’s Hospital was facing serious financialhardship as health care costs continued tospiral out of control and reimbursementsplummeted. A new chief executive officer(CEO) was hired to turn things around in aneffort to save the hospital. The CEO wasdetermined to change the organization’sculture, which he identified as apathetic andaccustomed to mediocrity. He noted that thehospital’s financial performance was suffering,and he attributed much of this to a variety ofprocess issues as well as a lack of focus onthe core business of patient care.

The CEO immediately took action to look atfinancial issues and cut costs. A drastic costand labor reduction strategy was implementedwith an aggressive timeline to turn thefinancial bottom line around. Within a fewmonths, the hospital started to show less of afinancial loss, and things seemed to stabilizefinancially. However, the morale of the staffhad taken a significant hit. Turnover increasedas the staff’s sense of job security decreased,and the impact on the patients began to beseen in an increase in patient complaints andlowered patient satisfaction scores. Anemployee training program was introduced toreemphasize the need for customer service,but it had no impact on results. Finally, theCEO hired a consultant who performed anassessment. A multilevel program wasimplemented that incorporated all levels andall aspects of the hospital. This assisted seniormanagement in understanding the linkagesbetween finances, employee morale, andpatient satisfaction. After 2 years, a mindset ofaccountability started to emerge that began aculture shift to one of service. Finally, all theorganizational metrics started moving in theright (and same) direction.Questions

1. What were the key components ofchanging the organizational culture?2. Why wasn’t the employee trainingprogram effective?3. Why do you think a culture change wasnecessary?4. What steps do you think the consultantrecommended in order to effect thischange?

▶ The OrganizationDevelopment ProfessionalThe behavioral science nature of the field requiresOD practitioners to have a particular skill set inorder to ensure success. The role of the ODpractitioner consists of a variety of activities,depending on the relationship between thepractitioner and the organization. Gottlieb (2001)suggests that the primary role of the practitioner isassisting clients in achieving clarity andunderstanding. Other roles consist of assisting withdiagnosis, assisting with process, providinginformation, or providing training activities.Ultimately, the OD practitioner primarily facilitates achange initiative in an organization. The ODpractitioner is similar to a therapist who guidessomeone through a difficult time, recommendingstrategies and enabling the change process.However, just as a good therapist recognizes thatthe client must ultimately walk their own road tosuccess, so does the OD practitioner. The ODpractitioner provides a map of the road to change,but management must lead the organization alongthat road. Consequently, the relationship betweenthe organization and the OD practitioner requires a

delicate balance. The leaders and members of theorganization must ultimately work through theprocess and are responsible for ensuring thesuccess or failure of the initiative. It is critical thatOD practitioners establish a psychological distanceand set boundaries to clearly define roles in order toensure a successful relationship (Browne, Cotton,& Golembiewski, 1977) (see Case Study 19-2).CASE STUDY 19-2 WhatWent Wrong?Joan was asked to consult with a hospital thatwas attempting to enhance organizationaleffectiveness. She was able to meet brieflywith the CEO before she embarked on aseries of meetings with front-line managers.The managers were quite informative aboutthe issues they observed in their departments,and they provided Joan with what she thoughtwas an honest assessment of the issues.After 2 weeks of these meetings, she metagain with the CEO to review the data andrecommend a course of action. The CEOseemed genuinely interested in what Joanhad to say but disagreed with many of herconclusions and her plan of action. Hedetermined the problem to be poor team

dynamics, whereas Joan had suggested thatthe team issues were a symptom of problemprocesses that resulted in role ambiguity andapathy. The CEO decided that the easiercourse of action was to work on the teamdynamics and directed Joan to pursue thatcourse of action.Against Joan’s better judgment, sheembarked on a team-building initiativeinvolving many months and over 500employees. As a result of the initiative, thereseemed to be some better camaraderie, yetthe role ambiguity and other problemspersisted. Six months after the completion ofthe team-building project, the CEOcommented at the senior managementmonthly meeting that it had been a waste oftime with no significant outcomes and vowedto 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 practitionersuccessful, including a combination of technical,

interpersonal, and consulting skills (Block, 1981).Technical skills include specific education or trainingin some area. An example might be specific trainingin statistical process control whereby a particularprocess improvement was initiated or a TotalQuality Management or Six Sigma program wasimplemented. Specific expertise in the psychologyof change management would be another exampleof appropriate expertise.Another skill set of OD practitioners is interpersonalskills. Listening skills are as critical as the ability tomaintain a psychological distance. Marginality hasalso been identified as a key characteristic of aneffective OD practitioner (Browne et al., 1977;Burke, 1982; Gottlieb, 2001); this involves theability to be involved in an organization withoutbeing unduly influenced (Church, Hurley, & Burke,1992). The ability to be collaborative is another keycharacteristic (Argyris, 1970) and involves theability to facilitate rather than direct activities. In aqualitative analysis conducted by Gottlieb (2001, p.45), clusters of roles were identified for an ODprofessional. These roles include the following:1. Assisting in clarification, such as by askingquestions, challenging, and confronting.2. Diagnosing, which includes data gatheringand the analyzing and interpreting of data.

3. Designing or assisting with the design andimplementation of interventions.4. Providing expert information on organizationtheory, change, or business issues.5. Process identification, which includesassisting clients with understanding processoptions.6. Facilitating interventions by guiding anddirecting groups through process changes orstrategies to ensure effective communicationduring the implementation and intervention.7. Training activities, which may run the gamutfrom the training needs assessment throughthe training design and delivery of trainingprograms.Overall, depending on the type of initiative, the skilllevel and role of the OD practitioner will vary.However, one key characteristic is the ability toapply theory to practical application.Some OD practitioners are professionals who areemployed by the organization, serving as ongoinginternal consultants. Alternatively, organizationsmay contract for the services of an externalconsultant. Each of these options has pros andcons, and the leaders of the organization must beable to identify which type of consultant would bebest suited for their organization for the issue at

hand. The internal consultant has an advantageover the external consultant because the individualhas a working knowledge of the organization, knowsthe key players, understands what interventionshave been attempted previously, and may haveaccess to data without the need to start fromscratch. The downside of utilizing an internalconsultant is that the consultant might be too closeto the individuals working in the organization andmight not be able, in the eyes of the leadership, toseparate the relationships. Additionally, if theinternal consultant has been employed by theorganization for a considerable length of time, theymay be blind to the issues that are creating theorganizational symptoms and thus might not havesufficient objectivity.In contrast, an external consultant does not have anestablished psychological connection with theorganization, so they may bring the objectivity thatthe internal consultant might lack. In addition, anexternal consultant is often skilled at a particularintervention or set of interventions that have beenused in other organizations, so the consultant bringsexperiences in implementing the intervention.Another advantage of an external consultant is thatthey might have a particular skill set that the internalconsultant does not possess. For example, if anorganization wants to implement Six Sigma, the

internal consultant might not have the training orskill set to assist in the implementation of thiscomplex process. One disadvantage of an externalconsultant is that there is no prior relationship withthe organization in many cases, so the external ODpractitioner must begin with rapport and trust-building steps. This lack of a relationship can, insome cases, hamper the data-collection steps,especially if employees are mistrustful of an outsideperson. However, this may also be an advantage tothe data-collection initiatives, as employees often donot want to provide information to an internal personfor fear of retaliation.

▶ Action ResearchAs was mentioned earlier, OD is a systematicprocess. Most OD practitioners use a model ofplanned change known as the Action ResearchModel (Cummings & Worley, 2009). According toRothwell, Sullivan, and McLean (1995), actionresearch can be used as a model to represent thecomplex activities that occur in a change process.As Figure 19-1 illustrates, the Action ResearchModel contains eight main steps. This model mayserve as a road map for change agents to follow asthey implement change in an organization(Rothwell et al., 1995). Ultimately, the goal ofaction research is to base the intervention on initialresearch, followed by feedback through further dataanalysis to determine the effectiveness or impact,make adjustments as necessary, and ultimately usethe results to support additional research (Rothwellet al., 1995).

Figure 19-1 Action Research Model

▶ Steps in the OrganizationDevelopment ProcessAs illustrated in Figure 19-1, traditional OD theoristshave identified eight steps in the Action ResearchModel (Burke, 1982; McLean & Sullivan as cited inRothwell, Sullivan, & McLean, 1995), which hasserved as the template for OD practitioners to use.However, other practitioners have recommendedthat the model be consolidated into a smallernumber of identified steps. The two models arecompared in Table 19-1. A few additional pointsabout each of the major steps are worth noting.Table 19-1 Comparison of the Two Models for ActionResearchBurke(1982);McLeanandSullivan(1989)Cummingsand Worley(1997)Description1. Entry2. Startup1. Entry andcontractingKey leaders identify a need and workto begin the OD process. An ODpractitioner is identified, and the keycomponents of the workingrelationship between the organization

and practitioner are established.Ground rules, mutual expectations,and deliverables are identified.3.Assessmentandfeedback2. DiagnosingData-collection techniques areemployed to determine the extent ofissues identified by the organization.A diagnosis of relevant organizationalprocesses, interpersonalrelationships, or group analysis maybe made.4. ActionplanningSteps are taken to work with theorganization to ensure the long-termsuccess of any intervention. Keyrelationships are established, andmutual plans are developed. Theimpact of change on any changeinitiative is reviewed, and steps areput into place to assist theorganization through the changeprocess.5.Intervention3. Planning andimplementingchangeThe planning phase is similar to theaction planning phase. The plan isimplemented and carried out. Theprocess of managing change isimplemented, and steps are taken toensure the success of theintervention.6.Evaluation7. Adoption4. EvaluatingandinstitutionalizingchangeThe change process is evaluatedthrough data analysis andcomparison to previous data. Thechange becomes part of theorganization, and the members of theorganization begin to adopt these

strategies and take ownership fortheir success.8.SeparationThe OD practitioner begins thedisengagement process from theorganization if it is an externalconsultant or the disengagement ofthe project if it is an internalconsultant.Entering and ContractingThe entering and contracting phase is the firstcritical step in the planned change process. Duringthis stage, a contract is developed between theorganization and OD practitioner, during whichmutual expectations are identified. Theseexpectations should include the desired outcomes,such as greater employee satisfaction, increasedrevenues, or lower turnover; the length of theengagement; and communication and reportingarrangements—for example, who is the primarycontact at the organization for the OD practitioner,frequencies of reports and updates, and so on. Inaddition, ground rules need to be established thatoutline how to handle sensitive issues such asfeedback of difficult information, maintainingemployee confidentiality (and whether that is anexpectation), and how to terminate the engagementif there are concerns or issues from either party

(Cummings & Worley, 1997; Rothwell et al.,1995).DiagnosisThe diagnosing phase is the second major phase inthe general model of planned change. It involves astrategic plan for understanding the organizationand gathering, analyzing, and feeding back ofinformation to managers and organization membersabout the problems or opportunities that exist. Whenwell done, diagnosis clearly points the organizationand the OD practitioner toward a set of appropriateintervention activities that will improve organizationeffectiveness (Cummings & Worley, 2009).There are various methods of collecting data withinthe organization. Cummings and Worley (1997)outline the most typically utilized methods. Usually,a variety of methods may be used, the choice beingdetermined largely by efficiency, sample size, andtype of information needed. The most commonlyused methods are questionnaires, interviews,observations, and unobtrusive methods.Questionnaires are often the first method used forcollecting information within an organization(Cummings & Worley, 1997). Questionnaires areoften utilized because of their relative ease ofadministration and the ability to collect informationfrom large groups of people while providing some

response anonymity. Additionally, if developedcorrectly, questionnaires enable efficiency inquantifying and analyzing information. Anexperienced OD practitioner understands how toconstruct an effective tool for capturing theinformation that would be relevant for performing anorganizational analysis. Such expertise is neededbecause it is important to understand the statisticalproperties of sample size, the power of results, andscale construction as well as how to create anonbiased instrument. Additionally, in the currentlitigious world, it is important to ensure that anyquestionnaire that is used in an organization has ahigh level of validity and does not seem to targetany particular group of individuals with a biasedresult.The construction of a questionnaire with anappropriate scoring scale is critical to the ability toeffectively analyze the data. All too often, new ODpractitioners create an open-ended questionnaireand send it out to 300 employees in the hopes ofcollecting a variety of responses, only to discoverthat there is no easy way to analyze the results,since every employee has written somethingdifferent. Another difficulty in using a questionnairemethod is that it is rare that everyone who receivesa questionnaire completes it. It is likely that youhave received many e-mail requests to complete a

satisfaction survey, only to delete them or fail tocomplete them in their entirety. The reality is thatthere is typically a relatively low response rate forquestionnaires, and the missing data mean that apiece of the puzzle is missing. This nonresponsebias is impossible to interpret but exists and makesan impact on analysis. Therefore, OD practitionerscommonly attempt to send questionnaires to asmany employees as possible in an attempt toensure a sample with enough respondents toreduce statistical error of the results.A second type of data-collection tool is the use ofinterviews (Cummings & Worley, 1997).Occasionally, interviews are used as a follow-up toresults obtained from a questionnaire, but thismethod is also used to capture data that cannot bereadily obtained in questionnaires. Through a two-way communication approach, an effectiveinterviewer can delve into issues identified by theemployee and attempt to get to the heart of anyissue that has been identified. However, coding ofresponses is a hurdle for analyzing the results of theinterview. Additionally, the interviewer hearswhatever responses the interviewee chooses togive, which might not be true or accurate. Thisresponse bias may make it difficult to obtain validresults, but it can be overcome to some degreethrough effective rapport building and reassurance

of confidentiality from the interviewer. The finaldisadvantage of this approach is that it is verydifficult to conduct a large number of interviews, sothe sample size tends to be small.Another method of data collection is observation(Cummings & Worley, 1997). Observation isdesigned to allow the OD practitioner to seefirsthand what is occurring with either a particulargroup of people or a process. For example, oneorganization might be concerned about the lack ofteamwork among a group of employees, and datacollected from a questionnaire revealed a variety ofpossible reasons for this. Because the data-collection results were somewhat ambiguous, theOD practitioner might decide to go in and observethe interpersonal dynamics occurring among theteam members. This might reveal communicationpatterns, leadership issues, or ineffective conflict-resolution strategies within the team that might notbe discovered through traditional data-collectionstrategies. In another example, a process might beobserved in order to determine whether there areinherent inefficiencies that might not be recognizedby the employees performing the various tasks inthe process because they are so accustomed toperforming those tasks regularly. Thus, theobservation method of data collection has somedistinct advantages.

However, as with all data-collection techniques, theobservation method also has some pitfalls. Themost apparent downside is that employees behavedifferently than they ordinarily would simply becausethey are now being observed (known as theHawthorne Effect, based on the Hawthorne Studies;see Roethlisberger & Dickson, 1939; Homans,1950). Many employees become concerned thatthey will face some outcome if, during theobservation, some negative data are collectedregarding their work performance. Since the maingoal for many employees is job security, it isprobable that in some cases the employees will altertheir behavior simply to “look good.” Additionally,observers face considerable difficulty in codingobserved behavior into some type of aggregateresult. Observers must also guard against havingpreconceived ideas of what should occur so thatthey are in fact recording actual behavior rather thaneither an ideal or a judged version of what actuallyoccurred.One additional type of data collection that isfrequently utilized by OD practitioners is theunobtrusive method (Cummings & Worley, 1997).The interesting component in this type of datacollection is that the data are obtained directly frompreexisting information. These types of data exist invarious formats throughout every organization.

Examples include financial reports; humanresources information such as turnover, vacancyrates, performance appraisals, and exit interviews;safety reports; and customer satisfactioninformation, to name a few. The advantage of thismethod is that the data are relatively easy to utilizeonce they have been obtained, although in someorganizations, the information systems ormechanisms by which organizations collectinformation are cumbersome or in some casesnonexistent. A second advantage is that the dataare typically free of biases that may be introduced inusing other data-collection strategies.Planning and Implementing ChangeOD practitioners make use of an enormous varietyof interventions. According to Cummings andWorley (1997, p. 141), three major criteria areneeded for an effective intervention: “(1) the extentto which it fits the organization, (2) the degree towhich it is based on casual knowledge of intendedoutcomes, and (3) the extent to which it transferscompetence to manage change to organizationmembers.” Essentially, the types of ODinterventions that are typically utilized fall intoseveral broad categories (Cummings & Worley,1997). A brief overview of these interventions isoutlined here, although some are discussed in

greater detail later in the chapter. Theseinterventions include the following:1. Strategic Interventions: Strategicinterventions deal with large-scaleorganizational strategic issues, such asensuring that the organization maintains acompetitive advantage, and marketingstrategies as well as other organizationalperformance issues. Assessing theorganizational environment and externalfactors that affect performance may identifyan intervention whereby a diversification inproducts or change in geographic locationmay be the key to long-term organizationalsuccess.2. Technostructural Interventions:Technostructural interventions deal withstructural issues within an organization, suchas organizational design issues or workdesign issues. An example of this might bethe recognition through data collection thatan organization with a functional structure isno longer efficient in its business strategy.The structure is providing some limitationsthat are ultimately affecting coordinationbetween products and services and resultingin customer service or quality issues.

3. Human Process Interventions: Humanprocess interventions deal primarily withissues between people within anorganization. Often, there are distinctcommunication barriers, a negative historybetween employees, or perhaps ineffectiveleadership. In these interventions, the datamight point to a problem involvingfundamental communication processes, andthe recommended intervention might be astrategy to assist the group in improvinginterpersonal relationships. An interventionsuch as communication training involving theJohari Window (Luft, 1984) or a team-building strategy might be appropriate inthese cases.4. Human Resource Management Interventions:Human resource management interventionsdeal with larger-scale human resourceissues. Interventions in this area might bebased on data suggesting that there is anexodus of good employees from theorganization. Exit interviews might reveal thatemployees are disenchanted with rewardprograms or with organizational successionplanning. Interventions such as a careerplanning system might be ways to addresssuch concerns.

Evaluating and InstitutionalizingChangeThe true test of the effectiveness of an ODintervention is the outcome. In order to truly knowwhether there is an effective outcome, there has tobe some sort of follow-up evaluation andmeasurement. The follow-up evaluation should bedetermined at the outset and agreed upon by bothparties as part of the original contract. Feedback tomanagers about the intervention’s results providesinformation about whether the changes should becontinued, modified, or suspended (Cummings &Worley, 2009). Institutionalizing successful changesinvolves reinforcing them through feedback,rewards, and training.It is critical that the OD practitioner be viewed solelyas the facilitator of the new process rather than asthe owner. It is therefore extremely important thatthe impact of the intervention be transferred back tothe organization. In other words, the organizationmust transfer responsibility and accountability fromthe OD practitioner to the organization and ensurethat the proper steps have been taken to weave thenew strategy into the fabric of the organization.

▶ Organization DevelopmentInterventionsThe following are some typical OD interventionssuggested by Rothwell, Sullivan, and McLean(1995) that might be utilized by OD practitioners:1. Team Building: Team building can be done ina variety of ways, including providingassessments to team members, team-building workshops, or in-depth groupanalysis. Regardless of the strategy that isutilized, the goal is to increase theeffectiveness and cohesiveness of either anintact work group or a project team.2. Process Improvement: The processimprovement intervention is designed to lookat work processes and improve the way inwhich individuals work within the process.The goal is to improve efficiency.3. Total Quality Management: The total qualitymanagement intervention is designed toenable groups of people to work together ona single problem and, through a regimentedprocess utilizing specific problem-solvingtools, work to solve the issue at hand. Someof the many tools that the team is trained to

use are Pareto diagrams, cause-and-effectdiagrams, brainstorming, and flowcharts.Teams typically meet regularly over a longperiod of time in an effort to solve theproblem or mission that they have beengiven. This intervention not only is aneffective intervention for problem solving orprocess improvement, but also affects teamdynamics and provides opportunities foremployee involvement.4. Work Redesign: The work of Hackman andOldman (1980) suggests that there aresignificant relationships between core jobdimensions (skill variety, task identity, tasksignificance, autonomy, and feedback) andcritical psychological states (experiencedmeaningfulness of work, experiencedresponsibility for outcomes of work, andknowledge of actual results of workactivities). These relationships producepersonal and work outcomes (internalmotivation, high-quality work performance,high satisfaction, and low absenteeism andturnover). On the basis of this model, ODpractitioners may opt to look at the design ofthe job to determine what core jobdimensions are inherent in the work.Depending on the outcome of the analysis, a

redesign of the job may be recommended sothat specific psychological states areaddressed in the core job.5. Structural Change: As was mentioned earlier,it is possible to change the organizationalstructure if the current structure is determinedto be ineffective. Changing the structureessentially changes reporting relationships tostreamline and improve quality outcomes.6. Training: Training is often seen as the onlyintervention needed. Often, organizations fallinto the trap of assuming that a trainingprogram will be the panacea that addressesand solves all of its organizational issues.This is an unrealistic assumption, but trainingis considered to be a very effectiveintervention when conducted with the correctgoal in mind or as an adjunct to an additionalinitiative. The goal of training should be toimprove a skill base.7. Performance-Management Systems:Performance-management systemsintervention is one of the Human ResourceManagement Interventions. A performance-management system consists of goal setting,appraisal, and reward systems. Someorganizations have none of the componentsin place; some have one or two components;

some have all. This intervention may involvedesigning a performance-managementsystem in an organization where none existsor the redesign of one in an organization thathas an ineffective system. The goal of thisstrategy is to identify the appropriatemechanisms, specific to an individual, formeasuring employee performance.

▶ Appreciative InquiryA relatively new approach or process for plannedchange is appreciative inquiry (AI). Whereas theAction Research Model is primarily deficit based,focusing on the organization’s problems and howthey can be solved so that it functions better, AIfocuses on what the organization is doing right(Cummings & Worley, 2009; Fitzgerald, Murrell &Newman, 2002). AI suggests that for organizationalchange to take place, the organization needs tobegin with the recognition of its positive attributesand then ask questions that will take it along thepath toward the organization it visualizes itselfbecoming (Cooperrider & Srivastva, 1987). Similarto an athlete using visualization to prepare for anupcoming competition, whereby the athlete mentallyreviews every step of the competition and visualizessuccess, so does AI challenge the organization tocapitalize on its strengths. AI is a change processguided by an OD practitioner who is adept atmaneuvering through the maze of possibilities thatmight be exposed by examining the positive issuesthat are identified (see Case Study 19-3). The ODpractitioner essentially helps the organization to seethe future and then sets the organization on a path

to make that visualization a reality (Cummings &Worley, 2001).CASE STUDY 19-3 CreatingPositive Conversations AroundExceptional Health Care DiningServicesFocus of the Appreciative Inquiry: To havea group of 20 Foodservice Directors discussand identify their experience with exceptionaldining services and transfer that learning totheir health care facilities.Client Organization: UHF Purchasing is agroup purchasing organization that providesprime vendor contracts, product supplycontracts and services to health care facilitiesthrough a national purchasing agreement. Themajority of the participants worked in long-term care facilities or small communityhospitals throughout the state of Wisconsin.The Food Service Directors meet quarterly todiscuss trends and issues affecting thefoodservice departments. The AIC consultantwas invited in to create positive conversationsaround the dining experience and to teach theFoodservice Directors to train their staff in anappreciative approach.

Client Objectives/Specific GoalsBuild energy around training regardingexcellent customer satisfactionEducate the Foodservice Directors onan appreciative approach to learningversus gap analysisCreate a dialogue in which FoodserviceDirectors can share and learn fromothers in the Purchasing GroupWhat Was Done: UHF Purchasing created alearning seminar “Breakfast for Champions” inwhich Foodservice Directors could gettogether for four hours. An interview guidewas developed to explore in detail theelements that make up an excellent diningexperience. The participants paired up forinterviews and then shared with the group thestories and their key learning from theinterviews. The participants identified themesand elements that contributed to theirexceptional dining experience. Theparticipants shared with each other how theycould use a similar process for training theirstaff.Outcomes

Collectively the Foodservices Directorscreated a list of elements for anexceptional dining experienceFoodservice Directors were exposed toan appreciative process for trainingReprinted with permission from Peirick, R. (2003). Creating PositiveConversations around Exceptional Healthcare Dining Services.AI is often explained by using the five Ds: Define,Discover, Dream, Design, and Deliver (Fitzgerald,Murrell, & Newman, 2002, pp. 209–211).Phase 1: Define—The most critical phase of theprocess is defining the topic(s) for an appreciativeinquiry.Phase 2: Discover—This step typically begins withpaired appreciative interviews exploring participants’peak experiences of each topic and what made thoseexperiences possible. Participants look for the best ofwhat happened in the past and what is currentlyworking well. In this phase, questions are designed toget people talking and telling stories about what theyfind is most valuable or appreciated and what worksparticularly well.Phase 3: Dream—During this phase, the best of thepast is amplified into collectively envisioned anddesired futures. In other words, the participants dreamof “what might be.”Phase 4: Design—In this phase, participants identify

key facets of organizational systems and structuresthat will be needed to support the realization of theircollectively generated dreams. During this step,members determine the types of systems, processes,and strategies that will enable the dream to berealized.Phase 5: Deliver—During the fifth or implementationphase, participants self-select projects or tasks thatthey would like to work on or otherwise support.Actions are implemented over time in an iterative,appreciative learning journey. The overall results arechanges that occur simultaneously throughout theorganization, all serving to support and sustain thedream.

▶ ConclusionIn general, organizational development (OD) is oneof the most popular and widely used approaches forimplementing organizational change (Waclawski &Church, 2002). Many types of interventions areavailable and at the disposal of a well-trained ODpractitioner. A successful OD initiative will be basedon a thorough analysis of any symptoms ofproblems, and this analysis will be based on athorough analysis of data. The partnership with theorganization is critical, and the OD practitioner mustensure that the organization ultimately understandsand accepts that the responsibility for the success ofany intervention lies with management, not the ODpractitioner.

Discussion Questions 1. Identify and discuss the variouscharacteristics of OD. 2. Describe the unique features of OD thatdifferentiate it from other change initiatives. 3. How would you describe the role of the ODprofessional? What skills are necessary foran OD practitioner? 4. Explain the various components of the ActionResearch Model. 5. Identify and explain the steps necessary inthe OD process. 6. Why is data collection so important to the ODprocess? 7. Identify and explain the various interventionsused in the OD process. 8. What is appreciative inquiry, and how is itused in the OD process?CASE STUDY 19-4Prescription for Change—OpioidCrisisKaiser Health NewsDoctors Can Change Opioid PrescribingHabits, but Progress Comes in Small DoseBy Julie Appleby and Elizabeth Lucas

AUGUST 14, 2019When they started practicing medicine, mostsurgeons say, there was little or noinformation about just how many pain pillspatients needed after specific procedures.As a result, patients often were sent homewith the equivalent of handfuls of powerful andaddictive medications. Then the opioid crisishit, along with studies showing one possibleside effect of surgery is long-term dependenceon pain pills. These findings prompted somemedical centers and groups of physicians toestablish surgery-specific guidelines.But questions remained: Would anyone payattention to the guidelines and would smalleramounts be sufficient to control patients’ pain?Yes, appears to be the answer to both — insome measure — according to a study thatencompassed nearly 12,000 patients in 43hospitals across Michigan. The researcherspublished details of their work in a letterWednesday in the New England Journal ofMedicine.Seven months after specific guidelines forcertain operations were issued in October2017, surgeons reduced by nearly one-third

the number of pills they prescribed patients,with no reported drop in patient satisfaction orincrease in reported pain, according to theresearch.“We’re not trying to deny patients narcotics,”said Dr. Joceline Vu, one of the paper’sauthors and a general surgery resident at theUniversity of Michigan.“ But there’s anacceptable level where people are still happyand still have their pain under control, but wehave dropped the number to a minimum.”Overall, doctors prescribed eight fewer pillsper patient—from 26 to 18—across ninecommon surgical procedures, including herniarepair, appendectomy and hysterectomy,based on guidelines from the Michigan OpioidPrescribing Engagement Network (MichiganOPEN), a collaboration of hospitals, doctorsand insurers.Patients also reported taking fewer pills,dropping from 12 to 9 on average acrossthose procedures, possibly because they wereprescribed fewer in the first place.Still, while researchers say the study offersconsiderable reason for encouragement, itillustrates how hard it is to change prescribing

habits. In May 2018, at the study’s conclusion,the average number of pills prescribedexceeded the most up-to-daterecommendations for all nine procedures.And that’s in Michigan, where there has beena concerted push to change prescribinghabits. Most states don’t have such a broadeffort ongoing.“There is a misconception that this is all fixed,”said Dr. Chad Brummett, co-director ofMichigan OPEN and one of the researcherson this study. “I do think people are stilloverprescribing. Definitely.”The guidelines come amid ongoing concernabout the opioid crisis and a continuedexamination of the role prescription drugsplayed in its escalation.The likelihood of persistent opioid use riseswith the number of pills and the length of timeopioids are taken during recuperation fromsurgery. But there’s another avenue ofconcern. When doctors write scripts with agenerous number of pills, the chance thatpatients won’t take them all increases, alongwith the potential for the unused pills to maketheir way from medicine cabinets to the street,

or to fall into the hands of other familymembers.“That can be a bigger concern for many of us,”said Vu. “It seems that in surgery, forwhatever reason, we wrote prescriptions for alot more opioids than people actually needed.”The Michigan OPEN guidelines recommendedamounts based on how much pain medicationpatients actually took following surgery.Other institutions developed their ownsurgery-specific prescribing principles,including Johns Hopkins Medicine inBaltimore and the Mayo Clinic in Minnesota.Although they use different methods todetermine the number of pills, most ended upwith similar parameters, often in the range of0–20 pills, depending on the procedure.All the prescribing directives apply to patientswith acute pain, such as those who hadsurgery, not people with chronic pain, Vu andother researchers emphasized. Even so,chronic-pain patients argue that the focus onsetting postsurgical prescribing levels hasmade it far more difficult for them to gettreatment.

“These patients feel besieged … and say, ‘Ineed these pills to get out of bed in themorning’,” said Vu. “This project and study isnot about chronic pain. It’s about preventingharm to healthy people coming in for surgery.”What are some of the guidelines? Michigan, inits initial recommendation, called for no morethan 10 pills equivalent to 5 milligrams ofoxycodone for a minor hernia repair, and nomore than 20 for a minimally invasivehysterectomy.The resulting changes offer important context.Before the guidelines, for instance, patientswith minor hernia repair operations were beingprescribed 29 pills, according to the study.That fell to 14 by May 2018, which is still fourmore pills than the guidelines suggest.For a hysterectomy, though, patients received31 pills before the guidelines and 19 after, justbelow the “no more than 20” recommended.And following their initial guidelines, MichiganOPEN revised its recommendations, furtherlowering the range amounts to 0–10 for herniarepair and 0–15 for a hysterectomy.In sheer numbers, opioid prescribing rates inthe U.S. peaked in 2010, but remain among

the highest in the world, according to studiesand other data. The postsurgical prescribingfalloff seen in Michigan does not likely reflect abroader trend, especially where there is lessemphasis on such guidelines.The KHN/Hopkins analysis originally foundthat prescribing from 2011 to 2016 was wellabove levels now recommended byorganizations like Michigan OPEN and theHopkins medical center. For example,Medicare patients took home 48 pills in theweek following coronary artery bypass; 31following laparoscopic gallbladder removal; 28after a lumpectomy; and 34 after minimallyinvasive hysterectomies.According to postsurgical guidelinesspearheaded by Hopkins last year, thosesurgeries should require at most 30 pills for abypass; 10 pills for minimally invasivegallbladder removal, lumpectomy andminimally invasive hysterectomy.In July, when 2017 Medicare data becameavailable, KHN and Hopkins did an additionalanalysis, which showed, on average, smalldecreases in the number of pills taken homefrom the pharmacy by patients in the firstweek after leaving the hospital. But the drop

was smaller than the reductions seen inMichigan.For example, nationwide prescribing followingbypass surgery averaged 45 pills, a drop ofthree; after a hysterectomy, the drop was fourpills from the 6-year average, to 30; andlumpectomy patients took home five fewerpills, for an average of 23.“Those reductions are not sufficient,” said Dr.Marty Makary, the surgeon who spearheadedthe development of guidelines at JohnsHopkins Bloomberg School and whose staffhelped perform the Medicare analysis forKHN. “The data represents prescriptions asrecent as a year and a half ago, and we’rethree years into the opioid crisis. We’re talkingabout mopping up the floor while the spigot isstill on.”You have been hired as an external ODconsultant to work with pain specialists,surgeons, the emergency department, andadministration to change opioid prescribinghabits at Oak Bluff Hospital.Discussion Questions1. Describe what specific activities youwould you would take using an action

research approach.2. How could you use appreciative inquiry toapproach the problem?Reproduced from Doctors can change opioid prescribinghabits, but progress comes in small doses. Available fromhttps://khn.org/news/doctors-opioid-prescribing-habits-change-comes-in-small-doses.CASE STUDY 19-5 GatewayHospitalGateway Hospital is a 500-bed tertiary-carehospital located in a busy metropolitan area.In a recent employee satisfaction survey, thehospital scored well below the national normson most scales. It has been experiencinghigher than average turnover and vacancyrates. Recruitment for professional positions isvery difficult because the hospital has gaineda reputation as a bad place to work, especiallyfor new employees; the term “eat their young”seems to be a prevalent description. Salariesare below the local market, as are annual payincreases. Many departments seem to have acritical shortage of staff, and closing serviceshas been a recent topic of discussion.

Additionally, the financial picture of theorganization is bleak. The payor mix haschanged; Medicare cutbacks are affected thebottom line, as are changes in privateinsurance funding. Key physicians arebeginning to take their services elsewhere asthey sense the inefficiency of the hospitalprocesses.The various stresses appear to be having asignificant impact on the overall morale ofemployees. Poor teamwork is rampant, andcommunication breakdowns seem to occuroften. Several leaders have been let go in aneffort to address issues.The leadership of Gateway Hospital isextremely concerned about the organization’sprognosis and has decided to begin toaddress the issues by enlisting the assistanceof a consulting team. One member of the teamis a financial expert who has been hired toaddress the significant financial issuesaffecting the hospital in a short timeframe.Because the environment is changing rapidly,the consultant must get a handle on how tohelp the hospital operate successfully, giventhe current financial downslide.

A second member of the team has been hiredto address the morale and employee issues. Areview of the employee opinion survey isconducted, and trends are identified in exitinterviews. Employee interviews and focusgroups are held in an attempt to determine theroot cause of the morale issues and thereasons for the breakdown in teamwork andcommunication.After the data have been collected andanalyzed, the team presents the results to thehospital leadership. After a series ofdiscussions, leadership admits that many ofthe financial pressures have created a knee-jerk reaction to staffing issues. Employeehours are often cut back dramatically, whichcreates a crisis mode and the need to askemployees to work harder. This has created asignificant lack of trust from the employees’perspective, coupled with the fact thatemployees have not felt that they have beenapprised of the reasons for the rollercoasterchanges and have not been offered any wordsof appreciation when they have either reducedtheir hours or worked in a crisis.The consultant team and the leadership agreethat in order to fix the “people” issues of the

organization, there will need to be a cultureshift in leadership and employee interactionsso that trust can be rebuilt.Discussion Questions1. On the basis of these issues, what ODinterventions do you think should beutilized to address the problems thishospital is facing?2. How would you proceed if you were theconsultant in this case?3. What skill set do you think the ODpractitioner will need in order to beeffective in this organization?4. What timeline would you establish if youwere this consultant?CASE STUDY 19-6 CityHospitalCity Hospital is a growing hospital in a largemetropolitan city. The hospital is currentlyexperiencing an issue that many otherorganizations also face: that of themultigenerational workforce. The seniorleaders of this hospital are almost all BabyBoomers, but the population of employees isslowly becoming a younger workforce. The

leadership is struggling to deal with issuessuch as social media use at work, textingduring important meetings, requests forremote-working arrangements, excessive non-work-related Internet use, tattoos, bodypiercings, and so on. Equally troublesome is adifferent perceived commitment to the job andfrequent breakdowns in communication.Leadership has decided to hire an outsideconsultant to help the organization understandthe impact of the multigenerational workforceand to help the hospital to become a morecohesive organization.Discussion Questions1. Which type of OD intervention is theleadership using in this situation?2. What obstacles do you see in thissituation that may make this interventionmore difficult than other types?3. What recommendations do you have forthe hospital in this situation?4. What other interpersonal issues exist inorganizations besides generational onesthat may create a need for an ODintervention?

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Cummings, T. G., & Worley, C. G. (2001). Organizationdevelopment and change (7th ed.). Cincinnati, OH: South-Western College Publishing.Cummings, T. G., & Worley, C. G. (2009). Organizationdevelopment and change (9th ed.). Cincinnati, OH: South-Western College Publishing.Fitzgerald, S. P., Murrell, K. L., & Newman, H. L. (2002).Appreciative inquiry: The new frontier. In J. Waclawski & A. H.Church (Eds.), Organization development: A data-drivenapproach to organizational change (pp. 203–221). SanFrancisco, CA: Jossey-Bass.Gottlieb, J. Z. (2001). An exploration of organization developmentpractitioners’ role concept. Consulting Psychology Journal:Practice and Research, 53(1), 35–51.Hackman, J., & Oldman, G. (1980). Work redesign. Reading, MA:Addison-Wesley.Hanson, H., Moir, M. J., & Wolf, J. A. (2011). Organizationdevelopment in health care: The dialogue continues. In J. A.Wolf, H. Hanson, & M. J. Moir (Eds.), Organizationdevelopment in health care: High impact practices for acomplex and changing environment (pp. 273–279). Charlotte,NC: Information Age Publishing.Homans, G. C. (1950). The human group. New York, NY:Harcourt, Brace and Company.Luft, J. (1984). Group processes: An introduction to groupdynamics (3rd ed.). Palo Alto, CA: Mayfield.Ott, J. S. (1996). Classic readings in organizational behavior (2nded.). Belmont, CA: Wadsworth Publishing Company.

Roethlisberger, F. J., & Dickson, W. J. (1939). Management andthe worker. Cambridge, MA: Harvard University Press.Rothwell, W. J., Sullivan, R., & McLean, G. N. (1995). Practicingorganization development, a guide for consultants. San Diego,CA: Pfeiffer and Company.Waclawski, J., & Church, A. H. (2002). Organization development:A data-driven approach to organizational change. SanFrancisco, CA: Jossey-Bass.

CHAPTER 20Managing Resistance toChangeLEARNING OUTCOMESAfter completing this chapter, the student shouldbe 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. We wish to acknowledge and thank Dr. Jeffrey Ritter, who wasthe contributing author of an earlier version of this chapter, whichappeared in Organizational Behavior in Health Care (2014),Jones & Bartlett Learning.**

▶ OverviewPlanned change arises from a single change orseries of changes in organizational goals andobjectives (e.g., increased patient satisfaction).These changes may originate from an organizationrevising its mission, creating a new vision, orresponding to other internal or external forces.Unplanned change arises from the unexpected,which impinges on the well-being of theorganization. Unplanned changes occur because ofthings like sudden shifts in the marketplace,reduced demand for a product or service, theemergence of more competitive products orservices, changes in technology, depressedeconomic conditions, natural disasters, or the deathor impairment of a senior manager.Whether planned or unplanned, many changeswithin an organization will meet with resistancebecause, as Lippitt (1973, p. 3) noted, “change is avery complex phenomenon involving the multiplicityof man’s motivations in both micro and macrosystems and that a man gets satisfied with hisequilibrium and is resistant to changing his statusquo.” Resistance to change is not limited to clinicalor entry-level administrative staff. Resistance may

also be expressed by middle managers, seniorexecutives, and even board members. Therefore, itis a top priority for managers to understand thefactors involved in change management. Ifmanagers understand these factors, they canincrease employees’ readiness for change, therebyreducing the resistance to organizational change.

▶ Drivers of ChangeOrganizations function within three identifiableenvironments: external/social, industry/task, andinternal (see Figure 20-1). The primary forcescreating the need for change originate in anorganization’s external and industry environments.Change occurs as the organization attempts torespond and adapt to the new demands from theseenvironments.

Figure 20-1 EnvironmentsWheelan, T. L., & Hunger, J. D. (1997). Strategic management andbusiness policy (6th ed., p. 10). Upper Saddle River, NJ: Addison-Wesley. Used with permission.Today’s organizations face many challenges. In theexternal/social environment, war and terrorism areviewed as powerful political and legal forces that

affect organizations worldwide. Economic forcesinclude other countries’ economic threats ofinflation, deflation, and recession; trade wars; andsanctions. Advances in technology and big dataavailability are major forces affecting today’sbusinesses. The internet has dramaticallyempowered consumers and has enabled buyersand sellers to come together with drasticallyreduced transaction and intermediary costs,creating much more robust marketplaces for thepurchase and sale of goods and services. Theseexternal forces affect all organizations, and theyhave had a direct impact on changes in the healthcare industry/task environment. For example,patients have become informed consumers ofhealth care services’ value and costs; cloning andgene modification capabilities have challenged anorganization’s ethical practices; special interestgroups, such as insurance companies andemployer-sponsored health consortiums, havedirectly affected the way health servicesorganizations do business; and technologicaladvances in robotic surgery, new drugs andtreatments, and telemedicine as well as securitybreaches have had far-reaching effects on thehealth care industry. Federal, state, and localgovernments, with their ever-changing healthpolicies and regulations, have had a direct and

major impact on the industry, and the politicizationof health care means that major swings can be feltindustry-wide.In addition to external forces, internal forces areinfluencing change within health servicesorganizations. Internal forces are related to anorganization’s structure, processes, and resources.Because of the many external factors cited above,health care organizations are experiencingdecreasing reimbursements and increasing costs,resulting in smaller profit margins. In addition, theorganizations are being challenged to deliverpatient-centered care with value-based outcomes.As a result, health care systems are consideringand engaging in redesign to include more alignmentand inclusion across systems (Fischer, Berwick, &Davis, 2009), such as vertically integrated modelsalong the continuum of care, Accountable CareOrganizations, and joint ventures with insurers andemployers. Whatever the reasons that create aneed for change, a planned response must bedeveloped and implemented by management toensure the organization’s future effectiveness.

▶ Resistance to ChangeAlthough resistance to change is often deeplyembedded in organizations, there are situations inwhich individuals will embrace change. Thisgenerally occurs when they perceive that thechange will benefit them in some way. Kirkpatrick(2001) identified change outcomes that would causeindividuals to react positively to change:Security—The change may increase demandfor an individual’s skill set.Money—The change may involve salaryincreases.Authority—The change may involve promotion.Status/prestige—There may be changes intitles, work assignments, and additionaldecision-making responsibilities.Better working conditions—The physicalenvironment may change, including newequipment and updated technology.Self-satisfaction—Individuals may feel a greatersense of achievement and challenge.However, managers need to be aware that mostorganizational change efforts will be met withresistance. Resistance to change may arise fromtwo sources: organizational barriers and individual

barriers. Organizational barriers may include (1)lack of a change agent, (2) inadequate financesand/or capacity, (3) poor leadership (4) resistance tochange by senior management, (5) lack of thenecessary technology, (6) time restraints, or (7)poor market conditions. Overcoming organizationalbarriers to change may be beyond the control of themanager and is usually a topic in a strategicmanagement course. Because our concern is tounderstand the behavior-oriented change process,our focus will center on understanding theindividual’s barriers or resistance to change.Individuals’ Barriers to ChangeFor individuals, resistance to change may involveaffective, behavioral, and cognitive components(Palmer, Dunford, & Akin, 2009). The affectivecomponent relates to how an employee feels aboutthe change, the cognitive component relates to howthe employee thinks about the change, and thebehavioral component relates to what the employeedoes when confronted with the need to change(Palmer et al., 2009). For most individuals, it iscontextual factors that determine how they will react(Bareil, Savoie, & Meunier, 2007).The results of the famous Hawthorne Studiesshowed that employees behave differently simplybecause they are being observed. Roethlisberger

(1941) proposed that an individual’s attitudes affecttheir response to change. In other words, how aperson feels about a change determines theirresponse. Feelings are not random. Feelings and/orattitudes toward an object are based on thecollective experience of one’s life; thus, differentemployees may be affected differently when facedwith the same change in the workplace.As illustrated in Figure 20-2, Roethlisberger’s Xmodel suggests that two primary forces areinfluencing an individual’s perception, attitude, andresponse toward change. The first force consists ofthe worker’s cumulative life experiences. Thesecond, which functions within the formalorganizational setting, is the influence of the socialforces or informal groups. The identification of thesesocial forces subsequently led to considerableresearch efforts in the area of group dynamics.These studies revealed the great potential for socialforces to directly influence an individual’s behaviorand beliefs, which in turn serve as the foundationsfor establishing or changing an attitude.

Figure 20-2 Roethlisberger’s X Chart (Model for Change)Reproduced from Roethlisberger, F. J. (1941). Management andmorale (p. 21). Cambridge, MA: Harvard University Press.Employees may resist change as a result of manyissues. Palmer et al. (2009, pp. 163–168) provideus with some of the commonly cited barriers:Discomfort with uncertaintyPerceived negative effects on interestsPerceived breach of psychological contractLack of clarity as to what is expectedExcessive changeDiscomfort with UncertaintyEmployees require a stable psychological conditionin the workplace. When changes occur, issues ofprofessional and personal insecurity are kindledprimarily by a lack of knowledge and understandingof what changes are taking place and the official

causes for the change. Management’s failure tofurnish realistic information in a timely fashion addsto employees’ uncertainty. This uncertainty oftenresults in lower morale, increased absenteeism, andreductions in both the quality and quantity of output.Perceived Negative Effects onInterestsEmployees may lack an understanding of the likelyeffect of the change on their interests, which canrelate to numerous factors, such as their level ofauthority, status, salary, autonomy, and job security.Employees find it easier to be supportive of changesthat they perceive as nonthreatening to theirinterests and will resist those that are seen asdamaging to these interests.Perceived Breach of PsychologicalContractEmployees form beliefs about the nature of thereciprocal relationships between them and theiremployers—that is, a “psychological contract.”Change often leads to a disruption of employees’expectations. The employee–employerpsychological contract becomes unbalanced ashistorical feelings of trust and perceptions of honestrelationships become questionable.

Lack of Clarity as to What IsExpectedResistance to change may be the result ofmanagement’s failure to provide a clear message atthe organizational level about the behavior expectedof employees. As Gadiesh and Gilbert (2001, p.74) noted, “A brilliant business strategy … is of littleuse unless people understand it well enough toapply it.”Excessive ChangeResistance to change can be characterized ashaving two forms. The first form occurs when anorganization is pursuing several change initiativessimultaneously and employees perceive them asunrelated or in conflict. The second form occurswhen the organization is introducing numerouschange projects before other changes have beencompleted and employees feel that their resources(including their time) are being spread too thin, notallowing for the initiatives to be effectivelyimplemented. Such “waves of change” may causeemployee initiative fatigue and burnout.Creating and influencing readiness for changewithin an organization help managers to prevent orminimize the likelihood of resistance to change(Armenakis, Harris, & Mossholder, 1993).Readiness for change refers to organization

members’ shared determination to implement achange (change commitment) and shared belief intheir collective capability to do so (change efficacy)(Weiner, 2009). Armenakis et al. (1993) identifiedfive elements for developing organizationalreadiness for change: (1) create a clear andcompelling message for the need for change(discrepancy), (2) demonstrate that it is the rightchange (appropriateness), (3) ensure thatemployees demonstrate self-efficacy (i.e.,confidence in skills and ability) supported by therequired organizational infrastructure (i.e.,technology, policies, procedures, managerial talent)for successful change implementation andcontinued sustainability (efficacy), (4) ensure thatkey leaders, both formal and informal, visiblysupport the change (principal support), and (5) helpemployees to understand how the change benefitsthem (personal valence).

▶ Lewin’s Change ModelTo fully understand the influence of group dynamicson an individual’s attitude toward change, considerthe work of Kurt Lewin (1947) and his model ofForce Field Analysis. Lewin’s model permits us toview change as a series of forces working indifferent directions. In effect, some forces andinterests within an organization that push for changemay be offset by forces and interests that arestriving to maintain the status quo (see Figure 20-3).

Figure 20-3 Lewin’s Force Field AnalysisFor implementation of change, there must be anincrease in the strength of the forces for change(i.e., driving forces), and the strength and position ofopposing forces (i.e., restraining forces) must bereduced or removed. Employing this model requiresan improved managerial understanding of theexternal and internal environments. By identifyingeach force, it becomes possible to distinguishbetween forces and issues that may be changedand those that cannot be changed.

According to Lewin (1947), change can be enactedin one of two ways: by increasing the force forchange in the desired direction or by reducing thestrength of any opposing forces. Borkowski andAllen’s (2002) research on physicians’nonacceptance of clinical practice guidelines in theirmedical practice illustrates the application of Lewin’sForce Field Analysis in the change process. Clinicalpractice guidelines are viewed as important tools toreduce variances of medical services received bypatients and to improve the quality of care byestablishing “best practices.” As such, there is greatconcern as to why these guidelines have beenunsuccessful in significantly influencing physicianpractice patterns. Borkowski and Allen suggestedthat the driving forces for acceptance andimplementation of clinical practice guidelinesrepresented knowledge and attitudinal change andwere viewed positively by physicians, whereas therestraining forces represented changes beingimposed by some external force that were viewedby physicians with resentment and negativity (seeTable 20-1).Table 20-1 Suggested Driving and Restraining ForcesRegarding Physicians’ Acceptance of Clinical Practice GuidelinesDriving ForcesRestraining ForcesHigh-quality patient care (e.g.,Administrative edicts (e.g., cost

professional competence)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 accreditationmechanismsConvenient sources of adviceUtilization reviewWhen these forces or variances are understood, arealistic approach to planning change can beundertaken. As reflected in Figure 20-4, Lewinprovides us with a three-step process forimplementing planned change:

Figure 20-4 Lewin’s Three Step Change Process1. Unfreeze: Workers who are involved inperpetuating resistance acquire anunderstanding of variances that existbetween current practices and behavior anddesired activities and behavior. Using theclinical guidelines example, unfreezing mayoccur when managers effectivelycommunicate the need for change (driving

forces), such as mortality and/or morbidityrates, hospital readmission data, and bestpractices benchmarks.2. Change: On the basis of new objectives, aseries of revised policies, procedures, andoperating practices is implemented. It isimportant that members of the affectedworkforce understand the reasons for changeand participate in the design of newapproaches. Participating in the changedesign, followed by appropriate training andreorientation, presents each worker with theopportunity to buy into the new approaches.Physician participation (whether directly orindirectly) in the development of a clinicalpractice guideline does increase theacceptance of it, as measured by hospitals’reduced length of stays and inpatient costs(Borkowski & Allen, 2002).3. Refreezing: Changes are implemented andmonitored, and they are adjusted wherenecessary. New organizational goals arereinforced by subsequent changes in dailyactivities. Continuous monitoring ensuressuccessful operating practices. For example,audit of and feedback on physicians’ practicepatterns is a common reinforcement used bymanagers.

Kotter (1995, 1996), building on Lewin’s changemodel, identified eight steps for managers to followfor successful organizational change. The first foursteps change the status quo (i.e., unfreezing), steps5 through 7 introduce new policies (i.e., change),and step 8 institutionalizes the changes (i.e.,refreezing). The eight steps, as described by Kotterand Cohen (2002), are listed in Table 20-2.Table 20-2 Steps for Organizational ChangeLewin’s Change Model—Steps for Successful OrganizationalChangeUnfreeze1. Establish a Sense of Urgency: The first stepmust be to unfreeze the organization’s currentstate and establish a sense of urgency about theneed for change (i.e., the desired new state).Managers need to increase the feeling ofurgency (e.g., by discussing crises, potentialcrises, or major opportunities) so that employeesstart telling each other that something must bedone about the problems and opportunities.2. Create a Powerful Guiding Coalition:Management needs to create a powerful guidingcoalition, a group that spans both the functionsand levels of the organization (i.e., includesmembers who are not part of seniormanagement). This requires pulling together theright people with the right characteristics andsufficient power to drive the change effort.

3. Develop a Vision: Management must create avision to direct the change effort and developstrategies for achieving that vision. In otherwords, management must create the rightcompelling vision to direct the effort and assistthe guiding team to develop bold strategies formaking the vision reality.4. Communicate the Vision: Management must useevery vehicle possible to communicate the newvision and strategies, including teaching newbehaviors by the example of the guiding team.Managers need to send clear and crediblemessages about the direction of the change,using words, actions, and technology to opencommunication channels and overcomeconfusion and distrust.Change5. Empower Others to Act on the Vision:Management must eliminate barriers to changeand must encourage risk taking and creativeproblem solving. Management must changesystems, structures, processes, and proceduresthat create barriers for employees to achieve thevision.6. Plan for and Create Short-Term Wins:Management must plan for visible short-termperformance improvements to diffuse cynicism,pessimism, and skepticism. In addition,employees who are involved in theimprovements must be recognized andrewarded. These strategies build momentum by“speaking” to what employees deeply care about.7. Consolidate Improvements and Produce MoreChange: Management should use the credibility

achieved by short-term wins to create morechange. This may include hiring, promoting, anddeveloping employees who can reinvigorate thechange process with new projects and themesand assume change agent roles.Refreeze8. Institutionalize New Approaches: Managementmust reinforce changes by highlightingconnections between new behaviors andorganizational success. Managers should usethe employee orientation and promotionsprocesses as well as the power of emotion toenhance new group norms and shared values.Modified from Kotter, J. P., & Cohen, D. S. (2002). The heart ofchange. Boston, MA: Harvard Business Review Press.

▶ Transformation of HealthCare OrganizationsMany health care entities are implementing changemanagement to transform their organizations fordelivering high-quality patient care. For example,VanDeusen Lukas et al. (2007) examined 12health care systems that either were participants inthe Robert Wood Johnson Foundation’s PursuingPerfection program or have reputations for havinglong-standing commitments to improvement andhigh-quality care. The researchers identified fiveinteractive elements as being critical for thesuccessful transformation of a health careorganization (see Figure 20-5):

Figure 20-5 Key Elements of Organizational Transformation toDeliver High-Quality Patient Care

Reproduced with permission of the Turning Point Program, whichwas funded by the Robert Wood Johnson Foundation, Princeton,NJ.1. Strong impetus to change: The impetus tochange can be external or internal to theorganization. In most cases, externalpressure for change is the strongest impetus(e.g., regulatory, changes in reimbursementschemes).2. Leadership commitment to quality:Leadership is a critical element fororganizational transformation. Leaders mustdemonstrate authentic passion for andcommitment to quality and must steer thechange through the organization’s structuresand processes to maintain urgency, set aconsistent direction, reinforce expectations,and provide resources and accountability tosupport the change.3. Improvement initiatives that actively engagestaff in meaningful problem solving:Improvement initiatives must actively engagestaff across disciplines and hierarchical levelsin problem solving focused on objective,meaningful, urgent problems (e.g.,eliminating never events and reducingunnecessary readmissions). These initiatives,

such as clinical redesign and improvedoperations, must be built into routine newwork practices that are visible as well aseasier to perform, more reliable, and moreefficient than old practices.4. Alignment to achieve consistency oforganization goals with resource allocationand actions at all levels of the organization:Changes must be aligned with theorganizational mission and strategicdirection. Therefore, changes need to beconsistent with the organization’s plans,processes, information technology, resourcedecisions, actions, results, and analysis tosupport key organization-wide goals.5. Integration to bridge traditionalintraorganizational boundaries amongindividual components: For an organization tosucceed, change initiatives must beintegrated across intraorganizationalboundaries to improve coordination andcontinuity of care (e.g., patient flow, casemanagement, electronic medical records).Extensive integration is needed to breakdown barriers between departmental silos sothat the system operates as a fullyinterconnected unit to support organization-wide goals.

▶ SummaryThe primary objective of change is to ensure thefuture competitive sustainability of an organization.The rationale and need for change rise from bothexternal and internal forces. For successfulimplementation, managers need to recognize andappreciate employees’ attitudes, taking intoconsideration the various organizational andindividual barriers that are likely to create resistanceto the required change. In addition, managementshould use a documented, step-by-step processthat includes specific opportunities for feedback,evaluation, and adjustments. As Peter Senge(1990) advocates, organizations must develop thecapacity to adapt and change continuously. Senge(1990) relates that organizations must learn tocreate attributes and implement practices that (1)dismiss old ways of thinking, (2) share ideas freely,(3) create an organizational vision, and (4) establisha collective effort to design a plan to achieve thevision. To become a continuously learningorganization requires management to establish acommitment to change and develop an openorganizational culture.

Discussion Questions 1. Identify and describe the drivers of change. 2. Explain the components of Roethlisberger’sX model. 3. Explain the concept of Lewin’s changemodel. 4. Identify and explain the various barriers tochange. 5. Describe the steps used by managers in thechange process.

CASE STUDYCase Study 20-1 Smyrna UniversityHospital Department of Internal Diseases:Finally Walking Side by SideSmyrna UniversitySmyrna University was founded as the fourthuniversity of Turkey and the first university ofthe Aegean region, in accordance with thedecision of the “Turkish Ministry of Education”with the requirement of law numbered 6595 inMay, 1955. The rapidly growing university wasnot only eliciting the welleducated workforce ofthe Aegean region but also it was the onlyresearch and education institution thatcontributed to the commercial, health, socialand cultural development of the Aegeanregion. Soon after the establishment of theTurkish Higher Education Council in 1981,the university had separated into twouniversities. While the Smyrna Universitycontinued its academic activities under thesame name, a new government universitynamed September University was founded in1982. This new university was the second12

state university of the Aegean region andfounded with faculties that were transferredfrom Smyrna University.Since the establishment of new universities in1982, Smyrna University played a vital roleduring the establishment and development ofthe new universities. The university played afundamental position in education for theAegean region and in 2001 it had become theguarantor for the foundation of the first privateuniversity in Izmir. Today Smyrna University isrepresenting Turkish universities in the “500Leading Universities of World” and accordingto the evaluation of “University Ranking byAcademic Performance,” the university is thefifth leading education institution in Turkey(http://www.hurriyetegitim.com/kurum/1004015144/izmir/onlisans-lisans/ege-universitesi.aspx).Soon after the founding of the SmyrnaUniversity, it started its first academic year(1955–1956) with 90 students. Today, morethan 50,000 students are educated in 11faculties, 8 institutes, 13 vocational schools, 1state conservatory, and 26 research centers.There are more than 3,200 academicians and4,000 administrative staff employed by theuniversity.

Smyrna University Faculty of Medicine andHospitalSmyrna University Faculty of Medicine wasone of the first two faculties of SmyrnaUniversity, which was founded in 1955. Duringthe early years of its foundation, education forfundamental sciences was conducted inseveral buildings, prefabs, and temporarystructures around Bornova, where othersubunits of faculty, including internal diseases,child care, and chest diseases werecontinuing education in buildings belonging tovarious hospitals around the city. In 1971, theuniversity was moved to their permanentcampus, which was located in Bornova, andsince then Smyrna University Faculty ofMedicine has been maintaining its academic,research, and healthcare activities in thiscampus. In 1981, the university hadrestructured its academic activities as a resultof the Higher Education Law numbered 2547(Official Gazette No: 17506; Date: November6, 1981;http://www.resmigazete.gov.tr/default.aspx).With this new regulation, all departments ofSmyrna University Faculty of Medicine weregrouped under three major scientific divisions.345

Under each division were included majormedical departments.Beside its academic activities as a medicalschool, the faculty has been sustaininghealthcare services under the name ofSmyrna University Faculty of MedicineHospital (www.egehastane.ege.edu.tr). All ofthe academic staff in the university are, at thesame time, working as physicians in theSmyrna University Faculty of MedicineHospital. Therefore “Smyrna UniversityHospital” is often referred to as a “universityhospital” whose duties are well ahead of justpatient care as:1. Medical Education: Training current andfuture doctors and resident physicians,and provide clinical education.2. Research Center: Creating newknowledge through conducting basicscience and clinical investigation.3. Patient Care: Delivering comprehensivehealthcare services to patients throughone or more hospitals.As a result of all these duties SmyrnaUniversity Faculty of Medicine Hospital alwayskeeps in track with the recent development inpatient care and treatments. Today, the

healthcare services are operated in threedifferent hospitals stretched through thecampus as:1. Smyrna University Faculty of MedicineChildren’s Hospital2. Smyrna University Faculty of MedicineAdult’s Hospital3. Smyrna University Faculty of MedicineOncology (Cancer Care) HospitalThe future physicians who completed theirtheoretical “clinical education” are then taskedto work as interns in the university hospital.Among these interns who preferred tocontinue their career in internal diseases willbe the future members of Department ofInternal Diseases of the “adult hospital” of theuniversity. Department of Internal Diseases(DID) has been developing patient careservices since 1958 and today it is operatingin 4 different buildings stretched through thecampus with 52 academic staff, 100 medicalstaff, 65 nurses, and 370 employees. DID wasthe largest clinic of the hospital and,moreover, in terms of academic members, itwould not be an exaggeration to compare thedepartment with the other faculties of theuniversity.6

Internal Diseases Department Needed aNew Head, Early Elections, and anUnexpected Candidate: Prof. Dr. SelimSince the establishment of the DID as aseparate department under the MedicalSciences Division, one after another, therewere nine individuals elected in succession forthe head position. Prof. Dr. Selim acted as avice head for the Department of InternalDiseases during the illness of the ninth head,Prof. Dr. Gurhun. Unfortunately, the illnesswas so deleterious, that Selim’s temporaryagency position had lasted for nearly a year.In that trial period, he had found that he wasready for responsibility and that there wasmuch to be done in the DID. Acquiring thehead position would enable him to impose hisethical codes on the team of DID, includingpatients, nurses, residents, and medical staff.After the mourning of Prof. Dr. Gurhun, Prof.Dr. Selim decided to stand as a candidate forthe head of DID. However, he had discoveredthat people were ready to protest and werenot very pleased with his candidacy. Therehad been one other candidate, but Selim hadwon the race with a one vote margin.This large department had been managed byProf. Dr. Selim since 2002. He felt at home7

there, having spent time in DID as a physician,as an academician, as a manager, and all atonce for most of the time. He had beenworking in the faculty since his graduationfrom the Smyrna University Faculty ofMedicine in 1981. His admirable commitmentto the faculty was not only because he hadbeen a member of the faculty for 30 years butit was also because his father—the mayor ofIzmir in 1955—was the one who signed thefoundation protocol and worked hard toestablish the university in its early years.Both the local and national press had startedto talk about the changes in the DID ofSmyrna University Hospital. What washappening there? In order to evaluate theantecedents and consequences of thischange under the supervision of the newhead, a meeting was arranged with Prof. Dr.Selim.When the meeting started it was nearly 7 p.m.in the evening. Although a tired man wasexpected, who would not be able to interviewfor more than 30 minutes, Prof. Dr. Selim wasstanding with an inspiring smile and he wasfull of vim. On sight, he greeted theinterviewers with a glad hand and made sure

that everybody was comfortable in thishospitable room. The room was elegant andcozy, with one of the walls decorated withphotos of previous department heads. Heoffered tea and cookies and smoothly gavethe permission to record the whole interview,which took nearly 2 hours.As of 2011 Prof. Dr. Selim had beencontinuing his third period as DID’s head.Since his first days he spent hours walkingaround the patient rooms, talking to them andlistening as they poured out their grievances.He nearly spent all his time at the hospital. Hesaid that “We are more than physicians. Thewhite coat we wear means treating all patientsequally, regardless of their status, race,gender, and any other features.” Patients werenot his only concern; he also stayed in touchwith students, academics, and medical andadministrative staff of DID. It sometimes tookhim nearly an hour to reach to his office fromthe other end of the “20 meters” corridor thatleads to his own consulting room, because onthe way he answered any question directed tohim, shook each hand offered, and listened toany problems without any refusal. He statedthat it was very important for him to be intouch with everybody around him believing

that he could learn important details about thedepartment that might have been missedthrough formal communication. For example;in one of his long walks, Prof. Dr. Selim feltcompletely helpless with what he heard abouta promising young lady: she had abandonedher medical education in her second year dueto some financial problems. This eventtriggered Prof. Dr. Selim, and there had beenestablished a charitable fund in the faculty thatsupported the education of the poor students.With the voluntary contribution of the doctors,nearly 230 students received scholarshipsfrom this fund in the last 10 years. However,each scholarship student must have workedfor faculty where needed according to theiracademic programs and competencies. Someworked in the library and some of them helpedthe administrative staff with new technologysuch as computers, thus these students wereaware that they received this scholarship inreturn for their efforts.The Main Problems of Department ofInternal Diseases: When Prof. Dr. SelimHad Acquired the Head PositionIn the very early days of Prof. Dr. Selim’spromotion as head, there were severalproblems to be addressed at the DID. The

staff, even the doctors, avoided Prof. Dr.Selim, choosing to walk in the oppositedirection when they saw him. By doing thisthey were barring the most importantcommunication channel that Prof. Dr. Selimprefers, face to face. Besides, no one hadtaken the accountability of what they did. Theproblems were all around but nobody hadundertaken them. Therefore, DID was unableto find solutions and fell into a vicious circlewhere the same problems repeatedlyemerged.On the other hand, everybody wascomplaining to one another about a variety ofproblems at DID. Whether from habit or not,nurses, employees, and doctors—thus, nearlyall members of DID—were complaining abouteach other. Some were for trivial reasons butsome were destructive to their relationship,such that personnel were criticizing andcomparing the working hours, attendanceperiods, reward systems, promotions, etc.Academic promotion of some physicians hadbeen delayed for years for personal reasonsin the department. Although the proceduresand requirements for the promotions mustfollow the faculty laws and regulations, theserules are ignored in most of the cases.

However, according to Prof. Dr. Selim, anykind of academic appellation could not beunder the control of one person; rather, itdepended on the merit of that person whodecisively and worked hard for it. Thus theacademic promotion of doctors could not bedirected by personal closeness to the head, orvalue attributed to their “surnames” by thesociety.Another challenge faced by Dr. Selim was infinancing the department. The Turkishgovernment allocated a determined amount offinancial funds for hospitals. Each hospitalthen allocated those financial funds amongdepartments. However, the financial funds thathad been designated to DID had never been asufficient amount to maintain Prof. Dr. Selim’sideal department. The overall physicalstructure of the DID was not sufficient tosatisfy contemporary health services. Thepatient rooms were inadequate to meet themoderate hospitalization services, and theequipment supplied to the administrative andacademic staff was so limited that it was evenslowing down the daily routine of thedepartment. The assistant doctors, doctors,and nurses were not allowed to use theprinters in the department to print their

educational materials, such as academicpapers, due to the limited number of paperssupplied to DID. They were only using thesepapers for routine administrative activities andfor patient reports.The Consequences of ManagementAlteration and Leadership Style: ThingsStarted to Change at DIDThis section summarizes significant phrasesfrom the interview with Prof. Dr. Selim thathighlights the work he did at the Departmentof Internal Diseases.The professor’s agency position for one yearwas a great chance for him to draw up hisroad map. During this period he saw thedeficiencies of the department. Therefore, themain concern of Prof. Dr. Selim was to makeradical changes in the department when hedecided to be a candidate for the headposition as the overall management principleswere not overlapping with the working andethical principles held by Prof. Dr. Selim. Assoon as the professor became the head ofDID, his main concern was showing thedeficiencies of the current state.Organizational members were no longer seenas negative factors; rather they were the

solution centers. This new role model, whowas fair, hardworking, devoted, andopenminded, started to inspire the wholedepartment. The winds of change had startedto be felt at all levels of the department. At theend of his first year as the head, the numberof complaint petitions had started to decreaseand in the last 9 years no petitions wereforwarded to head of the DID. As it wasmentioned above for some of the academicpromotions, the faculty laws and regulationswere ruled out; however, during those 9 yearsno one had lost any academic promotion dueto a conflict of interest or personal reasons.With Prof. Dr. Selim, they started to feel freeto visit the head office whenever somethingwent wrong within the DID, knowing that thedoor was always open to them with a genuinelistener behind it. He allowed theorganizational members to take active roles indecision-making processes and keptcommunication channels open all the time. Heaimed to raise the awareness oforganizational members about improperapplications. Therefore, members of DID wereready to take any responsibility for theirmistakes, believing that problems needed asolution for the well-being and success of DID.

At last they were walking side by side in thecorridors. The best example of the positiveeffects in the DID could had easily beeninterpreted from the latest newspaper accountentitled “Halil Ibrahim Library Lends Books toPatients in DID at Symrna UniversityHospital.” An employee named Halil Ibrahimwas distributing books to patients in DID at theend of working hours from his “mobile library.”He had been working as a sanitary in DID for15 years when Prof. Dr. Selim had acquiredthe head position in the department. He triedto distribute books and newspapers topatients in the past but he could not continuethis attempts with his limited income. Soonafter he shared his idea with Prof. Dr. Selimhe was given a book cart where he couldplace books and walk around the corridorseasily. Prof. Dr. Selim also started a second-hand book campaign for the Halil IbrahimMobile Library. With this campaign, all nurses,doctors, academicians, and even patientrelatives brought books to him. There was nosuch service in any other department of thefaculty; moreover, not in any other private orpublic hospital around Izmir. All theseexamples were major indicators of themultidimensional effects of all staff, from the

head to janitor, on the development oforganizations with effective projects andvaluable staff contributions.Soon after he started to work as the head, hebegan to look for new financial resources forthe department, although it was not his area ofresponsibility. The initial funds raised wereused to meet the daily administrative needs ofthe department. Thus, for example, scarcity ofpaper for both assistants and administrativestaff was no longer a problem for thedepartment.As mentioned above in DID, the patient roomshad not been meeting the requirements ofmodern physical health conditions, with 6–8beds in less than 20 square meters and acommunal toilet at each floor. In fact, this isthe leading problem of the Turkish healthcaresector. Thus, as of 2007 in Turkey, the totalnumber of doctors per 100,000 people is only123. However, this number is 567 in Italy, 330in France, and 287 in Armenia. On the otherhand, the total number of patient beds per10,000 people is 25,(http://www.biyoetik.org.tr/files/hekim%20sayisi%20yetersiz%20mi.pdf:19.09.2011which means that in Turkey the attainabilityand fair distribution of healthcare services was

very limited. The need of beds for patientswas a more tremendous problem for universityhospitals where nearly 60–70% of all teachinghospital patients entered because of seriousillnesses that required long-term treatment(Yi_it, & A_ırba_, 2004). Therefore in order toincrease the number of patients treated, thehospital administration preferred to increasethe number of patient beds per room.However, on the other side, this increasedecreased the quality of healthcare servicessupplied to patients. As mentioned above,Smyrna Hospital was one of those universityhospitals that experienced the similar patientbed problem because of the huge gapbetween supply and demand of healthcareservices in Turkey. Probably the solutionfound for rooms has been the leadingcontribution of Prof. Dr. Selim to both DID andthe Faculty of Medicine. Prof. Dr. Selim’s offerfor two-bed patient rooms with air conditioningand a private toilet had initially increased thetension in the academic committee at thosedays where the general belief was tohospitalize as many patients as possibleregardless of the number of nurses and healthconditions. In Turkey the majority of thehospitals tried to increase the number of

patients treated and therefore, regardless ofthe insufficient healthcare services due to theinadequate number of doctors and nursesthey employed, they chronically invested inincreasing the number of beds. However, Prof.Dr. Selim interpreted that, “I always believethe number of nurses is the main determinantof the number of patients as each persondeserve the best condition for hospitalizing.”With the help of donations and differentsources of financial aid, DID started to makemodifications in patient rooms. At each stageof the construction the professor had askedfor the assistance of end users of thesemodifications. During the construction of newpatient rooms, he always collaborated with theorganizational members, knowing that theywere the ones who would work underrenewed conditions. For example, for thelocation, ergonomics, and decoration fornursing centers, he held long discussions withthe nurses and modified the existing centersaccording to the feedback he received fromthem. Soon after they had started to renovatethe patient rooms, the microbiologydepartment complained to the Dean about themodification, accusing the DID of causinginfection for hospitalizing patients. The

unavoidable fallout of such modifications likethe smell and dust, and chemicals such aspaints and polishes were impeding thehygiene of the entire building where DIDoperated. Prof. Dr. Selim stated that, “I amsure that they were all right about theircomplaints. Although we have taken all thenecessary precautions, the dust and the noisespread around had bothered the otherdepartments. Especially the microbiologydepartment was very sensitive to it, as theywere operating on the ground floor of ourbuilding.” The Dean, who considered that thearguments of Prof. Dr. Selim were reasonable,had not taken any legal action about thecomplaints of the microbiology department,and the renovation continued. This was thevery best proof of the administrative supportgiven to Prof. Dr. Selim for his longstandingefforts to transform DID into an enhancedplace for both patients and healthcare staff.The hospital administration assignedadditional rooms for DID in the existingbuilding. However, all these rooms neededsimilar modifications. As mentioned above,due to insufficient financial position, DID hadto raise its own funds for the modification ofthese rooms. This time the required fund was

reasonably more than the hospital couldsupport individually, therefore Prof. Dr. Selimhad talked to the rector about his ideas andgot the permission to take this subject to theIzmir representative of the governing politicalparty. By chance, the Izmir representative wastrying to contact Prof. Dr. Selim for a healthproblem at that time, and he promised to helphim; although due to his heavy schedule wasnot able to head the fundraising drive himself.Prof. Dr. Selim continued to search for othersources of donations and contracted two ofIzmir’s philanthropic families. Both agreed tohelp Prof. Dr. Selim and did more than theypromised to do at the very beginning of theproject. One of these families granted to helphim just because Dr. Ali Selim, Prof. Dr.Selim’s father, was the person whom thefamily admired. Prof. Dr. Selim added that“There again I felt the admirable inheritance Itook over from my father. Thank god I hadthose wonderful traces and the powerfulshadow of my father in my life.” So themodification of patient rooms was finished andever since then the DID had been operating intwo floors with facilities that best suit properhealth conditions and the demands ofpatients.

. . . then the rooms were ready tomeet the proper health conditions.Thus, there was no doubt that wemade a successful change! But itwas just the beginning andunfortunately the easiest part of anorganizational change. I am verysure that all those changes mightturn out to be a waste of time,energy, and money if the staffwould not appreciate the thingsdone in the department. That wasthe newest and the most difficultproblem of our department that Ihad experienced. When I acquiredthe head position I also acquiredthe team that I have been workingwith. They were sharing the visionand principles of the previous headand they were far away fromadopting my principles and sharingmy desire for change.As stated above by Prof. Dr. Selim, in Turkey,in governmental bodies, when you hadacquired a position you also acquired thestaff. Thus, the managers were not involved inthe decision process of hiring and selectingthe people they were going to work with.

Rather, they had to work with selectedemployees before they had been promoted tothat position, and furthermore they had tochoose among candidates that were sent tothem whenever a position must be filled.However, he believed that sustainabledevelopment could only be achieved if andonly if the new structure of the DID wasinternalized by all members of the department.So he kept in touch with the organizationalmembers all the time, listened to them, andtried to be a solution partner for problems inDID.Despite the insufficient HR policies discussedabove, the head nurse, Alaz, was his instantcounselor and best supporter during thosehard days. He vaguely recalled their firstmeeting with her and how he tested herpersonality and compatibility with his ethicalcodes.There was no doubt that Alaz wasa very young “head nurse”;however, she was the one whom Iwas looking for. The smile on herface and the light in her eyes gaveme an instant impression of anhonest personality. Her wide

sense of perspective underdifferent circumstances and senseof justice soon justified my firstthoughts about her.Thus the harmony between them hadtriggered Prof. Dr. Selim to think oftransferring daily routine businesses to thecontrol of the head nurse. From then, onlystrategic projects and/or complex problemsrelated to DID were discussed with the DID’shead. DID was no longer a place where “thehead orders and the rest obeys.” Prof. Dr.Selim said thatHer existence in the head nurseposition made me feel comfortablebecause from the “director’s chair”things might have been blurred oryou saw them only from the pointthat they were shown to you. Soonafter I delegated the leading of areasonable amount of dailyroutines to Alaz, I realized that bydoing this I was both indirectly keptin touch with the nurses and theirproblems, and caught any detailthat may have been missed if I hadworked alone. Finally, I have

created an organizational climateof my dreams that was verysupportive and open to new ideasfor better conditions.Prof. Dr. Selim was not only executing theadministrative duties, rather he was a full-timephysician and an academician. He carefullyconsidered university education and its majorobjectives. Education could be achievedthrough transferring knowledge, encouragingthe students by developing their competenciesand enlightening the exact nature of attitudesand behaviors. The first two could easily bedone by words, but the latter could only beachieved by exemplifying.The following quotation from the interviewproved that Prof. Dr. Selim was the follower ofthe opinion mentioned above:Today we are living in the age oftechnology, where everybodycould easily access knowledge.So, successful educators ormanagers helped their followers touse the knowledge and transfer itinto competencies thatdistinguished them from others. I

have been working very hard tomake DID a better place for allstakeholders. We renovated therooms, redesigned the jobdescriptions, reorganized theworking conditions, and reappliedthe rules and principles of thehospital. The best thing about allthose changes is that, this team isready to survive in this newsystem. Thus if I leave the positiontoday, without any question, theywill allow the sustainability of “newDID.” This is not because Iestablished a perfect system;rather it is all about thecooperation and coordination. Mymajor role during this greattransition was distributing justiceand sustaining the fair progress ofthe change. Today, I am verypleased with the atmosphere wefinally achieved. However, I nowstarted to think that there is a lifeoutside the walls of this clinic,which is very precious. I havebeen devoted myself to DID butdoing this caused me to miss thelife out there.

Discussion Questions1. Using the “Lewin’s Force Field Analysis,”illustrate the change process in DID.2. Analyze the change process of DIDaccording to the most appropriatemodel(s) of a “Planned OrganizationalChange” giving examples from the case.3. According to John Kotter, there are eightpitfalls to be avoided for the success of achange program. Discuss whether Prof.Dr. Selim made any of these mistakes,supporting your answer with examplesfrom the case.4. Discuss the leadership practices of theProf. Dr. Selim during the change processof DID. Which leadership theory (theories)do you think best describe(s) hisleadership style?5. According to the major concerns anddefinitions of an organizational changeprocess, what may happen to DID if Prof.Dr. Selim is not a candidate in the comingelection?Source: Adapted from Case Studies in OrganizationalBehavior and Theory for Health Care by Nancy Borkowski andGloria Deckard. Copyright © 2014 Jones & Bartlett Learning,LLC.

1 The Council of Higher Education was established in 1981.It is a fully autonomous supreme corporate public bodyresponsible for the planning, coordination, governanceand supervision of higher education within the provisionsset forth in the Constitution (Articles 130 and 131) andthe Higher Education Law (Law No. 2547). It has nopolitical or governmental affiliation. At present, there are139 universities in Turkey, 45 of which have foundationstatus: www.yok.gov.tr2 September University was founded on 20 July 1982.Seventeen previously founded institutions of SmyrnaUniversity and other various higher education instituteswere affiliated to the university in the same year. Thenumber of its academic units reached 41 by1992.Presently September University owns10 faculties, 5schools, 5 vocational schools, 5 graduate schools, and 5institutes: www.deu.edu.tr3 Symrna University Faculty of Medicine will be abbreviatedas faculty for the rest of the case.4 Bornova is one of the counties of Izmir, which is locatedvery close to the city center.5 Date of enactment: November 4, 1981. Published in theTurkish Official Gazette No: 17506; Date: November 6,1981. For the full body of act see the official site ofTurkish Official Gazettehttp://www.resmigazete.gov.tr/default.aspx. andplease refer tohttp://www.cepes.ro/services/pdf/Turkey3.pdf for theEnglish translation.6 The name of the “Department of Internal Diseases” will beabrivated as DID for the rest of the case.7 As mentioned in the text, before the faculty had beenrestructured with the law number 2547 and all academic

activities are grouped under 3 major divisions.

ReferencesArmenakis, A. A., Harris, S. G., & Mossholder, K. W. (1993).Creating readiness for organizational change. HumanRelations, 46(6), 681–704.Bareil, C., Savoie, A., & Meunier, C. (2007). Patterns ofdiscomfort with organizational change. Journal of ChangeManagement, 7(1), 13–20.Borkowski, N., & Allen, W. (2002). Using organizational behaviortheories to manage clinical practice guideline implementation.Journal of American 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 carereform: How physicians can help. New England Journal ofMedicine, 360(24), 2495–2497.Gadiesh, O., & Gilbert, J. L. (2001). Transforming corner-officestrategy into frontline action. Harvard Business Review, 79(5),73–79.Kirkpatrick, D. L. (2001). Managing change effectively:Approaches, methods and case examples. New York, NY:Routledge.Kotter, J. P. (1995). Leading change: Why transformation effortsfail. Harvard Business Review, 73(2), 59–67.Kotter, J. P. (1996). Leading change. Boston, MA: HarvardBusiness School Press.

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 thechange process. La Jolla, CA: University Associates.Palmer, I., Dunford, R., & Akin, G. (2009). Managingorganizational change: A multiple perspective approach. NewYork, NY: McGraw-Hill Irwin.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: Anorganizational model. Health Care Management Review,32(4), 309–320.Weiner, B. J. (2009). A theory of organizational readiness forchange. Implementation Science, 4, 67. doi:10.1186/1748-5908-4-67Wheelen, T. L., & Hunger, J. D. (1998). Strategic managementand business policy (6th ed.). Upper Saddle River, NJ:Addison Wesley.

Other Suggested ReadingsBardwick, J. M. (1991). Danger in the comfort zone. New York,NY: AMACOM.Burke, W. W. (1987). Organization development: A normativeview. Upper Saddle 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). Organizationaldecline and innovation: A contingency framework. Academy ofManagement Review, 23, 115–132.Riggio, R. E. (2003). Industrial/organizational psychology (4thed.). Upper Saddle 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.),Blackwell encyclopedic dictionary of organizational behavior.Oxford, UK: Blackwell.

© Valex/ShutterstockIndexNote : Page numbers followed by e, f, and t,indicate materials in exhibits, figures, and tables,respectively.Aabsenteeism, 133, 233, 241abuse of workers, 233ACA. See Affordable Care Actacceptance, 108, 303taccess to care, 33, 98accommodation, conflict and, 282, 284accountable care organizations (ACOs), 5, 214,300, 363ACHE. See American College of HealthcareExecutivesachievementmotivational need, 118–119oriented leaders, 192ACOs. See accountable care organizationsacquisitions, industry, 5action. See behaviorAction Research Model, 348, 348f , 349tacute stress, 235–236

Adams, J. StacyEquity Theory, 130–133, 132fadjourning stage, of group development, 320adjustment bias technique, 265Adler, Alfred, 47adoption, action research, 349tadrenaline, 252affect (feeling), 46affective conflicts, 276affiliation motivational need, 118, 120Affordable Care Act (ACA), of 2010, 5, 19, 164agedeveloping diversity training programs, 30population, 16t , 18–19ageism, 18, 61aggression, 149–150agreeableness, 65e , 215AI. See appreciative inquiryalarm phase, of GAS, 234Alderfer, C.ERG Theory, 110–111, 110t , 121tall-channel network, 89, 92, 92fAllen, Robert, 168allies, developing, 168Allport, Gordon, 46ambiguity, tolerance for, 268ambitious, 61

American College of Healthcare Executives(ACHE), 30, 2182014 diversity study, 31tAmerican Heritage Dictionary of the EnglishLanguage (4th ed.), 14American Hospital Association, 29American Recovery and Reinvestment Act of2009, 5American workers’ perception, 28fanalytic decision-making style, 268, 269anchoring bias technique, 265anchoring errors, 267anticipatory coping strategies, 245, 246, 253antirational decision making, 323–324appreciation, 83, 108appreciative inquiry (AI), 337, 3545 Ds of, 355approach/approach type, of intrapersonalconflict, 278approach/avoidance type, of intrapersonalconflict, 278Asian population, in United States, 17assertiveness, 169, 282assessment, action research, 349tThe Assessment of Men, 210assessor–developer role, 333assimilation, stress and, 238assistance. See support, for employees

attacking/blaming others, 168attitudes, 364adjusting, 53eassessment of, 53echanging, 50–53, 53–54ecultural values and, 238defined, 46formation of, 48–54measurement of, 49, 49f , 50eproblem behaviors and, 53etricomponent model of, 46, 46fattraction, 165attribution style, 147–148defined, 147self-assessment, 157–158esummary of, 148tattribution theory, 56–58, 145–147Kelley’s model of, 57fattributional training, 153attribution–emotion–behavior process, 146fauthoritarian leader, 176authority, 281authority-compliance/task manager, 179autocratic decision making, 268, 270autonomy, 108, 117job, 115, 237availability bias technique, 264–265availability error, 267

average group satisfaction, 93avoidance mode, of handling conflict, 282, 283favoidance/avoidance type, of intrapersonalconflict, 278awareness of self. See self-awarenessBBaby Boomers, 29balanced participation, 336Bales, R.E.Interaction Process Analysis, 301, 302f ,303tBanaji, Mahzarin, 14bank-wiring observation-room group studies,7–8Baptist Health South Florida, 252barriersto change, 363–364to communication, 81–85, 82tto effective teamwork, 337–338, 337tbaseline reward, 113bases of power. See powerbehavior (action), 46behavioral competencies, 218–219behavioral consequences, of stress, 232tbehavioral decision-making style, 268, 269behavioral science, 344–345behavioral study, 176–177

behavioral theories of leadership, 173–185“being need” (B-need), 107–108Belbin, R.M.Team Role Theory, 303beliefsabout stress, 239and thoughts (cognitions), 46belongingness needs, 106–107Benchmarking Survey by the Institute ofDiversity, 31Benne, K.Functional Roles Theory, 302–303, 304eBennis, Warren, 213Benson, Herbert, 250eBig Five personality framework, 65e , 206,215–216Blake, R.R.Leadership Grid, 178–180, 179fBlanchard, K.H.Situational Leadership Model, 194–196,195f“blatant prejudice,” 238Block, Peter, 213body language, 80Boudreau, R., 241boundary spanning, 98bounded rationality model, 262–264brainstorming, 322–323

Broadbent, D.E., 55burnout, 240–241, 241tBurton, G., 311–312Butler, Robert N., 18bystanders, 169CCampbell Interest and Skills Inventory, 65causal attributions, 146Centers for Medicare and Medicaid Services,20centralized communication network, 90, 91fCEO. See chief executive officerChaffee, M.W., 209–210chain network of communication, 90, 91f , 92fchangescase studies, 371–373drivers of, 362–363, 362fForce Field Analysis (Lewin), 366–369,366fforces for, 367timpetus to, 369Lewin’s model, 366–369management of, 346organizational readiness for, 365planned/unplanned, 361resistance to, 363–365three step process, 367–368, 367f

changing attitudes, 50–54step-by-step process in workplace, 53–54eworkshop for employees, 54echanging U.S. population, 16–21, 16tcharismatic leaders, 207, 211–213CHD. See coronary heart diseasechief executive officer (CEO), 31, 82–83, 90,139, 246, 318chief operating officer (COO), 31, 246chronic stress, 235–236circle network of communication, 89, 92, 92fclarity, 223CLAS. See Culturally and LinguisticallyAppropriate Servicesclear goals, 335clinical decision making, 266clinical outcomes, 32Clipper, Bonnie, 29cliques. See informal groupsclosed-mindedness, of groups, 310coalitions, 169, 368tas sources of power, 166, 168coercive power, 164cognitive conflicts, 276cognitive dissonance, 47–48cognitive errors, in clinical decision making(case study), 266cognitive resource theory, 190

cognitive theories. See process theories, ofmotivationcognitive-transactional theory (Lazarus), 229cohesiveness of groupsexperience of success by group, 308group size, 307group status, 308social loafing, 307–308outside threats to group, 308–309collaboration conflict-handling mode, 282–283,283fcollaborative leadership, 214–215practices and steps for leaders, 222–223traits and skills of leaders, 222command groups, 318commitment and stress, 252Commonwealth Fund, 35–36communicationbarriers to, 81–84case study, 90, 95chain pattern of, 89channels of, 76–81, 77fcross-cultural, 94–96diagonal flow, 87, 89discipline of OB, 4downward flow, 87, 89effective for knowledge management,85–87

electronic, 77, 78–80with external stakeholders, 96–98feedback in, 73–76flow within organizations, 87–89group decision making, 320–321horizontal flow, 87, 89informal, 93–94Johari Window model, 75–76and language assistance, 36–37networks, 89–93, 91f , 92fnonverbal, 80–81overcoming barriers to improving, 84–85overview, 71–72process, 72–73, 72fsociogram, 301strategic, 87stress, 247upward flow, 87, 88–89valuing in teams, 336verbal, 76–80vision, 368tcompetitionfor attention and time, 81style management, 282compliance, motivating to improve, 142compromise conflict-handling mode, 282, 283f ,284conceptual decision-making style, 268, 269

concluder–producer role, 333conflict management, 282–288, 336benefits of skilled conflict resolution andnegotiation, 288case study, 289–294negotiation models, 284–288resolution of, 53conflictscase study, 280–281defined, 275handling modes, 282–284, 283f , 293–294levels of, 277–282types of, 276–277conformity, 309connection power, 165conscientiousness, 65e , 215consensus attribution, 57consequences, negative and positive, 138consideration, in leadership, 207consistency attribution, 57consolidation, industry, 5constructive conflict, 276consultants, internal/external, 347consultative decision making, 270contemporary leadership theories, 205–220.See also leadershipcontent theories, of motivation, 105–106Alderfer’s ERG Theory, 110–111

case study and exercise, 122–126comparisons of, 121tJob Characteristics Model, 115–118Maslow’s Hierarchy of Needs Theory,106–110McClelland’s Three-Needs Theory,118–121Two-Factor Theory (Herzberg), 112–115contentment. See satisfaction, jobcontext, 87contingency theoriesFiedler’s, 188–190, 189f , 191of leadership, 180contingent rewards, 207continuous reinforcement schedule, 138Continuum of Leadership Behavior model,193–194, 194fcontrast effects, 59–60controllocus of, 251perception of, 237controllability, 56controller–inspector role, 333conventional and virtual team, 331COO. See chief operating officercooperation, 284cooperative relationships, 337cooperativeness, 282

coping strategies, 230coping with stress, at work, 245–247core four leader criteria, 21, 21tcoronary heart disease (CHD), 236cost/benefit analysis, of relationships, 302counseling, 88employees, 53creator–inventor role, 333cross-cultural communication, 94–96cross-functional project teams, 330Cross, Tamika, 15Cs (Nine) Expectancy Theory, 129cultural competency, 33–37. See also diversityaccreditation standard for, 35assessment tool for leaders, 38–41edefined, 33Hofstede’s Cultural Dimensions, 34–35ecultural differences, 22Culturally and Linguistically AppropriateServices (CLAS), 36–37D“dabs,” 22data collectionfor organization development, 350–351techniques, 349tday-to-day performance coaching, 213decentralized communication network, 89, 91f

decision making, 32, 261–272bounded rationality model, 262–264clinical, 266conformity, 309effective, 336escalation of commitment, 266–268framing heuristics, 268“garbage can” process, 323–324groups/groupthink, 309–311, 320–321heuristics/biases approach, 264–266intuition, 264rational approach in, 262, 263fstress and, 237styles of, 268–269, 268fVroom-Yetton model, 269–271, 270fdecoding, 73, 83deficiency needs (D-needs), 107defined roles, 335degree of centralization, 93delegation, of power, 164–165Delphi technique, 323demand appraisals, 231–232tdemocratic leaders, 176demographics of patients. See patientdiversitydemotivation, immunization to, 153Department of Health and Human Services, 33dependency, as source of power, 165–166

depersonalization, 240descriptive feedback, 73–74desirable motivational states, 150–151“desk/work rage” study, 233deviant behavior, 156diagnosis phase, in planned change process,350diagonal communication flow, 87, 89Dimbleby, R., 311–312diminished personal accomplishment, 240direction, establishing for team, 332directive decision-making style, 268–269directive leaders, 191–192discrimination, 20groupthink and, 198problems of racial and ethnic, 35sex, 239stereotypes and, 61in workplace, 31, 238dissatisfaction, job, 8, 112, 131, 133distinctiveness attribution, 57distress, 234, 250eDistress–Eustress model, 235fdistributive negotiation model, 284–285diversityassessment tool for leaders, 38–41ebased conflicts, 281cross-cultural communication, 94–96

defined, 14employee, 28–29groups, 321in health care leadership, 30–33management, 28–29prejudices, 238stereotyping, 60–61, 62evaluing in teams, 336“Diversity, Equity and Cultural CompetencyAssessment Tool for Leaders,” 38–41edivision of labor, 167downward communications, 87, 89Dreachslin, J.L., 32–33Drive: The Surprising Truth About WhatMotivates Us (Pink), 113driving forces, 366, 367tEeconomic analysis, 276economic changes and effect on health care, 5economic rationality model, 262–264, 263fED. See emergency departmentEdmondson, Amy, 328effective communication, for knowledgemanagement, 85–87EHR system. See electronic health recordsystemEI. See emotional intelligence

electronic communication, 77, 78–80electronic health record (EHR) system, 344email, 77, 78etiquette, 80temergency department (ED), 344emotional exhaustion and stress, 240emotional intelligence (EI), 206, 216–218components, 217–218temotional stability, 215empathy, 216lack of, 84employee(s)behavior, 57centered leaders, 178employer psychological contract, 365industry statistics, 4–6managers and conflicts, 281managing attributions, 155maturity of, 195–196motivation, 106needs, 109, 109fpower gains by, 165–166questionnaires, 88recruitment of, 64–65, 65esurveys of, 49, 49f , 50etermination of, 54eworkshop for, 54eempowerment, 150–151

Ennagram of Personality, 65entering and contracting phase, in plannedchange process, 349–350environmental barriers, to communication,81–83, 82tenvironmental contingency factors, 192–193environments, industry, 362–363equityassessment tool for leaders, 38–41edefined, 14Equity Theory, 48, 130–133, 132fERG Theory (Alderfer), 110–111, 110t , 121terrors, by management, 53escalation, of commitment, 266–268ethnicity/raceconflicts and stress based on, 281population, 16t , 17–18stereotyping, 61stress based on, 238–239eustress, 234evaluationaction research, 349tof change, 352evaluative feedback, 74exchange category, 169executive charisma, 212exhaustion phase, 234–235existence needs, 110–111

exit interviews, 88, 352expectancy, 128–129Expectancy Theory, Vroom’s, 127–130, 128fapplication using Newsom’s nine Cs, 129,130fcase study, 131expectations, from managersGalatea effect, 63Pygmalion effect, 63expert power, 165explorer–promoter role, 333external attributions, 56, 146external consultants, 347external/social environment, 362external esteem, 107external stakeholders, communicating with,96–98, 97fexternal stressors, 235–236, 236textinction reinforcements, 138extranets, 78extraversion, 65eextrinsic rewards, 134extroversion, 215eye contact, 80

Fface-to-face meetings, 77, 81facial and eye behavior, 80Fadiman, A., 22failures by management, 56false advertising, 64favorable image, creating, 168fear/jealousy, 83, 85Federal Employers’ Liability Act judgments, 233feedback, 117, 119, 120action research, 349tin communication process, 73–76, 87improving team performance with, 335Festinger, L., 47Fiedler, F.E.Contingency Theory, 188–190, 189f , 191fight-or-flight response, 234, 235–236, 249filter theory (Broadbent), 55Five-Factor Model of Personality, 65e , 206,215–216fixed-interval reinforcement schedule, 139fixed-ratio reinforcement schedule, 139flaming messages, 78Flynn, George J., 210follow-up evaluation, 352

Force Field Analysis model, Lewin’s, 366–369,366fFord, Henry, 6formal groups, 318–320forming stage, of group development, 320framing heuristics, 268French, John, 164Freud, Anna, 60Freud, Sigmund, 60frustration–regression principle, 111Function Role Theory (Benne and Sheats),302–303functional groups, 318future workforce, 29–30GGalatea effect, 63“garbage can” decision-making process,323–324, 324fGAS. See General Adaptation Syndromegenderexpression, 19–21identity, 19–21population, 16t , 19stereotyping, 61, 62e , 66–67stress and, 239General Adaptation Syndrome (GAS), 234–235Generation X, 29, 30

generational diversity, 30globality, 250GLOBE study, 175goal conflicts, 276Goal-Setting Theory, 135–137, 135fGolembiewski, R.T.phases of burnout, 241tgossip, through grapevine, 93grapevine networks, 93, 94fgrievance procedures, use of, 88group dynamics. See also team(s)affiliation, 120attitudes towards change, influence, 364,366cohesiveness, 307–309conformity, 309definition of, 300effect on productivity, 7–8experience of success by group, 308group interaction, 300–301group members roles, 302–304, 305tgroup norms, 304–307, 307tgroup size, 307group status, 308groupthink, 309–311individuals to join in groups, reason for,301–302inter- and intragroup conflicts, 279–281

overview, 299–300social loafing, 307–308outside threats to group, 308–309group(s)decision making, 270–271, 320–321, 321fdemands, 243, 243tdevelopment, 320emotional intelligence, 217feedback, 74formal, 318–320informal, 317–318interaction, 300–301irrational decision-making processes,323–324organizational goals (case study), 318overview, 315performance, 190rational decision-making processes,321–323structure, 317–320and team, 327types of, 315–316groupthink, 309–311and discrimination, 198growth needs, 110–111strength, 117H

Hackman, J.R., 115, 117halo effect, 58–59harassment, sexual, 239hard bargaining, 284Hawthorne Effect, 351Hawthorne Studies, 7–8, 343, 351HCA. See Hospital Corporation of Americahealth care industry/organizationsimplications for, 21–22leadership in, 30–33organizational behavior in, 4–6responsibility toward communities, 98transformation of, 369–370ftransformational leadership for, 209–210health service organizations (HSOs), 4, 61, 363Healthcare Causal Flow Leadership Model, 219Healthcare Equality Index (HEI), 20core four leader criteria, 21tHealthcare Executive CompetenciesAssessment Tool, 219Healthcare Leadership Alliance (HLA), 218healthcare professionals. See employee(s)healthy conflict resolution (case study),292–293HEI. See Healthcare Equality IndexHeider, Fritz, 146Hersey, P.

Situational Leadership Model, 194–196,195fHerzberg, F., 112Two-Factor Theory, 112–115, 116t , 121theuristics/biases approach, 264–266Hierarchy of Needs (Maslow) Theory, 8–9, 103,106–110, 107f , 301case study, 108comparison with other theories, 121tcriticisms of, 110–111employees’ needs, 109, 109fHispanic population, 17HLA. See Healthcare Leadership AllianceHofstede’s Cultural Dimensions, 33, 34–35ehomelessness, 61horizontal communication flow, 87, 89horizontal conflicts, 280horizontal integration, 5horn effect, 58Hospital Corporation of America (HCA), 246hostile aggression, 149hostile attribution style, 147, 148t , 150, 153House’s Path–Goal Leadership Theory,190–193, 192fHRC Foundation. See Human RightsCampaign FoundationHRM. See human resources managementHSOs. See health service organizations

human process interventions, 352human resources management (HRM), 9interventions in organization development,352Human Rights Campaign (HRC) Foundation,20humanistic psychology, 106hygiene factors and dissatisfaction, 112–115IIAT. See Implicit Association TestICE. See index of communicationeffectivenessidentification, as source of power, 165, 167IDSs. See integrated delivery systemsIFD. See Institute for Diversity in HealthcareManagementIHF. See International Hospital Foundationillumination experiments, 7immunization technique, 153implementation, of change, 351–352Implicit Association Test (IAT), 67implicit biases, 14impression management, 58, 63–64improvement initiatives, 369In-Group, 197–198In the Nation’s Compelling Interest: EnsuringDiversity in the Health Care Workforce (IOM),

36inclusion, defined, 14index of communication effectiveness (ICE), 86,86eindividual barriers, to change, 363–364individual coping strategies, 249–252individual distress, 232tindividual feedback, 74individual psychology theory (Adler), 47individual rolesdemands, 243, 243tin groups, 302–303, 304eindividual task demands, 243, 243tindividualism–collectivism, 34eindividualized consideration, 207individual’s behavior, 105. See also contenttheories, of motivationindividual’s socialization process, 51industry environments, 362inequalities, in employee treatment, 131inequity tension, 131influence (power), 118, 119–120, 163–171. Seealso powerinformal communication, 93–94informal groups, 317–318informal leaders, role of, 318informationfor organization development, 350, 351

as political tool, 168richness, 81information technology, 4informational power, 165Ingham, Harry, 75ingratiation/ingratiators, 168, 169initiating structure, in leadership, 207inputs, in Equity Theory, 131inspirational leadership, 207Institute for Diversity in HealthcareManagement (IFD), 30Institute of Medicine, 20, 22, 36, 88institutionalizing change, 352instrumental aggression, 149instrumentality, 128, 165Integra Realty Resources, 233integrated delivery networks, 5integrated delivery systems (IDSs), 281integrative negotiation model, 285–287intellectual leadership, 207intelligence, emotional. See emotionalintelligenceintelligent quotient (IQ), 216Interaction Process Analysis (Bales), 301, 302f, 303tinteractional conflicts, 279interactive negotiation model, 287–288

“Interface of Me and Them” (Burton andDimbleby), 311–312, 312fintergroup conflicts, 280–281internal attributions, 56, 146internal consultants, 347internal esteem, 107internal stressors, 235–236, 236tInternational Hospital Foundation (IHF), 219Internet, 78interorganizational conflicts, 281–282interpersonal conflicts, 279interpersonal demands, 231tinterpersonal relationships, 4stress and, 241, 243interpersonal skills, 347interpretations. See perceptionsinterrole conflict, 278–279interventionsaction research, 349tin OD process, 351–352, 353interviews/interviewing, 350–351program, 7, 8techniques in employee selection, 64intragroup conflicts, 279–280intranets, 78intraorganizational communication, forms of,87–89intraorganizational conflicts, 287

intrapersonal conflict, 278–279intrarole conflict, 278intrinsic rewards, 134intuitive decision making, 264IQ. See intelligent quotientirrational decision-making processes, 323–324JJDS. See Job Diagnostic Surveyjob analysis, 64job autonomy, 237job candidates, interviewing, 59Job Characteristics Model, 115–118, 116fjob demands–decision latitude model(Karasek), 237job design, 248–249Job Diagnostic Survey (JDS), 117–118job dissatisfaction, 8, 131, 133reduction in, 112job enrichment, 115job satisfaction. See motivation; satisfaction,jobjob stressors, 243tjob surveys, 124–125Johari Window, 75–76, 75eThe Joint Commission, 20, 35, 83“Joy in Work” framework, 247–248, 248f , 249tJung Typology Test, 67

KKaiser Family Foundation report, 20, 22Kaiser Permanente Facilities (case study), 329Karasek, Robert, 237Keeping Patients Safe: Transforming the WorkEnvironment of Nurses (IOM report), 88Kelley’s model of attribution theory, 57, 57fKilmann, R.H.two-dimensional taxonomy of conflict-handling modes, 282–284, 283fkinesics, 80kinetic power, 164knowledgemanagement and communication, 85–87,86fas source of power, 165Kotter, John, 168, 368–369Llabor negotiations, 285laissez-faire leadership style, 176, 179, 207language barriers, 35, 95. See also culturalcompetencylateral communication, 89Latham, G.P.Goal-Setting Model, 135–137, 135fLawler, Edward

Satisfaction–Performance Model, 133–135,134fLazarus, S.R.cognitive-transactional theory, 229LCME. See Liaison Committee on MedicalEducationLeader Behavior Description Questionnaire,177Leader–Member Exchange Theory (LMX),196–198, 197eleadersassessment tool for, 38–41ebehaviors, 207and managers, 174tmember relations, 188position power, 188and subordinates, 197types of, 210leadership. See also management; motivationbehavior study, 176–177Blake and Mouton’s Leadership Grid,178–180, 179fcase study, 199–203characteristics, 210charismatic, 207, 211–213commitment to quality, 369contemporary theories, 205–220contingency theories, 180, 187–203

discipline of OB, 4Fiedler’s Contingency Theory, 188–190,189fgovernance and, 36health care, 30–33Hersey and Blanchard’s SituationalLeadership Model, 194–196, 195fHouse’s Path–Goal Leadership Theory,190–193, 192finspirational, 207intellectual, 207Leader-Member Exchange Theory (LMX),196–198, 197emanagement vs., 173–174, 174t , 210Ohio State studies, 177–178, 177fpredictability, 93questionnaires, 182–185servant, 213–214socialized power need and, 119stereotyping of women, 61style, 176, 181style survey, 201–203eTannenbaum and Schmidt’s Continuum ofLeadership Behavior, 193–194, 194ftrait theory, 174–176, 175etransactional, 206, 207transformational, 206, 207–210, 208tUniversity of Michigan studies, 178–180

Leadership Grid, 178–180, 179fLeadership Linking Skills, 334learned helplessness, 148–149, 251, 251elearned optimism, concept of, 250–252Least Preferred Coworker (LPC) Scale, 189legal issues, employee, 54elegitimate power, 164–165lesbian, gay, bisexual, transgender, andquestioning community (LGBTQ), 20Lewin, K., 366–369behavioral study, 176–177change model, 366–368, 366f , 367f ,368–369tLGBTQ. See lesbian, gay, bisexual,transgender, and questioning communityLiaison Committee on Medical Education(LCME), 33, 35line-staff conflicts, 281Linking Skills Wheel, 334, 334flistening, 81. See also communicationskills, 347LMX. See Leader–Member Exchange Theoryloafing, social, 307–308Locke, E.A.Goal-Setting Model, 135–137, 135fLocke, Edwin, 135–137locus of causality dimension, 146locus of control, 251

long-term stress, 235–236LPC Scale. See Least Preferred CoworkerScaleLuft, Joe, 75

MMACRA. See Medicare Access & ChipReauthorization Act of 2015magnetic resonance imaging (MRI) scanner,344maintenance roles, in groups, 302–303, 304,304emanagement. See also leadership; team(s)of attention, 210of diversity, 28–29by exception, 207expectationsGalatea effect, 63Pygmalion effect, 63knowledge and communication, 85–87Leadership Grid (Blake and Mouton),178–180leadership vs., 173–174, 174t , 210line-staff conflicts, 281of meaning, 210mistakes by, 208–209, 208torganizational coping strategies, 246–247psychological closeness, increasing,153–154of self, 210, 216, 217tstakeholders, relationships with, 96–98

stress, 245of trust, 210Managerial Grid. See Leadership Gridmanagerial philosophy, 82managers. See also group dynamics; team(s)achieving organizational goals, 4, 49, 136,193attributions, 57, 153–154avoiding “blame game,” 58beliefs, 9fin change process, 368checklist for, 338–339efor communicating with externalstakeholders, 96, 98and conflict, 275, 281, 288and conflicts, 281contrast-effect bias, 59in decision-making process, 268developing power base, 167–168and employees, 153–154escalation of commitment, 268expectations from, 63health care, 30, 32, 49, 53, 209, 220, 266,300impoverished, 179and job enrichment, 115and leaders, 174tmiddle, 237–238

and moderators, 117participative management, 249tproviding support elements, 136punishment reinforcements, 138recognizing the needs of employee, 109,111and stress, 245Margerison–McCann Team ManagementWheel, 333–334, 334fmasculinity vs. femininity, 34eMaslow’s Hierarchy of Needs Theory, 8–9, 103,106–110, 107f , 301case study, 108comparison with other theories, 121tcriticisms of, 110–111employees’ needs, 109, 109fmasterpiece leaders., 214material appraisals, 230maturity, employee, 195–196Mayo, Elton, 7MBTI. See Myers-Briggs Type IndicatorMcClelland, David, 118Three-Needs Theory, 118–121, 121tMcGregor, Douglas, 8–9, 9fMechanic, David, 165–166Medicare Access & Chip Reauthorization Act of2015 (MACRA), 5

Medicare Prescription Drug, Improvement, andModernization Act of 2003, 5mental abuse, in workplace, 234mental processes, 210mergers, industry, 5messages, 87Michigan studies, 178–180middle management, stress of, 237–238military healthcare environment,transformational leadership in, 209–210Millennials, 29, 30mindful listening, 81minorities. See also cultural competencydiversity management, 29prejudices, 238racial and ethnic, 61stereotyping, 61stress based on, 238–239Modern Healthcare, 163Modernization Act of 2003, 5morale. See leadership; management;motivationmotivating potential score (MPS), 118motivationattribution theory and, 145–158content theories, 105–126, 121t. See alsocontent theories, of motivationdefined, 105

discipline of organizational behavior, 4equity theories of, 48process theories of, 106, 106f , 127–143promoting, 152–154of self, 216, 217tunhealthy, 156Motivation and Personality (Maslow), 103motivational statesaggression, 149–150attributions summary and, 152tdesirable/undesirable, 148–150empowerment, 150–151learned helplessness, 148–149resilience, 151Motivation–Hygiene Theory (Herzberg),112–115, 116tcase study, 115comparison with other theories, 121tprinciples of vertical job loading, 116tMouton, J.S.Leadership Grid, 178–180, 179fMPS. See motivating potential scoreMRI scanner. See magnetic resonanceimaging scannermultiple performance raters, 154Myers-Briggs Type Indicator (MBTI), 65N

NAHSE. See National Association of HealthServices Executivesnaïve psychology, 56, 146National Association of Health ServicesExecutives (NAHSE), 30National Center for Healthcare Leadership(NCHL), 219National Institute for Occupational Safety andHealth (NIOSH), 233National Quality Forum (NQF), 37NCHL. See National Center for HealthcareLeadershipneeds, levels ofAlderfer’s ERG Theory, 110–111Herzberg’s Two-Factor Theory, 112–115Maslow’s Hierarchy of Needs Theory, 8–9,106–110, 301McClelland’s Three-Needs Theory,118–121needs theories. See content theories, ofmotivationnegative conflict, 276negative feedback, 74, 209negative reinforcements, 138negative stressors, 234–235negotiation models, 284–288networks of communication, 89–93, 91f , 92fneuroticism, 65e

“never events,” 164Newsom’s Nine Cs, 129NIOSH. See National Institute forOccupational Safety and Healthnominal group technique, 323nondiscrimination policies, 20nonverbal communication, 80–81normative social influence, 309norming stage, of group development, 320norms, of group, 304–307, 307tNQF. See National Quality ForumThe Nurse Manager’s Guide to anIntergenerational Workforce (Clipper), 29nursing care, transactional leadership and, 209OOB. See organizational behaviorobese patients, 58obligation and power, 167observation method, of data collection, 351OD. See organizational developmentOffice of Minority Health (OMH), 33Ohio State leadership studies, 177–178, 177fOldham, G.R., 115, 117ombudsperson, use of, 89OMH. See Office of Minority Healthone-way communication, 73open-door policies, 88

openness, 65eto experience, 215operant conditioning. See ReinforcementTheoryopioid crisis (case study), 356–357opportunistic management style, 180optimistic attribution style, 147, 148t , 151organizational barriers, 363to effective team building, 337–338, 337torganizational behavior (OB), 105defined, 3development of, 7goals of, 3–4Hawthorne Studies, 7–8health care industry, 4–6history of, 6Theories X and Y, 8–9organizational change, 345steps for, 368–369torganizational coping strategies, 246–247organizational culture, 238organizational demands, 243, 243torganizational development (OD), 9Action Research Model, 348, 348f , 349tappreciative inquiry (AI), 354–355case study, 345, 356–359components of, 345interventions, 351–352, 353

overview, 343–345practitioners, 346–347, 350–351, 353–354steps in process, 348–352organizational politics, 168organizational readiness, for change, 365organizational structure and stress, 243organizational theory (OT), 9Ornelas, J., 214OT. See organizational theoryOut-Group, 197outcomesemployee, 352in Equity Theory, 131strategic communication plan, 87outside threats to groups, 308–309overestimation of group, 310Pparalanguage, 80parallel teams, 330participative decision-making techniques, 88.See also team(s)participative leader, 192, 337paternalistic management style, 180Path–Goal Leadership Theory, 190–193, 192fpatient diversity, 13–23Patient Protection and Affordable Care Act of2010 (ACA). See Affordable Care Act (ACA)

of 2010patient satisfaction, 5, 32peak experiences, 108People Linking Skills, 333perceived control, 237perceived dependence, 167–168perceived equitable rewards, 135perceived inequity, 131perceptions, 55–56of burnout, 241charismatic leadership, 207, 212–213conflict of perspectives, 279of control, 237of dependence as source of power,167–168employee selection, 64–65management of, 63–64processing system, 55fof similarity, 198social, 58–63stress and, 230perceptual defense, 55perceptual vigilance, 55performancecoaching, 213conflict and, 276evaluating worker’s, 59group, 190

multiple raters of, 154Satisfaction–Performance Theory,133–135, 134fof team, building, 331–335, 332fperformance-management systems, 353performance-oriented tasks, 335performing stage, of group development, 320permanent groups, 320Perry, D., 19person-role conflicts, 278personal barriers, to communication, 84–85personal growth, 110, 112, 117personal resource appraisals, 230personalities, 64, 65e , 67. See also attitudes;trait theory of leadershipstress and, 236–238personalized power, 119, 167perspectives, conflict of, 279pessimism vs. optimism, 251pessimistic attribute style, 147, 148t , 151physical abuse, in workplace, 234physical demands, 231tphysician–patient relationships, 5physiological consequences, of stress, 232tphysiological illnesses, 235physiological needs, 106–110Pink, Daniel, 113planned/unplanned changes, 361

planning change in organization development,351–352political behaviors, 168political decision making, 323–324poor performance, 63poor-structured problem, 261population, aging of, 16t , 18–19Porter, LymanSatisfaction–Performance Model, 133–135,134fpositive conflict, 276positive feedback, 74positive reinforcements, 137–138positive stressors, 234–235positivity, 336–337potential power, 164powerbases of, 167–168case study, 170–171coalitions, 166, 168defined, 164employee gains of, 165–166group, overestimation of, 310and influence, 163–171, 223organizational politics, 168potential and kinetic, 164sources of, 164–165and status relationships, 83

status within groups, 308upward influence, 169–170uses of, 167power distance, 34emotivational need, 118, 119–120“power pose,” 170practitioners, OD, 346–347, 350–351, 353praise, as political tool, 168predicting employee behavior. See processtheories, of motivationprejudices, 84, 238prescriptive feedback, 74presenteeism, 241–242preventive coping strategies, 245, 246, 249,252–253primary groups, 316The Principles of Scientific Management(Taylor), 6proactive coping strategies, 246, 249, 252–253problem solving, 108, 287–288, 369problems, types of, 261procedural conflicts, 276procedural feedback, 74process conflicts, 280process improvement, 353process theories, of motivation, 106case study, 140–143Equity Theory, 130–133, 132f

Expectancy Theory, 127–130, 128f , 130fGoal-Setting Theory, 135–137, 135fReinforcement Theory, 137–139, 137fSatisfaction–Performance Theory,133–135, 134fproduction-centered leaders, 178professionals, organization development,346–347project teams, 330projection, 60promotions, 62e , 64. See also recruitmentproviders. See employee(s)proxemics, 80PSC. See patient safety committeepsychological anxiety, 55psychological closeness, increasing, 153–154psychological consequences, of stress, 232tpsychological contract, 365psychological illnesses, 235psychological safety, 321psychometrics, 64punishment, 164reinforcements, 138Pygmalion effect, 58, 62–63Qquestionnaires, 350

Rrace/ethnicityconflicts and stress based on, 281population, 16t , 17–18stereotyping, 61stress based on, 238–239range of individual member satisfactionwithin communication network, 93rational decision-making processes, 262, 263f ,321–323brainstorming, 322–323Delphi technique, 323nominal group technique, 323rationality tactic, as political tool, 169Raven, Bertram, 164reactive coping strategies, 245, 246, 249, 253readinessfor change, 365realism, 108recognition, improving team performance with,335recruitment, 64–65, 65ereference groups, 316referent power, 165reflection, 337refreezing stage (implementing change), 367f ,368, 369treimbursement, 5

Reinforcement Theory, 137–139, 137frelatedness needs, 110–111relational feedback, 74relationship behavior, 177, 194–195relationship conflict, 279relaxation response to stress, 249, 250erelay-assembly group experiments, 7reporter–advisor role, 333representation error, 267representativeness bias technique, 264–265reputation, 167resilience, 151screening for, 152resistance phase, 234resistance to change, 363–365resource appraisals. See demand appraisalsresources, for employees, 136restraining forces, 366, 367treward power, 164rewards, 48, 113, 129, 134–137, 138, 207, 335.See also motivation; performance;satisfaction, jobrisk-taking, 119Robert Wood Johnson Foundation (RWJF), 30,37, 219Roethlisberger, Frederick, 7X model, 364, 364frole conflict, 243, 278

role demands, 231trole-making stage, 197role-taking stage, 197routinization stage, 197RWJF. See Robert Wood JohnsonFoundationSS-M-C-R model of communication process,72–73, 72fsafe environment, in groups, 321safety needs, 106–107sanctions. See punishmentsatisfaction, job, 112e. See also motivationburnout, 240–241leadership styles, based on, 176–177perceived control and, 237transformational leadership and, 209Satisfaction–Performance Theory, 133–135,134fschedules, reinforcement, 138–139Scheff, Thomas, 165Schmidt, W.Continuum of Leadership Behavior,193–194, 194fscientific management theory, 343Scott’s dilemma (case study), 47–48, 171, 255screening, for resilience, 152

secondary groups, 316security needs, 106Selection-for-Action View (Broadbent), 55selective perception, 55, 84, 85self-actualization, 107–108self-awareness, 216, 217–218tself-centered roles group, 302–303self-esteem, 60, 107self-fulfilling prophecy. See Pygmalion effectself-management, 216, 217tself-managing work teams, 330self-motivation, 216, 217tself-reflection, 223self-serving bias, 56Seligman, Martin, 250Selye, Hans, 234semistable teams, 332Senge, Peter, 213senior management, 252, 317. See alsoleadership; managementseparation, action research, 349tservant leadership, 213–214sex discrimination, 239sexual harassment, 239sexual orientation, 19–21Shafir, Rebecca, 81Sheats, P.Functional Roles Theory, 302–303, 304e

short-term stress, 235–236short-term wins, 369tshotguns, 169Sinek, Simon, 205situational favorableness, 189Situational Leadership Model (Hersey andBlanchard), 194–196, 195fSix Sigma program, 346, 347size of groups, 307, 315skill variety, 117Skinner’s Reinforcement Theory, 137–139,137fsocial awareness, 216, 217tsocial loafing, 307–308social perception, 58–63contrast effects, 59–60halo effect, 58–59projection, 60Pygmalion effect, 62–63stereotyping, 60–62social relationships. See Equity Theorysocial skills, 216, 218tsocial structure, 165socialization and attitudes, 51socialized power, 119, 167sociogram, 301, 301fsolitude, 108source of information, evaluating, 84

The Spirit Catches You and You Fall Down(Fadiman), 22spontaneity, 108stability, 250dimension, 146emotional, 215perception and, 56stable teams, 328, 332staff. See employee(s)stakeholder(s)analysis, 97ecommunications with, 96–98status quo, 84stereotyping, 58, 60–62, 62estimuli, 55storming stage, of group development, 320strategic communication, 87strategic goals, 32strategic interventions, in organizationdevelopment, 352stresscoping with, 245–247defined, 229individual coping strategies, 249–252“Joy in Work” framework, 247–249learned optimism, concept of, 250–252management programs, 245, 252–253organizational coping strategies, 246–247

overview, 229–233process model for, 230fin today’s workplace (case study), 244work-related. See work-related stressstressors, 234–236structural change, 353subordinate contingency factors, 192–193subordinates. See employee(s)success. See also achievementenabling, 153external barriers to, 148group dynamics, 308group potency for, 321superleadership, 211support, for employees, 136–138supportive leaders, 192surgical safety checklist, 306esustainability, 210symbolic leader, 211

TTABP. See Type A behavior patternstactical reinforcement, 87tacticians, 169Tannenbaum, R.Continuum of Leadership Behavior,193–194, 194ftask behavior, 194task conflict, 279–280task demands, 231ttask feedback, 74task groups, 318, 320task identity, 117task interdependence groups, 321Task Linking Skills, 334task manager, 179task-oriented roles, in groups, 302–303, 304,304etask significance, 117task structure, 188Taylor, Frederick, 6, 343Taylorism, 6Team Management Wheel, 333–334, 334fteam(s)approaches for building performance,331–335, 332f

barriers to effective teamwork, 337–338,337tbuilding, 353characteristics of successful, 335–337checklist for managers, 338–339edefined, 328and group, 327overview, 327performance curve, 332, 332fTeam Role Theory (Belbin), 304and teaming, 328–330types of, 330virtual and conventional types of teams,331“teaming,” 328–330TeamSTEPPS program, 329technical skills, 210, 346technostructural interventions, in organizationdevelopment, 352termination of employees, 54e. See alsopunishmentTheories X and Y, 8–9third-party facilitators, 287Thomas, K.W.two-dimensional taxonomy of conflict-handling modes, 282–284, 283fThree-Needs Theory (McClelland), 118–121case study, 120–121

comparison with other theories, 121tthruster–organizer role, 333Thyler, G., 209time, as barrier, 81tolerance for ambiguity, 268Total Quality Management, 346, 353trainingattributional, 153in diversity, 61OD intervention, 353trait theory of leadership, 174–176, 175etransactional leadership, 206, 207transformational leadership, 206, 207–208charismatic leadership, 207, 211–213contradictory view of, 208–209, 208timplications for health care industry,209–210inspirational leadership, 207intellectual leadership, 207and servant leadership, 213–214trust, 223turnover, and absenteeism, 133Two-Factor Theory (Herzberg), 112–115case study, 115comparison with other theories, 121tprinciples of vertical job loading, 116ttwo-way communication, 73Type A behavior patterns (TABP), 236

Type A personality, 236, 250Type B personality, 236Uuncertaintyavoidance, 34ediscomfort with, 364–365unconscious biases, 14unconstructive conflict, 276undesirable motivational states, 148–150unequal treatment, 22eunfreeze stage (implementing change),367–368, 367f , 368tuniformity, pressures toward, 310uninsured population, 5University of Michigan leadership studies,178–180unobtrusive method, of data collection, 351upholder–maintainer role, 333upward appeal, 169upward communication flow, 87, 88–89upward influence, 169–170urgency, establishing, 332, 368tU.S. Department of Health and HumanServices, 33U.S. populationchanging demographic profile of, 16–21demographics of, 16–21, 16t

U.S. workforce, 29Vvalence, 128value-based purchasing (VBP) initiative, 164value orientation, 268variable-interval reinforcement schedule, 139variable-ratio reinforcement schedule, 139VBP initiative. See value-based purchasinginitiativeVDL. See Vertical Dyad Linkageverbal abuse, in workplace, 234verbal communication, 76–80. See alsocommunicationvertical conflicts, 280Vertical Dyad Linkage (VDL), 196–197vertical integration, 5vertical job loading, Herzberg’s principles of,115, 116tVIE Theory. See Vroom’s Expectancy Theoryviolence, in workplace, 233–234. See alsostressVirtual Integrated Practice program, 331virtual integration, 5virtual teams, 331visioncommunication, 368tdeveloping, 368t

voice intonation, 95Vroom-Yetton decision-making model,269–271, 270fVroom’s Expectancy Theory (VIE), 127–130,128fapplication using Newsom’s nine Cs, 129,130fcase study, 131WW. K. Kellogg Foundation, 36well-structured problem, 261Wheatley, Margaret, 213wheel pattern centralized communicationnetwork, 91–92, 92fWhite population, 17work redesign, 353work-related stressbeliefs about stress, 239burnout, 240–241causes of, 243–244gender and, 239individuals and, 236personalities and, 236–238presenteeism, 241–242stressors, 234–236, 236tunderrepresented populations, 238–239violence in workplace, 233–234

work teams, 330and team building, 327–338worker’s performance, evaluating, 59workforce. See also employee(s)CLAS, 36future, 29–30workplacechanging attitudes in, 53–54ecommunication. See communicationexternal barriers to success in, 148informal and formal groups in, 317–320stereotypes in, 62estress. See stresssurveys, 49, 50eteams in, 327violence, 233–234workshops, for employees, 54ewritten communication, 77. See alsocommunicationXX model for change (Roethlisberger), 364, 364fX-theory management, 8–9YY-pattern centralized communication network,89, 90, 91f , 92f

Y-theory management, 8–9Yerkes-Dodson curve, 235fZzero-sum approach, 284

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