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 are the five conflict modes? What is the basis/cause of the conflict in the case described? What conflict style/handling-mode should be used 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: Be 4-6 pages in length. Formatted according to Saudi Electronic University and APA writing guidelines, and Provide support for your statements with in-text citations from a minimum of three scholarly articles from peer-reviewed journal articles. THIRD EDITION Organizational Behavior in HEALTH CARE Nancy Borkowski, DBA, CPA, FACHE, FHFMA Professor, Department of Health Services Administration School of Health Professions University of Alabama at Birmingham Birmingham, AL World Headquarters Jones & Bartlett Learning 5 Wall Street Burlington, MA 01803 978-443-5000 info@jblearning.com www.jblearning.com Jones & Bartlett Learning books and products are available through most bookstores and online booksellers. To contact Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jblearning.com. Substantial discounts on bulk quantities of Jones & Bartlett Learning publications are available to corporations, professional associations, and other qualified organizations. For details and specific discount information, contact the special sales department at Jones & Bartlett Learning via the above contact information or send an email to specialsales@jblearning.com. Copyright © 2016 by Jones & Bartlett Learning, LLC, an Ascend Learning Company All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission from the copyright owner. The content, statements, views, and opinions herein are the sole expression of the respective authors and not that of Jones & Bartlett Learning, LLC. Reference herein to any specific commercial product, process, or service by trade name, trademark, manufacturer, or otherwise does not constitute or imply its endorsement or recommendation by Jones & Bartlett Learning, LLC and such reference shall not be used for advertising or product endorsement purposes. All trademarks displayed are the trademarks of the parties noted herein. Organizational Behavior in Health Care, Third Edition is an independent publication and has not been authorized, sponsored, or otherwise approved by the owners of the trademarks or service marks referenced in this product. There may be images in this book that feature models; these models do not necessarily endorse, represent, or participate in the activities represented in the images. Any screenshots in this product are for educational and instructive purposes only. Any individuals and scenarios featured in the case studies throughout this product may be real or fictitious, but are used for instructional purposes only. This publication is designed to provide accurate and authoritative information in regard to the Subject Matter covered. It is sold with the understanding that the publisher is not engaged in rendering legal, accounting, or other professional service. If legal advice or other expert assistance is required, the service of a competent professional person should be sought. 08706-2 Production Credits VP, Executive Publisher: David Cella Publisher: Michael Brown Associate Editor: Nicholas Alakel Associate Production Editor: Rebekah Linga Senior Marketing Manager: Sophie Fleck Teague Manufacturing and Inventory Control Supervisor: Amy Bacus Composition: Cenveo Publisher Services Cover Design: Scott Moden Rights & Media Research Coordinator: Mary Flatley Cover Image: © NadyaJema/Shutterstock, Inc. Printing and Binding: Edwards Brothers Malloy Cover Printing: Edwards Brothers Malloy Library of Congress Cataloging-in-Publication Data Borkowski, Nancy, author. Organizational behavior in health care / Nancy Borkowski. — Third. p. ; cm. Includes bibliographical references and index. ISBN 978-1-284-05104-9 (paper) I. Title. [DNLM: 1. Health Services Administration. 2. Group Processes. 3. Health Personnel—psychology. 4. Organizational Culture. 5. Personnel Management. W 84.1] RA971.35 362.11068’3—dc23 2015003497 6048 Printed in the United States of America 19 18 17 16 15 10 9 8 7 6 5 4 3 2 1 To my husband Contents Preface Contributors About the Author PART I—INTRODUCTION Chapter 1 Overview and History of Organizational Behavior Chapter 2 Diversity and Cultural Competency in Health Care Chapter 3 Attitudes and Perceptions Chapter 4 Workplace Communication PART II—UNDERSTANDING INDIVIDUAL BEHAVIORS Chapter 5 Content Theories of Motivation Chapter 6 Process Theories of Motivation Chapter 7 Attribution Theory and Motivation PART III—LEADERSHIP Chapter 8 Power, Politics, and Influence Chapter 9 Trait and Behavioral Theories of Leadership Chapter 10 Contingency Theories and Situational Models of Leadership Chapter 11 Contemporary Leadership Theories PART IV—INTRAPERSONAL AND INTERPERSONAL ISSUES Chapter 12 Stress in the Workplace and Stress Management Chapter 13 Decison Making Chapter 14 Conflict Management and Negotiation Skills PART V—GROUPS AND TEAMS Chapter 15 Overview of Group Dynamics Chapter 16 Groups Chapter 17 Work Teams and Team Building PART VI—MANAGING ORGANIZATIONAL CHANGE Chapter 18 Organization Development Chapter 19 Managing Resistance to Change Index Preface In 2005 with the first edition of this book, I wrote, “the U.S. health care industry has grown and changed dramatically over the past twenty-five years.” That was an understatement! Since the passing of the Patient Protection and Affordable Care Act of 2010, the industry has experienced some of the most dynamic changes health care managers have seen. In the coming years, more system-wide changes will occur as we continue our push forward to achieve value-based health care. Health care managers are quickly learning that what worked in the past may not work in the future. As such, I was compelled to write an organizational behavior book specifically for health care managers who are on the front lines every day, motivating and leading others in a constantly changing, complex environment. This is not an easy task, as I know firsthand! The purpose of this book is to provide health care managers and other professionals with an in-depth analysis of the theories and concepts of organizational behavior while embracing the uniqueness and complexity of the industry. Although health care is similar to other industries, it is also very different. As the nation’s largest industry, it employs more than 15 million people in numerous interrelated and interdependent segments. Using an applied focus, this book provides a clear and concise overview of the essential topics in organizational behavior from the health care manager’s perspective. It is my goal that this book will give you a greater understanding of why and how people and groups behave the way they do in the workplace. With this knowledge, you will be able to predict and thus effectively influence the behavior of those you lead. Please let me know if I accomplish my goal! You can reach me at nborkows@uab.edu. In addition, I tried to ensure that I referenced all the individuals whose work contributed to the development of this book. However, if by chance I failed to give credit to someone along the way, please contact me so I may make the necessary correction. At this time I wish to acknowledge individuals without whose efforts and support I would not have been able to complete this book. First, I wish to thank my colleagues and third edition contributors, Jean Gordon, Paul Harvey, Mark Martinko, and Jeff Ritter. Second, I thank my wonderful family for their patience, understanding, and support over the years. Finally, I wish to thank the many wonderful and caring people employed throughout the health care industry that I have had and will have the opportunity to work with. My life continues to be blessed by these dedicated individuals! Thank you for purchasing (and reading) my book. I welcome your comments and suggestions. With personal regards, Nancy M. Borkowski, DBA, CPA, FACHE, FHFMA Contributors Jean Gordon, RN, MBA, MSN, DBA Visiting Professor Florida International University Miami, Florida Paul Harvey, PhD Associate Professor of Management Peter T. Paul College of Business and Economics University of New Hampshire Durham, New Hampshire Mark Martinko, PhD UQ Business School University of Queensland Brisbane, Australia Jeffrey Ritter, DBA Assistant Professor Barry University Health Management Programs College of Nursing and Health Sciences Miami Shores, Florida About the Author Nancy M. Borkowski, DBA, CPA, FACHE, FHFMA, is Professor in the Department of Health Services Administration at the University of Alabama at Birmingham. She received her DBA with specializations in health services administration and accounting from Nova Southeastern University. Dr. Borkowski has over 20 years’ experience in the health care industry and is a two-time past recipient of the American College of Healthcare Executives’ (ACHE) Southern Florida Senior Career Healthcare Executive Award, which recognizes individuals who have made significant contributions to the advancement of health management excellence. A nationally recognized author, Dr. Borkowski is also a certified public accountant, board certified in health management, and a Fellow of both the American College of Healthcare Executives and the Healthcare Financial Management Association. The first edition of her book Organizational Behavior in Health Care, referred to as “one of the most significant advances in the field of health services administration,” was honored with the American Journal of Nursing’s 2005 Book of the Year Award for nursing leadership and management. Dr. Borkowski is the author of three textbooks that are widely used in graduate and undergraduate health administration and nursing programs both nationally and internationally. Dr. Borkowski’s work has been published in the Journal of Ambulatory Care Management, Leadership in Health Services, Group & Organization Management, Organizational Behavior and Human Decision Processes, Health Care Management Review, Journal of Health Administration Education, Journal of Health and Human Services Administration, International Journal of Public Administration, and various other journals. Her teaching interests are leadership, organizational behavior, and strategic management. Dr. Borkowski is a past recipient of the ACHE’s Excellence in Teaching Award, which is given to faculty who engage in furthering academic excellence and management students. the professional development of health Over the past decade, Dr. Borkowski has served in various leadership roles for the Academy of Management’s Health Care Management Division, the American College of Healthcare Executives’ Southern Florida Regent’s Advisory Council, the South Florida Healthcare Executive Forum, and various other health-related organizations. In 2013, Dr. Borkowski received the Jessie Trice Hero Award for her leadership and commitment to improving the lives of underserved and minority populations. She has also been honored with the Exemplary Service Award from the American College of Healthcare Executives (2012) and the Reeves Silver Merit Award from the Healthcare Financial Management Association (2014). PART I Introduction Part I includes four different but related topics. In Chapter 1, the history of organizational behavior and its importance to today’s health care managers are discussed. Chapter 2 describes the changing environment in which health care managers find themselves. The chapter examines the numerous issues that have emerged within the health care industry because of the nation’s changing demographics. Chapter 3 deals with attitudes and perceptions, which are the “backbone” to understanding organizational behavior. You will find the terms “attitude” and “perception” frequently referred to within the various organizational behavior theories. Finally, Chapter 4 discusses the importance of communications. Recent surveys revealed that 70 percent of small to mid-size businesses claim that ineffective communication is their primary problem. Sentinel event data from The Joint Commission estimates that communication failure was the root cause of patient harm 70 percent of the time in 2,400 reported negative outcomes studied. No wonder the ability to communicate effectively is considered an essential job skill for today’s health care managers and leaders. CHAPTER 1 Overview and History of Organizational Behavior LEARNING OUTCOMES After completing this chapter, the student should understand: The definition of organizational behavior. The major challenges facing today’s and tomorrow’s health care organizations and health care managers. The importance of the Hawthorne Studies to the study of organizational behavior. The importance of McGregor’s Theory X and Theory Y to the study of organizational behavior. The difference between organizational behavior, organization theory, organizational development, and human resources management. OVERVIEW Organizational behavior (OB) is an applied behavioral science that emerged from the disciplines of psychology, sociology, anthropology, political science, and economics. OB is the study of individual and group dynamics within an organization setting. Whenever people work together, numerous and complex factors interact. The discipline of OB attempts to understand these interactions so that managers can predict behavioral responses and, as a result, manage the resulting outcomes. According to Ott (1996, p. 1), OB asks the following questions: 1. Why do people behave the way they do when they are in organizations? 2. Under what circumstances will people’s behavior in organizations change? 3. What impacts do organizations have on the behavior of individuals, formal groups (such as departments), and informal groups (such as people from several departments who meet regularly in the company’s lunchroom)? 4. Why do different groups in the same organization develop different behavior norms? From Ott. Classic Readings in Organizational Behavior, 2E. © 1996 South-Western, a part of Cengage Learning, Inc. Reproduced by permission. There are three goals of OB. First, OB attempts to explain why individuals and groups behave the way they do within the organizational setting. Second, OB tries to predict how individuals and groups will behave on the basis of internal and external factors. Third, OB provides managers with tools to assist in the management of individuals’ and groups’ behaviors so they willingly put forth their best effort to accomplish organizational goals. In the health care industry, OB has become more important because people with diverse backgrounds and cultural values have to work together effectively and efficiently. WHY STUDY ORGANIZATIONAL BEHAVIOR IN HEALTH CARE? The largest U.S. industry is health care, which currently employs over 18 million individuals. The industry will account for almost a third of the nation’s projected job growth through 2022, adding almost 5 million jobs. The projected 2.6 percent-per-year growth rate is the fastest among all major service producing sectors (Bureau of Labor Statistics, 2013). Each segment of the health care industry (e.g., hospitals, home health, rehabilitation facilities) employs a different mix of health-related occupations, ranging from highly skilled licensed professionals, such as physicians and nurses, to those with on-the-job training. Furthermore, each segment of the industry has various economic structures (e.g., for-profit, not-for-profit, governmental). As such, today’s health care managers need to possess the skills to communicate effectively with, motivate, and lead diverse groups of people within a large, dynamic, and complex industry. Communication, motivation, and leadership are all concepts within the discipline of OB. Furthermore, managers need to understand the causes of workplace problems, such as low performance, turnover, conflict, and stress, so that they may be proactive and minimize these unnecessary negative outcomes. With a greater understanding of OB, managers are better able to predict and, thus, influence the behavior of employees to achieve organizational goals. Given the service-related intensity of the industry, the understanding of individuals’ behavior and group dynamics within health service organizations is critical to a health care manager’s success. Research indicates that the primary reasons managers fail stem from difficulty in handling change, not being able to work well in teams, and poor interpersonal relations. There is a saying that employees don’t leave organizations, they leave managers! THE HEALTH CARE INDUSTRY Changes within the health care industry over the past 30 years have been powerful, far-reaching, and continuous. Since readers are probably familiar with most of these changes from either their own experiences or from a previous health care delivery system course, the discussion will address some of the trends or future concerns that will impact tomorrow’s health care industry. Past changes and future trends are interrelating forces that have or will shape tomorrow’s health care organizations, whether they occur at the system level or the organizational level. Declining reimbursement and changes in payment schemes for services has had, and will continue to have, two of the deepest impacts on the industry. Technology has also caused significant changes within the industry. Biomedical and genetic research, along with advances in information technology and use of “big data,” are producing rapid changes in clinical treatments. In addition, the industry has experienced more government mandates, such as the Health Insurance Portability and Accountability Act of 1996; the Medicare Prescription Drug, Improvement, and Modernization Act of 2003; the American Recovery and Reinvestment Act of 2009; and most recently, the Patient Protection and Affordable Care Act of 2010 (ACA). With an increased focus on chronic disease management, patients are living longer and are requiring more long-term and home health care services now and in the future. Patients’ and health care workers’ characteristics are also changing. Both populations are becoming older and more diverse. Patients are better informed and, as such, have increasingly higher expectations of health care professionals. This trend has changed the way health care services are delivered, with a focus on patient satisfaction and safety, as well as on quality of services. Physician–patient relationships have changed because patients are beginning to understand that much of the responsibility for wellness lies with them. The economics of health care is in a state of flux. For example, reimbursements are moving toward value-based payments; therefore, we see an increase in the use of evidence-based medicine. There are continuing shortages of staff, especially in the areas of primary care physicians, nurses, imaging technicians, and pharmacists, leading to competition for wellqualified people. There are changes taking place in the disease environment. Many factors of modern life are contributing to the emergence of new diseases, reemergence of old ones, and evolution of pathogens immune to many of today’s medications. In addition, because of potential terrorism attacks, health care providers are concerned with biodisaster preparedness. Finally, even with some states’ Medicaid expansion programs and the ACA, there continues to be the issue of caring for the uninsured that contributes to the overuse and misuse of hospital emergency departments. To deal with these changes, we have seen a number of health care organizations restructure themselves into integrated delivery networks, which may be part of a local, regional, or national system. We have seen increased vertical, horizontal, and virtual integration. Vertical integration focuses on the development of a continuum of care services to meet the patient’s full range of health care needs. This integration model, in which a single entity owns and operates all the segments providing care, may include preventive services, specialized and primary ambulatory care, acute care, subacute care, long-term care, and home health care, as well as a health plan. Recently, we have seen the creation of accountable care organizations (ACOs), in which groups of doctors, hospitals, and other health care providers have joined together to provide coordinated care to predetermined patient populations. Horizontal integration usually occurs through mergers, acquisitions, and/or consolidation within one segment of the industry. For example, during the 1990s there were numerous hospital acquisitions by the large, for-profit, publicly held hospital chains of Hospital Corporation of America (HCA), Tenet Healthcare, and Health Management Associates (now part of Community Health Systems)—and these acquisitions continue today. In addition, not-for-profit hospitals have merged with for-profit health systems as a result of competition and the need to reduce cost by economies of scale. Virtual integration, which emphasizes coordination of health care services through patientmanagement agreements, provider incentives, and/or information systems, has increased. This virtual integration has evolved to meet the need for better technology and information infrastructures that allow for information sharing, patient care management, and cost control. Because of the dramatic changes and the future trends in the health care industry, most managers have been required to change the way they and other employees carry out their job responsibilities. These changes have been forced upon the industry by the need to increase productivity due to decreasing reimbursement and increasing competition. At the same time, health care providers must deliver patient-centered, value-based care. These are not easy tasks. As a result, many health care providers are breaking down their traditional hierarchical structures and moving toward multidisciplinary team-managed environments. Employees are finding themselves in new roles with new responsibilities. All of these changes cause disruptions in the workplace. The study of OB will assist health care managers to minimize the negative effects (such as stress and conflict) related to this “new” environment and maximize their ability to motivate staff and lead their organizations effectively. HISTORY OF ORGANIZATIONAL BEHAVIOR The beginnings of OB can be found within the human relations/behavioral management movement, which emerged during the 1920s as a response to the traditional or classic management approach. Beginning in the late 1700s, the Industrial Revolution was the driving force for the development of large factories employing many workers. Managers at that time were concerned “about how to design and manage work in order to increase productivity and help organizations attain maximum efficiency” (Daft, 2004, p. 24). This traditional approach included Frederick Taylor’s (1911) wellknown framework of scientific management, or “Taylorism,” as it is now labeled. Taylor believed that efficiency was achieved by creating jobs that economized time, human energy, and other productive resources. Through his time-and-motion studies, Taylor scientifically divided manufacturing processes into small, efficient units of work. Through Taylor’s work, productivity greatly increased. For example, Henry Ford developed his assembly line according to the principles of Taylorism and was able to churn out Model Ts at a remarkable and economical pace (Benjamin, 2003). Although the classic approach to management focused on efficiency within organizations, Taylor did attempt to address a human relations aspect in the workplace. In his book The Principles of Scientific 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 manager must give some special incentive to his men beyond that which is given to the average of the trade. This incentive can be given in several different ways, as, for example, the hope of rapid promotion or advancement; higher wages, either in the form of generous piecework prices or of a premium or bonus of some kind for good and rapid work; shorter hours of labor; better surroundings and working conditions than are ordinarily given, etc., and, above all, this special incentive should be accompanied by that personal consideration for, and friendly contact with, his workmen which comes only from a genuine and kindly interest in the welfare of those under him. It is only by giving a special inducement or incentive of this kind that the employer can hope even approximately to get the initiative of his workmen. Although Taylor discussed a concern for workers within the scientific management approach, the human relations or behavioral movement of management did not begin until after the landmark Hawthorne Studies. THE HAWTHORNE STUDIES Elton Mayo, Frederick Roethlisberger, and their colleagues from Harvard Business School conducted a number of experiments from 1924 to 1933 at the Hawthorne Plant of the Western Electric Company in Cicero, Illinois. The Hawthorne Studies were significant to the development of OB because the researchers demonstrated the important influence of human factors on worker productivity. It was through these experiments that the Hawthorne Effect was identified. The Hawthorne Effect is the bias that occurs when people know that they are being studied. Roethlisberger and Dickson (1939) in their book Management and the Worker and Homans (1950) in his book The Human Group provided a comprehensive account of the Hawthorne Studies. There were four phases to the Hawthorne Studies: the illumination experiments, the relay-assembly group experiments, the interviewing program, and the bank-wiring observation-room group studies. The intent of these studies was to determine the effect of working conditions on productivity. The illumination experiments were conducted to determine whether increasing or decreasing lighting would lead to changes in productivity. The researchers were surprised to learn that productivity increased by both the control group (no change in lighting) and the experimental group (lighting alternated upward and downward). The researchers determined that it was not the lighting that caused the increased productivity; rather, it resulted from the attention received by the group. In the relay-assembly group experiments, productivity of a segregated group of workers was studied as they were subjected to different working conditions. The researchers and management observed the group closely for five years. During the first part of the experiment, the working conditions of employees were improved by extending their rest periods, decreasing the length of their workday, and providing them a “free” day and lunches. In addition, the workers were consulted before any changes were made, because their agreement had to be obtained before the change would be implemented. The workers of the group were given the freedom to interact with one another during the workday. Furthermore, one researcher also served as their supervisor who, during the experiment, expressed concern about their physical health and well-being. The researchers eagerly sought the employees’ opinions, hopes, and fears during the experiment. During the improved-conditions period, the workers’ productivity increased. In part two of the experiment, the original working conditions were restored. Surprisingly, the researchers found that the employees’ productivity remained at the previous high level (when they had the improved working conditions). This result was attributed to group dynamics because the group was allowed to develop socially with a common purpose. The bank-wiring observation-room experiment was similar to the relayassembly experiment. A group of workers were segregated so their productivity and group dynamics could be studied. The workers were paid with a piecework rate that reflected both group and individual efforts. The researchers found that the wage incentive did not work. The group had developed its own standard as to what constituted a “proper day’s work.” As such, the group’s level of productivity remained constant because they did not want management to know that they could produce at a higher level. If a member of the group produced more than the agreed-upon level, the other members influenced the “rate buster” to return his productivity level to the group’s norm. In addition, if a member of the group failed to produce the required level of output, the other members traded jobs to ensure that the group’s output level remained constant. The results of the bank-wiring experiment mirrored the relay-assembly experiment results. The researchers concluded that there was no cause-and-effect relationship between working conditions and productivity and that any increase or decrease in productivity was attributed to group dynamics. As a result of the bank-wiring experiment, researchers became very interested in exploring informal employee groups and the social functions that occur within the group and that influence the behavior of the individual group members. As part of the Hawthorne Studies, the researchers conducted extensive interviews with the employees. Over 21,000 interviews were conducted to determine the employees’ attitudes toward the company and their jobs. A major outcome of these interviews was that the researchers discovered that workers were not isolated, unrelated individuals; they were social beings and their attitudes toward change in the workplace were based upon (1) the personal social conditioning (values, hopes, fears, expectations, etc.) they brought to the workplace, formed from their previous family or group associations, and (2) the human satisfaction the employees derived from their social participation with coworkers and supervisors. What the researchers learned was that an employee’s expression of dissatisfaction may be a symptom of an underlying problem in the workplace, at home, or in the person’s past. THEORIES X AND Y Another significant impact in the development of OB came from Douglas McGregor (1957, 1960) when he proposed two theories by which managers view their employees: Theory X (negative/pessimistic) and Theory Y (positive/optimistic). Theories X and Y reflect polar positions and are ways of seeing and thinking about people, which, in turn, affect their behavior. Theory X states that employees are unintelligent and lazy. They dislike work, avoiding it whenever possible. In addition, employees should be closely controlled because they have little desire for responsibility, have little aptitude for creativity in solving organizational problems, and will resist change. In contrast, Theory Y states that employees are creative and competent; they want meaningful work; they want to contribute; and they want to participate in decision-making and leadership functions. Borrowing from Maslow’s Hierarchy of Needs, McGregor stated that the autocratic or Theory X managers were no longer effective in the workplace because they relied on an employee’s lower needs for motivation (physiological concerns and safety), but in modern society those needs were mostly satisfied and thus no longer acted as a motivator for the employee. For example, managers would ask, “Why aren’t people more productive? We pay good wages, provide good working conditions, have excellent fringe benefits, and provide steady employment. Yet people do not seem to be willing to put forth more than minimum efforts.” The answers to these questions were embedded in Theory X’s managerial assumptions of people. If managers believed that their employees had an inherent dislike for work and must be coerced, controlled, and directed to achieve organizational goals, the resulting behavior was nothing more than self-fulfilling prophesies. The manager’s assumptions caused the staff’s “unmotivated” behavior. However, at the opposite end of the spectrum from Theory X, McGregor proposed Theory Y, where managers created opportunities, removed obstacles, and encouraged growth and learning for their employees. McGregor stated that participative or Theory Y managers supported decentralization and delegation of decision making, job enlargement, and participative management because they allowed employees degrees of freedom to direct their own activities and to assume responsibility, thereby satisfying their higher-level needs (see Figure 1–1). Figure 1–1 McGregor X-Y Theory Diagram SUMMARY Since 1960, a wealth of information has emerged within the study of OB, which will be addressed in this textbook. In Part I, the issues of diversity, perceptions, attitudes, and communication are discussed. Part II addresses motivation and individual behaviors. Part III examines the subject of leadership from four approaches—power and influence, behavioral, contingency, and transformational. Part IV emphasizes the importance of intrapersonal and interpersonal issues within the context of stress and conflict management. Part V examines group dynamics, working in groups, and teams and teambuilding. Part VI provides an overview of managing organizational change within the context of organizational development. Before we conclude this chapter, I would like to explain the differences between OB and three other related fields—organization theory (OT), organizational development (OD), and human resources management (HRM). As noted previously, OB is the study of individual and group dynamics within an organization setting and, therefore, is a microapproach. OT analyzes the entire organization and is a macro perspective, since the organization is the unit examined. The field of OD describes a planned process of change that is used throughout the organization, with the goal of improving the effectiveness of the organization. Since, like OT, OD involves the entire organization, it is a macro examination. Finally, HRM can be viewed as a micro-approach to “managing” people. The difference between HRM and OB is that the latter studies human behavior in various settings with an emphasis on explaining, predicting, and understanding behavior in organizations, whereas HRM emphasizes systems, processes, procedures, and so forth for personnel management and is usually housed in a functional unit within organizations. DISCUSSION QUESTIONS 1. Define organizational behavior. 2. What are some of the major challenges facing today’s and tomorrow’s health care organizations and health care managers? Why? 3. Why did the Hawthorne Studies have an impact on the study of organizational behavior? 4. Why did McGregor’s Theory X and Theory Y have an impact on the study of organizational behavior? 5. Discuss the difference between organizational behavior, organization theory, organizational development, and human resources management. X-Y THEORY QUESTIONNAIRE What Do You Know About Organizational Behavior? Question 1. OB is the study of individuals, groups and organizations. 2. Under Theory Y, managers create opportunities, remove obstacles, and encourage growth and learning for their employees. 3. Attitudes are very individual and subjective, and therefore we do not currently have ways to measure an employee’s attitude about their jobs. 4. Extroverts do best in quiet, non-social jobs such as computer work, while Introverts show the best job performance when they must work and present in front of large groups of people. 5. Motivation is described as the conscious or unconscious stimulus, incentive, or motives for action towards a goal resulting from psychological or social factors, the factors giving the purpose or direction to behavior. 6. Employee motivation has a direct impact on a health services organization’s performance. 7. Process theories of motivation assist managers in predicting employees’ behavior so the behavior may be influenced, if necessary. 8. An employee’s degree of job satisfaction is proportionate to the actual amount of rewards he or she is receiving. 9. Power may be defined as the influence over the beliefs, emotions, and behaviors of people. 10. A leader is a person who directs the work of employees and is responsible for results. 11. Management and leadership are both necessary for an organization to achieve its goals. 12. The leader who is able to respond to ever-increasing levels of environmental uncertainty through the utilization of more than one style of leadership will be most likely to increase motivation, satisfaction, and productivity of employees. 13. Transactional leadership is all about change, innovation, improvement, and entrepreneurship through vision and inspiration. 14. Transactional and transformational leader approaches are clearly oppositional. 15. Due to stress being a complex and highly personalized True/False ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ 16. 17. 18. 19. 20. process, some individuals see a specific situation as a threat, whereas other individuals see the same situation as a challenge or opportunity. Managers are under the constraints of limited time and resources, personal bias and other factors, which make rational decision-making unrealistic. Conflict is inevitable and unavoidable. Individuals join groups to satisfy their need for safety and social needs. Barriers to effective teamwork fall within four categories: (1) lack of management support, (2) lack of resources, (3) lack of leadership, and (4) lack of training. The two primary forces influencing an individual’s perception, attitude, and response toward change are cumulative life experiences and social (informal group) forces. Scoring: The correct answers to the above 20 questions are: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. False True False False True True True True False True False True True False False True True True True True ______ ______ ______ ______ ______ ______ Interpretation: How much do you know about organizational behavior? If you scored well – good for you! However, the above questions only represent a very small part of organizational behavior. If you didn’t score high – don’t be concern. You will learn the many theories and concepts of organizational behavior that will provide you with the necessary skill set to successfully manage and lead others. REFERENCES Benjamin, M. (2003, February 24). Fads for any and all eras. U.S. News & World Report, 134, 74–75. Bureau of Labor Statistics, U.S. Department of Labor. (2013). Industry employment and output projections to 2022. Available at: www.bls.gov/opub/mlr/2013/article/industry-employment-and-outputprojections-to-2022.htm Daft, R. L. (2004). Organization theory and design (8th ed.). Mason, OH: Thomson South-Western. Homans, G. C. (1950). The human group. New York, NY: Harcourt, 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 (2nd ed.). Albany, NY: Wadsworth Publishing Company. Roethlisberger, F. J., & Dickson, W. J. (1939). Management and the worker. Cambridge, MA: Harvard University Press. Taylor, F. W. (1911). The principles of scientific management. New York, NY: Harper and Brothers. CHAPTER 2 Diversity and Cultural Competency in Health Care Jean Gordon, RN, DBA LEARNING OUTCOMES After completing this chapter, the student should be able to: Define diversity. Define cultural competency. Define diversity management. Understand why changes in U.S. demographics affect the health care industry. OVERVIEW Demographics of the U.S. population have changed dramatically in the past three decades. These changes directly impact the health care industry in regard to the patients we serve and our workforce. By 2050, the term “minority” will take on a new meaning. According to the U.S. Census Bureau, by midcentury the white, non-Hispanic population will comprise less than 50 percent of the nation’s population. As such, the health care industry needs to change and adopt new ways to meet the diverse needs of our current and future patients and employees. The American Heritage Dictionary of the English Language (4th ed.) defines diversity as: “(1) the fact or quality of being diverse; difference, and (2) a point in which things differ.” Dreachslin (1998) provided us with a more specific definition of diversity. She defined diversity as “the full range of human similarities and differences in group affiliation including gender, race/ethnicity, social class, role within an organization, age, religion, sexual orientation, physical ability, and other group identities” (p. 813). For our discussions, we will focus on the following diversity characteristics: (1) race/ethnicity, (2) age, and (3) gender. This chapter is presented in three parts. First, we discuss the changing demographics of the nation’s population. Second, we examine how these changes are affecting the delivery of health services from both the patient’s and employee’s perspectives. Because diversity challenges faced by the health care industry are not limited to quality-of-care and access-to-care issues, in part three of our discussions we explore how these changes will affect the health services workforce, and more specifically the current and future leadership within the industry. CHANGING UNITED STATES POPULATION There is no doubt that the demographic profile of the U.S. population has undergone significant changes within the past 10 years regarding age, gender, and ethnicity (see Table 2–1). Table 2–1 Population of the United States by Age, Gender, and Race/Ethnicity a a Percentages do not add up to 100 percent due to rounding and because Hispanics may be of any race and are therefore counted under more than one category. Data from U.S. Census Bureau, 2010 Census. DP-1 - United States: Profile of General Population and Housing Characteristics: 2010 Demographic Profile Data: U.S. Census Bureau 2000 Census Data as shown in the 2009 Population Estimates table; U.S. Census Bureau: National Population Estimates; Decennial Census. Data from the 2010 Census provide insights to our racially and ethnically diverse nation (Humes, Jones, & Ramirez, 2011). According to the 2010 Census, 308.7 million people resided in the United States on April 1, 2010— an increase of 27.3 million people, or 9.7 percent, between 2000 and 2010. The vast majority of the growth in the total population came from increases in those who reported their race(s) as something other than White alone and those who reported their ethnicity as Hispanic or Latino. For the first time in the 2000 Census, individuals were presented with the option to selfidentify with more than one race, and this continued with the 2010 Census. Using the five race categories (White, Black/African American, American Indian/Alaska Native, Asian, and Native Hawaiian/Other Pacific Islander) required by federal agencies, there are 57 possible multiple race combinations that could have been selected by individuals in addition to “some other race.” In fact, over 7 million or 2 percent of the U.S. population did so in the 2010 Census by identifying with and choosing “some other race” or “two or more races.” It is predicted that the number of Americans reporting themselves or their children as multiracial will increase in the future. In addition to the changing ethnic and racial composition of America, another issue is the aging population. According to the 2010 Census, 40 million people (13 percent of the U.S. population) are 65 years of age or older. This is 12.3 million more people than in 2000 (see Figure 2–1). Figure 2–1 Population 65 Years and Over by Age and Sex, 2000 and 2010 (numbers in thousands) Data from U.S. Census Bureau, 2010 Census. DP-1 - United States: Profile of General Population and Housing Characteristics: 2010 Demographic Profile Data: U.S. Census Bureau 2000 Census Data as shown in the 2009 Population Estimates table. During the past decade, the population aged 65 and over grew at a faster rate (15.1 percent) than the population under age 45. This trend was expected as the Baby Boomers (those born between 1946 and 1964) began reaching age 65 in 2011 (see Figure 2–2). In addition to the increasingly older population, there is a declining number of young people in America. From 1940 to 2010, the percentage of the American population under the age of 18 fell from 31 percent to 24 percent (U.S. Census Bureau, 2012). This decline in America’s younger population will have a direct effect on the industry’s ability to recruit health care professionals to provide sufficient services in the future. Young people of all ethnicities must be attracted to the health care industry as a career choice in order to meet the health care needs of the country’s growing population. Males and females are almost evenly divided for the total population, representing 49.2 percent and 50.8 percent, respectively; however, in the population under 25 years, males dominate females, with 105 males for every 100 females. Among older adults, the male–female ratio reverses, with women outnumbering men. However, there was an interesting change in the male–female ratios for the population aged 60 and older between 2000 and 2010 (Howden & Meyer, 2011). A greater increase in the male population relative to the female population for these age groups was noted. Males aged 60 to 74 increased by 35.2 percent, while their female counterparts increased by 29.2 percent. A narrowing of the mortality gap between men and women at older ages in part accounts for this difference. Figure 2–2 Projected Population of the United States by Age, 2000–2050 (Numbers in thousands) Data from Population Division, U.S. Census Bureau. Race/Ethnicity The U.S. population has continued to diversify during the past 10 years, as minority populations continue to increase at a faster rate than the White population. Although the White population still represents the largest group (63.7 percent) of the U.S. population, this is down from 75.1 percent in 2000 (see Table 2–1). In 2010, the Hispanic population represented the largest minority in the United States, 16.3 percent of the population. This is up from 4.5 percent in 1970, the first census in which Hispanic origin was identified. The remaining population is composed of 12 percent Black, 5 percent Asian and Pacific Islanders, 1 percent American Indians and Alaska Natives, and 3 percent those who identified themselves as belonging to another or more than one race (see Table 2–1). The Asian population in the United States is increasing rapidly as a percentage of the total population. From 2000 to 2010, the population of those people who identified themselves as being Asian (either alone or in combination with another race) grew 43.3 percent, while the total population grew only 9.7 percent (see Table 2–1) Aging Population The world’s population is aging. According to the United Nations (2013), slow population growth brought about by reductions in fertility leads to population aging; that is, it produces populations where the proportion of older persons increases while that of younger persons decreases. Globally, the number of persons aged 60 and over is expected to more than triple by 2100, which will represent 34 percent of the world’s population, or more than 3 billion individuals. Of this group, the number of persons aged 80 and over is projected to increase almost sevenfold by 2100, representing just under one-third of the world’s population aged 60 and over. The United States is experiencing the same as the world’s aging population. As reported by Howden and Meyer (2011), the 2010 Census reflects that the number of people under age 18 was 74.2 million (24.0 percent of the total population). The younger working-age population, ages 18 to 44, represented 112.8 million persons (36.5 percent). The older working-age population, ages 45 to 64, made up 81.5 million persons (26.4 percent). Finally, the 65 and over population was 40.3 million persons (13.0 percent). Between 2000 and 2010, the population under the age of 18 grew at a rate of 2.6 percent. The growth rate was even slower for those aged 18 to 44 (0.6 percent). On the opposite side, the country is experiencing substantially faster growth rates for older ages. For example, the population aged 45 to 64 grew at a rate of 31.5 percent. The large growth in this age group is primarily attributable to the aging of the Baby Boom population. As noted previously, the growth rate (15.1 percent) of the 65 and over population was faster than the population under age 45. One of the most striking characteristics of the older population is the change in the ratio of men to women as people age. As Howden and Meyer (2011, p. 3) point out, this is a result of differences in mortality for men and women, where women tend to live longer than men. As such, there are more females then males at older ages. However, over the past decade an increase in the male population relative to the female population has been noted. For example, in 2010, there were 96.7 males per 100 females, representing an increase from 2000, when the ratio was 96.3 males per 100 females (Howden & Meyer, 2011). This lowering of male mortality may be attributible to technological advances, more preventive screening, and healthier lifestyles. While the elderly population is not as racially and ethnically diverse as the younger generations, it is projected to increase in its racial and ethnical makeup over the next four decades. As in the past, the highest proportion of the U.S. population aged 60 and over is White (78.8 percent). However, within the racial composition of the older population, White is projected to decrease by 10 percent by 2050, and all other race groups will increase in their own populations. This change is already being seen. In 2000, the aged White population was 82.5 percent, a 7 percent decrease compared with 2010. The remaining makeup of this population group is 8.8 percent Black, 7.3 percent Hispanic, and 3.6 percent Asian, with other races forming the remainder. As noted, this population group’s racial composition will continue to change over the next 40 years. Gender As previously noted, according to the U.S. Census Bureau, in 2010, 50.8 percent of the U.S. population was female, and 49.2 percent was male— almost identical to the 2000 Census. That translates to 96 men for every 100 women. However, the ratio of men to women varies significantly by age group. There were about 105 males for every 100 females under 25 in 2010, reflecting the fact that more boys than girls are born every year and that boys continue to outnumber girls through early childhood and young adulthood. However, the male–female ratio declines as people age. For men and women aged 25 to 54, the number of men for each 100 women in 2010 was 99. Among older adults, the male–female ratio continued to fall as women increasingly outnumbered men. For people 55 to 64, the male– female ratio was 93 to 100, but for those 85 and older, there were only 48 men for every 100 women. These male–female ratios reflect a new trend that has been occurring since 1980. From 1900 to 1940, there were more males. Beginning in 1950, there were increasingly more females due to reduced female mortality rates. This trend reversed between 1980 and 1990 as male death rates declined faster than female rates and as more men immigrated to the United States than women (United States Department of Commerce, 2003). When we look at education, it appears that females are outpacing men. Among the population aged 25 and older, 88 percent of both men and women were high school graduates. But of this group, 39 percent of men had graduated from college, as compared with 61 percent of women. However, even with college degrees, only a high minority (44 percent) of women are employed in management or professional positions. Exhibit 2–1 Hofstede’s Cultural Dimensions One of the most extensive cross-cultural surveys ever conducted is Hofstede’s (1983) study of the influence of national culture on organizational and managerial behaviors. National culture is deemed to be central to organizational studies, because national cultures incorporate political, sociological, and psychological components. Hofstede’s research was conducted over an 11-year period, with more than 116,000 respondents in more than 40 countries. The researcher collected data about “values” from the employees of a multinational corporation located in more than 50 countries. On the basis of his findings, Hofstede proposed that there are four dimensions of national culture, within which countries could be positioned, that are independent of one another. Hofstede’s (1983, pp. 78–85) four dimensions of national culture were labeled and described as: • Individualism–Collectivism: Individualism–collectivism measures culture along a self-interest versus group-interest scale. Individualism stands for a preference for a loosely knit social framework in society wherein individuals are supposed to take care of themselves and their immediate families only. Its opposite, collectivism, stands for a preference for a tightly knit social framework in which individuals can expect their relatives, clan, or other in-group to look after them in exchange for unquestioning loyalty. Hofstede (1983) suggested that selfinterested cultures (e.g., individualism) are positively related to the wealth of a nation. • Power Distance: Power Distance is the measure of how a society deals with physical and intellectual inequalities, and how the culture applies power and wealth relative to its inequalities. People in large Power Distance societies accept hierarchical order in which everybody has a place, which needs no further justification. People in small Power Distance societies strive for power equalization and demand justification for power inequalities. Hofstede (1983) indicated that group-interest cultures (e.g., Collectivism) have large Power Distance. • Uncertainty Avoidance: Uncertainty Avoidance reflects the degree to which members of a society feel uncomfortable with uncertainty and ambiguity. The scale runs from tolerance of different behaviors (i.e., a society in which there is a natural tendency to feel secure) to one in which the society creates institutions to create security and minimize risk. Strong Uncertainty Avoidance societies maintain rigid codes of belief and behavior and are intolerant toward deviant personalities and ideas. • Weak Uncertainty: Avoidance societies maintain a more relaxed atmosphere in which practice counts more than principles and deviance is more easily tolerated. • Masculinity Versus Femininity: Masculinity versus femininity measures the division of roles between the genders. The masculine side of the scale is a society in which the gender differences are maximized (e.g., need for achievement, heroism, assertiveness, and material success). Feminine societies are ones in which there are preferences for relationships, modesty, caring for the weak, and the quality of life. Hofstede proposed that the most important dimensions for organizational leadership are Individualism/Collectivism and Power Distance, and the most important for decision-making are Power Distance and Uncertainty Avoidance. Uncertainty Avoidance plays an integral part in a country’s culture regarding change. For example, Nahavandi and Malekzadeh (1999, pp. 495–496) point out that countries such as Greece, Portugal, and Japan have national cultures that do not easily tolerate uncertainty and ambiguity. Therefore, the resultant behavior emphasizes the issue avoidance or the importance of planned and well-managed activities. Other countries, such as Sweden, Canada, and the United States, are able to tolerate change because of the potential for new opportunities that may come with change. The question frequently asked is whether Hofstede’s (1983) cultural dimensions are still applicable today. Patel (2003) found that the characteristics of Chinese, Indian, and Australian cultures corroborated Hofstede’s study results. Patel’s study of the relationship between business goals and culture, measured by correlating the relative importance attached to the various business goals with the national culture dimension scores from Hofstede’s study, found that although the four cultural dimension scores were nearly 20 years old, they were validated in this large, cross-national survey. In a study that measured 1,800 managers and professionals in 15 countries, statistically significant correlations with the Hofstede indices validated the applicability of the first study’s cultural dimension findings (Hofstede et al., 2002). The findings from these studies suggest that Hofstede’s cultural dimensions continue to be robust and are still applicable measure components of national culture differences. NOTE: Hofstede (1991) subsequently included an additional dimension based on Chinese values referred to “Confucian dynamism.” Hofstede renamed this dimension as a long-term versus short-term orientation in life. IMPLICATIONS FOR THE HEALTH CARE INDUSTRY The changing demographics of America’s population affect the health care industry twofold. First, health care professionals and organizations need to have cultural and linguistic competence to provide effective and efficient health services to diverse patient populations. However, before we continue our discussion, we need to define what is meant by cultural and linguistic competence. Over the years, cultural competence has been defined in many ways, such as “ongoing commitment or institutionalism of appropriate practice and policies for diverse populations” (Brach & Fraser, 2000; WeechMaldonado et al., 2002; see Hofstede’s Cultural Dimensions, Exhibit 2–1). Linguistic competence has been defined as “the capacity of an organization and its personnel to communicate effectively, and convey information in a manner that is easily understood by diverse audiences including persons of limited English proficiency, those who have low literacy skills or are not literate, and individuals with disabilities” (Goode & Jones, 2004). For our discussions we adopted the definition used by the Office of Minority Health (OMH) of the U.S. Department of Health and Human Services, which defines “cultural and linguistic competence as a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and that enables effective work in cross-cultural situations.” (United States Department of Health and Human Services, 2013). Second, because of the changing demographics of the nation’s population, the health care industry needs to ensure that the health care workforce mirrors the patient population it serves, both clinically and managerially. As noted by Weech-Maldonado et al. (2002), health care organizations must develop policies and practices aimed at recruiting, retaining, and managing a diverse workforce in order to provide both culturally appropriate care and improved access to care for racial/ethnic minorities. DIVERSITY ISSUES WITHIN THE CLINICAL SETTING Consider the following: Scenario One: An insulin-dependent, indigent black non-Hispanic male was treated at a predominantly Hispanic border clinic. Later, he was brought back to the clinic in a diabetic coma. When he awoke, the nurse who had counseled him asked whether he had been following her instructions. “Exactly!” he replied. When the nurse asked him to show her, the monolingual Spanish-speaking nurse was startled when the patient proceeded to inject an orange and eat it. Scenario Two: As Maria (an elderly, monolingual Hispanic female) was being prepared for surgery, which was not why she came to the hospital, her designated interpreter (a young female relative) was told by an English-speaking nurse to tell Maria that the surgeon was the best in his field and she’d get through this fine. The young interpreter translated, “the nurse says the doctor does best when he’s in the field, and when it’s over you’ll have to pay a fine!” These may seem rather humorous misunderstandings, but real-life experiences such as these happen every day in the United States (Howard, Andrade, & Byrd, 2001). For example, a survey by the Commonwealth Fund (2002) found that black non-Hispanics, Asian Americans, and Hispanics are more likely than white non-Hispanics to experience difficulty communicating with their physician, to feel that they are treated with disrespect when receiving health care, to experience barriers to access to care, such as lack of insurance or not having a regular physician, and to feel they would receive better care if they were of a different race or ethnicity. In addition, the survey found that Hispanics were more than twice as likely as white non-Hispanics (33 percent versus 16 percent) to cite one or more communication problems, such as not understanding the physician, not being listened to by the physician, or not asking questions they needed to ask. Twenty-seven percent of Asian Americans and 23 percent of black nonHispanics experience similar communication difficulties. Cultural differences between providers and patients affect the provider– patient relationship. For example, Fadiman (1998) related a true and poignant story of cultural misunderstanding within the health care profession. Fadiman described the story of a young female epileptic Hmong immigrant whose parents believed that their daughter’s condition was caused by spirits called “dabs,” which had caught her and made her fall down, hence the name of Fadiman’s book The Spirit Catches You and You Fall Down. The patient’s parents struggled to understand the prescribed medical care that only recognized the scientific necessities, but ignored their personal belief about the spirituality of one’s soul in relationship to the universe. From a unique perspective, Fadiman examined the roles of the caregivers (physicians, nurses, and social workers) in the treatment of ill children. She studied the way the medical care system responded to its own perceptions that the family was refusing to comply with medical orders without understanding the meaning of those orders in the context of the Hmong culture, language, and beliefs. Because of our increasingly diverse population, health care professionals need to be concerned about their cultural competency, which is more than just cultural awareness or sensitivity. Although formal cultural training has been found to improve the cultural competence of health care practitioners, Kundhal (2003) reported that only 8 percent of U.S. medical schools and no Canadian medical schools had formal courses on cultural issues. However, changes are occurring within the industry (see Exhibit 2–2) to assist health care practitioners in the developing of their cultural competences as they encounter more diverse patients. For example, in 2000 the Liaison Committee on Medical Education (LCME), the accrediting body of medical schools, introduced the following accreditation standard for cultural competence: The faculty and students must demonstrate an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments. Medical students should learn to recognize and appropriately address gender and cultural biases in healthcare delivery, while considering first the health of the patient. This standard has given added impetus and emphasis to medical schools to introduce education in cultural competence into the undergraduate medical curriculum (Association of American Medical Colleges, 2005, p. 1). In addition, The Joint Commission has implemented patient-centered communication accreditation standards, which require hospitals to meet certain mandates related to qualifications for language interpreters and translators, identifying and addressing patient communication needs, collecting patient race and ethnicity data, patient access to a support individual, and nondiscrimination in care (The Joint Commission, 2014). Exhibit 2–2 Unequal Treatment A study in 2002 by the Institute of Medicine, entitled Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, found that a consistent body of research demonstrates significant variation in the rates of medical procedures by race, even when insurance status, income, age, and severity of conditions are comparable. This research indicated that U.S. racial and ethnic minorities receive even fewer routine medical procedures and experience a lower quality of health services than the majority of the population. For example, minorities are less likely to be given appropriate cardiac medications or to undergo bypass surgery, and are less likely to receive kidney dialysis or transplants. By contrast, they are more likely to receive certain less desirable procedures, such as lower-limb amputations for diabetes. The study’s recommendations for reducing racial and ethnic disparities in health care included increasing awareness about disparities among the general public, health care providers, insurance companies, and policy makers. Modified from unequal treatment: Confronting racial and ethnic disparities in health care (p. 3), by B. D. Smedley, A. Y. Stitch, and A. R. Nelson (Eds.), 2002, Washington, DC: National Academy of Sciences, Institute of Medicine Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Over the past decade, the Commonwealth Fund has been a leader in the effort “to eliminate the cultural and linguistic barriers between health care providers and patients, which can interfere with the effective delivery of health services” (Beach, Saha, & Cooper, 2006, p. vi). The Commonwealth Fund (2003), in addition to funding initiatives regarding quality of care for under-served populations, has also initiated an educational program that assists health care practitioners in understanding the importance of communication between culturally diverse patients and their physicians, the tensions between modern medicine and cultural beliefs, and the ongoing problems of racial and ethnic discrimination. The goals of this program are for clinicians to: 1. Understand that patients and health care professionals often have different perspectives, values, and beliefs about health and illness that can lead to conflict, especially when communication is limited by language and cultural barriers. 2. Become familiar with the types of issues and challenges that are particularly important in caring for patients of different cultural backgrounds. 3. Think about each patient as an individual, with many different social, cultural, and personal influences, rather than using general stereotypes about cultural groups. 4. Understand how discrimination and mistrust affect the interaction of patients with physicians and the health care system. 5. Develop a greater sense of curiosity, empathy, and respect toward patients who are culturally different, and thus be encouraged to develop better communication and negotiation skills through ongoing instruction. Reproduced from World’s Apart, Facilitator’s Guide by Alexander Green, MD, Joseph Betancourt, MD, MPH, and J. Emilio Carrillo, MD, MPH, The Commonwealth Fund, p. 4. In addition to the Commonwealth Fund, the W. K. Kellogg Foundation has led efforts to lessen the recognized disparity of racial and ethnic minority groups’ representation among the nation’s health professionals. It was the Kellogg Foundation that requested the Institute of Medicine’s (2004) study entitled In the Nation’s Compelling Interest: Ensuring Diversity in the Health Care Workforce. The Institute of Medicine found that racial and ethnic diversity is important in the health professions because: 1. Racial and minority health care professionals are significantly more likely than their peers to serve minority and medically underserved communities, thereby helping to improve problems of limited minority access to care. 2. Minority patients who have a choice are more likely to select health care professionals of their own racial or ethnic background. Moreover, racial and ethnic minority patients are generally more satisfied with the care that they receive from minority professionals, and minority patients’ ratings of the quality of their health care are generally higher in racially concordant than in racially discordant settings. 3. Diversity in health care training settings may assist in efforts to improve the cross-cultural training and competencies of all trainees. In addition to the Commonwealth Fund and the W. K. Kellogg Foundation, other organizations are active in bridging cultural differences in an attempt to lessen health disparities. For example, in 2000 the OMH developed a list of standards for Culturally and Linguistically Appropriate Services (CLAS), which health care organizations and practitioners should use to ensure equal access to quality health care by diverse populations. In 2013, these standards were expanded to reflect the growth in the field of cultural and linguistic competency. There are now 15 standards under four categories: (1) Principal Standard, (2) Governance, Leadership, and Workforce, (3) Communication and Language Assistance, and (4) Engagement, Continuous Improvement, and Accountability. Principal Standard 1. Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs. Governance, Leadership, and Workforce 2. Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy, practices, and allocated resources. 3. Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and workforce that are responsive to the population in the service area. 4. Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis. Communication and Language Assistance 5. Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services. 6. Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing. 7. Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided. 8. Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area. Engagement, Continuous Improvement, and Accountability 9. Establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them throughout the organization’s planning and operations. 10. Conduct ongoing assessments of the organization’s CLAS-related activities and integrate CLAS-related measures into measurement and continuous quality improvement activities. 11. Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery. 12. Conduct regular assessments of community health assets and needs, and use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area. 13. Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural and linguistic appropriateness. 14. Create conflict and grievance resolution processes that are culturally and linguistically appropriate to identify, prevent, and resolve conflicts or complaints. 15. Communicate the organization’s progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public. Reproduced from the National CLAS Standards, The office of Minority Health, U.S. Department of Health and Human Services. Another diversity area that has shown progress since 2007 is the use of the Healthcare Equality Index (HEI) of the Human Rights Campaign (HRC) Foundation by hospitals and other organizations. This survey is a resource for health care organizations seeking to provide equitable, inclusive care to lesbian, gay, bisexual, and transgender (LGBT) Americans—and for LGBT Americans seeking health care organizations with a demonstrated commitment to their care (HRC, 2014). In 2013, facilities in all 50 states and most U.S. veterans hospitals participated in using the HEI, with 93 percent and 87 percent reporting that sexual orientation and gender identity were included in their patient nondiscrimination policies, respectively. These nondiscrimination policies are required for Joint Commission accreditation. In addition, both The Joint Commission and the Centers for Medicare and Medicaid Services require that facilities allow visitation without regard to sexual orientation or gender identity. Furthermore, 96 percent and 85 percent of participants reported that sexual orientation and gender identity, respectively, were also included in their employment nondiscrimination policies. The HEI has two sections: (1) the core four leader criteria and (2) the additional best practices checklist. The Core Four Leader Criteria are reflected in Table 2–2. The Additional Best Practices Checklist is designed to familiarize HEI participants with other expert recommendations for LGBT patient-centered care, to help identify and remedy gaps. AGING POPULATION In addition to the changing ethnic and racial composition of America, another area of concern is the growing elderly population. Technology has given us the ability to enhance longevity; the challenge now is whether or not the health care profession can learn how to best serve this growing population of patients. Table 2–2 Health Care Equality Index’s Core Four Leader Criteria Criteria Patient Nondiscrimination a. Patient nondiscrimination policy (or patients’ bill of rights) includes the terms “sexual orientation” and “gender identity” b. LGBT-inclusive patient nondiscrimination policy is communicated to patients in at least two documented ways Equal Visitation a. Visitation policy explicitly grants equal visitation to LGBT patients and their visitors b. Equal visitation policy is communicated to patients in at least two documented ways Employment Employment nondiscrimination policy (or equal employment opportunity policy) includes the Nondiscrimination terms “sexual orientation” and “gender identity” Training in LGBT Patient- Staff receive training in LGBT patient-centered care Centered Care Copyright © 2014 by the Human Rights Campaign Foundation. Reproduced with permission. No further reproduction or distribution is permitted without written permission from the Human Rights Campaign Foundation. As our citizens grow older, more services are required for the treatment and management of both acute and chronic health conditions. The profession must devise strategies for caring for the elderly patient population. America’s older citizens are often living on fixed incomes and have small or nonexistent support groups. Although this may be considered an American infrastructure dilemma, the reality is that medical professionals must be able to understand and empathize with poor, sick, elderly people of all races, sexes, and creeds. The term “ageism” was coined in 1968 by Robert N. Butler, M.D., a pioneer in geriatric medicine and a founding director of the National Institute on Aging (NIA). Butler was among the first to identify the phenomenon of age prejudice, initially describing it as “a systematic stereotyping of and discrimination against people because they are old.” Ageism can be defined as “any attitude, action, or institutional structure, which subordinates a person or group because of age or any assignment of roles in society purely on the basis of age” (Traxler, 1980, p. 4). Health care professionals often make assumptions about their older patients on the basis of age rather than functional status (Bowling, 2007). This may be due to the limited training physicians receive in the care and management of geriatric patients. For example, Warshaw and colleagues (2002, 2006) related that medical residents have only limited training in geriatric medicine. Findings from Warshaw et al.’s 2006 study were compared with those from a similar 2002 survey to determine whether any changes had occurred. Of the participating three-year residency training programs, only 9 percent required six weeks or more of training. As in 2002, the residency programs continue to depend on nursing home facilities, geriatric preceptors in nongeriatric clinical ambulatory settings, and outpatient geriatric assessment centers for the medical residents’ geriatrics training. A report from the Alliance for Aging Research (2003) related that there continue to be shortcomings in medical training, prevention, screening, and treatment patterns that disadvantage older patients. The report outlined five domains of ageism in health care: 1. Health care professionals do not receive enough training in geriatrics to properly care for many older patients. 2. Older patients are less likely than younger people to receive preventive care. 3. Older patients are less likely to be tested or screened for diseases and other health problems. 4. Proven medical interventions for older patients are often ignored, leading to inappropriate or incomplete treatment. 5. Older people are consistently excluded from clinical trials, even though they are the largest users of approved drugs. On a positive note, Perry (2012) relates that progress against systematic ageism in health care has begun, in part, due to the passing of the 2010 Affordable Care Act (ACA). He notes that the law’s various provisions, such as Medicare’s increased focus on chronic disease prevention, new models of care for reducing re-hospitalizations, and improved care coordination, as well as annual screening for cognitive impairment, will assist with changing attitudes toward elderly patients. Before moving to our next discussion regarding diversity management, we pause to provide a brief overview of the efforts being made regarding the measuring and reporting of cultural competency. Measurement and reporting are needed to ensure that culturally competent care can be translated into: (1) improved health outcomes and more patient-centered care, and (2) actionable initiatives for providers that result in meaningful improvement. Through the support of the Robert Wood Johnson Foundation (RWJF), in 2009, the National Quality Forum (NQF) endorsed a comprehensive national framework based on a set of seven interrelated domains (and multiple subdomains) for evaluating cultural competency across all health care settings, as well as a set of 45 recommended practices based on the framework. This was followed by RAND’s development of a cultural competency implementation measurement tool. This tool is an organizational survey designed to assist health care organizations in identifying the degree to which they are providing culturally competent care and addressing the needs of diverse populations, as well as their adherence to 12 of the 45 NQF-endorsed cultural competency practices. In 2012, NQF endorsed 12 quality measures that address health literacy, language access, cultural competency, leadership, and workforce development (RWJF, 2014). These quality measures are the first endorsed by NQF that specifically address health care disparities and cultural competency. DIVERSITY MANAGEMENT Diversity management is a challenge to all organizations. Diversity management is “a strategically driven process whose emphasis is on building skills and creating policies that will address the changing demographics of the workforce and patient population” (Svehla, 1994; Weech-Maldonado et al., 2002). In 2004, the National Urban League published its first study on employees’ perceptions regarding the effectiveness of their companies’ diversity programs. The results of the organization’s 2009 follow-up survey found that progress has been made over the past five years in certain areas. However, leadership commitment to diversity and companies clearly communicating their platform on how they value diversity are still lagging (see Table 2–3). As reflected in Table 2–3, organizations have improved in communicating effectively regarding their diversity platforms but need to focus on their (1) commitment to, (2) accountability for, (3) action on, and (4) measurement of these initiatives. The good news is the notable increases reflecting the intrinsic acceptance of diversity and inclusion by the American worker. As reported by the National Urban League (2009), the playing field appears more level, diverse talent is being developed and retained, and customer/consumer diversity is being recognized. While some gains have been made in regard to increasing diversity in the field of health care management, recent studies continue to suggest that there is still ample room for improvement. The Institute for Diversity in Health Management, an affiliate of the American Hospital Association, was formed in 1994 to address the problem that was disclosed in a 1992 study that minorities held less than 1 percent of top management positions within the industry. In addition, the study revealed that African American health care executives made less money, held lower positions, and had less job satisfaction than their white counterparts. A 1997 follow-up study, expanded to include Latinos and Asians, found that although the gap had narrowed in some areas, not much had changed. As examples, a study by Motwani, Hodge, and Crampton (1995) found that only 27.7 percent of health care workers in six Midwest hospitals felt that their institutions had a program to improve employee skills in dealing with people of different cultures, and only 38.9 percent felt that management realized that cultural factors were sometimes the cause of conflicts among employees. WeechMaldonado, et al. (2002) found that hospitals in Pennsylvania had been relatively inactive with employing diversity management practices, and equal employment requirements were the main driver of diversity management policy. Five years later, Weech-Maldonado and colleagues (Weech-Maldonado, Elliott, Schiller, Hall, Dreachslin, & Hays, 2007; Weech-Maldonado, Elliott, Schiller, Hall, & Hays, 2007) continued to find low levels of diversity management activity within California hospitals. Since that time, the Institute for Diversity in Health Management, in collaboration with other organizations, designed several initiatives to expand health care leadership opportunities for ethnically, culturally, and racially diverse individuals, thus increasing the number of these individuals entering and advancing in the field. Table 2–3 American Workers’ Perception Data from National Urban League. Diversity Practices That Work: The American Worker Speaks II, 2009 Highlights. HEALTH CARE LEADERSHIP The American College of Healthcare Executives (ACHE), the National Association of Health Services Executives (NAHSE), the Institute for Diversity in Healthcare Management (IFD), the National Forum for Latino Healthcare Executives, and the Asian Health Care Leaders Association released a study in 2009 that measured the representation of black nonHispanics, Hispanics, women, and other minorities in health care executive leadership roles. This study was a follow up to similar studies completed in 1992, 1997, and 2002. The study, completed in 2008, was based on a random-sample survey of 1,515 health care executives. Respondents worked in a variety of settings—hospitals, health care–provider organizations, government health agencies, and consulting and educational institutes (see Table 2–4). Although the results of the 1997 study reflected improvements in diversity over the 1992 study (see: www.ache.org—Race and Ethnic Study 2002), the 2002 and 2008 results indicated that the health care industry did not do as well in promoting minorities and women in chief executive officer (CEO) and chief operating officer (COO)/senior vice president positions. In the 2008 ACHE study, as noted by the authors of the study (p. 12) and reflected in Tables 2–4 and 2–5, 34 percent of CEOs are white men, compared to 28 percent of them being Hispanic men, 16 percent black men, and 5 percent Asian men. However, these disparities are not apparent among women, where all racial/ethnic groups hold between 10 and 13 percent of CEO positions. When all senior executive positions are considered, including chief executive officer and chief operating officer/senior vice president, the proportion of white men in such positions continues to exceed that of minority men. However, among women, a higher proportion of Hispanic women than others are in senior executive positions. The two factors of race/ethnicity and gender are evident especially when comparing blacks and whites. For both blacks and whites, only about half as many women attained CEO or COO/senior vice president posts as their male counterparts. In the 2013–2014 Benchmarking Survey by the Institute of Diversity, the results highlighted that while there was some limited increase in the diversity of hospitals’ leadership and governance, more positive movement is needed. The study reported that minorities composed: • 14 percent of hospital board members (unchanged from 2011) • 12 percent of executive leadership positions (unchanged from 12 percent in 2011) • 17 percent of first- and mid-level management positions (up from 15 percent in 2011) Table 2–4 American College of Healthcare Executives 2008 Diversity Study SOURCE: American College of Healthcare Executives. Reprinted with permission. Table 2–4 American College of Healthcare Executives 2008 Diversity Study a Responses may not total to 100 because of rounding. Reproduced from American College Of Healthcare Executives with permission. Table 2–5 American College of Healthcare Executives 2008 Diversity Study a Responses may not total to 100 because of rounding. Reproduced from American College Of Healthcare Executives with permission. Dreachslin and Curtis (2004) noted that career advancement of women and racially/ethnically diverse individuals in health care management was characterized by: (1) underrepresentation, especially in senior-level management positions; (2) lower compensation, even controlling for education and experience; and (3) more negative perceptions of equity and opportunity in the workplace. The researchers identified three areas that are key organization-specific factors for shaping career outcomes for women and racially/ethnically diverse individuals: (1) leadership and strategic orientation (i.e., senior management’s commitment to successful implementation of diversity initiatives), (2) organizational culture/climate (i.e., the depth and breadth of the organization’s strategic commitment to diversity leadership and cultural competence), and (3) human resources practices (i.e., establishing best practices in advancing the management careers of women and racially/ethnically diverse individuals, such as formal mentoring programs, professional development, work/life balances, and flexible benefits). On the basis of Dreachslin’s and others’ research, the NCHL, ACHE, IFD, and the American Hospital Association developed the Diversity and Cultural Proficiency Assessment Tool for Leaders (see Exhibit 2–3). The assessment tool begins the process of developing a cultural awareness for the organization’s workforce. Going forward, managers will need to develop models that establish benchmarks for cultural competence to enable their organizations to develop competent interventions, thereby improving the quality of health care (Betancourt, Green, & Carrillo, 2002). Exhibit 2–3 A Diversity and Cultural Proficiency Assessment Tool for Leaders CHECKLIST As Diverse as the Community You Serve YES NO • Do you monitor at least every three years the demographics of your community to track change in gender and racial and ethnic diversity? _____ _____ • Do you actively use these data for strategic and outreach planning? _____ _____ • Has your community relations team identified community organizations, schools, churches, businesses, and publications that serve racial and ethnic minorities 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 on how 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 your hospital 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? _____ _____ When your hospital partners with other organizations for community health initiatives or sponsors community events, do you have a strategy in place to be certain you work with organizations that relate to the diversity of your community? _____ _____ • As a purchaser of goods and services in the community, does your hospital have a strategy to ensure that businesses in the minority community have an opportunity to serve you? _____ _____ Are your public communications, community reports, advertisements, health education materials, websites, etc. accessible to and reflective of the diverse community you serve? _____ _____ _____ _____ _____ _____ • Do your patient satisfaction surveys take into account the diversity of your patients? _____ _____ • Do you compare patient satisfaction ratings among diverse groups and act on the information? _____ _____ Have your patient representatives, social workers, discharge planners, financial counselors, and other key patient and family resources received special training in diversity issues? _____ _____ • Does your review of quality assurance data take into account the diversity of your patients in order to detect and eliminate disparities? _____ _____ • Has your hospital developed a “language resource,” identifying qualified people inside and outside your organization who could help your staff communicate with patients and families from a wide variety of nationalities and ethnic backgrounds? _____ _____ • Are your written communications with patients and families available in a variety of languages that reflects the ethnic and cultural fabric 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 continuing basis 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? _____ _____ • Do your recruitment efforts include strategies to reach out to the racial and ethnic minorities in your community? _____ _____ • 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 diversity and to surface potential problems? _____ _____ • • Culturally Proficient Patient Care • Do you regularly monitor the racial and ethnic diversity of the patients you serve? • • • • Do your organization’s internal and external communications stress your commitment to culturally proficient care and give concrete examples of what you are doing? Strengthening Your Workforce Diversity • • Do you compare the results among diverse groups in your workforce? Do you communicate and act on the information? _____ _____ Have you made diversity awareness and sensitivity training available to your employees? _____ _____ _____ _____ • 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? _____ _____ _____ _____ _____ _____ 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 your organization? _____ _____ • 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 as part of your strategic plan? _____ _____ • Does your organization have a process in place to ensure diversity reflecting your community on your Board and subsidiary and advisory boards? _____ _____ Have you designated a high-ranking member of your staff to be responsible for coordinating and implementing your diversity strategy? _____ _____ _____ _____ 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? _____ _____ • • Is the diversity of your workforce taken into account in your performance evaluation system? Expanding the Diversity of Your Leadership Team • Has 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? • • • • Have sufficient funds been allocated to achieve your diversity goals? • • © Used with permission of the American Hospital Association. Strategies for Leadership: a Diversity and Cultural Proficiency Assessment Tool for Leaders. 2004. http://www.aha.org/aha/content/2004/pdf/diversitytool.pdf In order to best serve their patient base, health care organizations and providers must be willing to invest the time, money, and effort needed to educate all their employees. Educating senior staff is important, but so is educating the entire health care workforce. Wilson-Stronks and Murtha (2010), Cejka Search and Solucient (2005), and Kochan et al. (2003) have linked the effects of diversity to business performance. Kochan and colleagues (2003) concluded that the impact of diversity is dependent upon the following factors: organizational culture, human resource practices, and strategy. In other words, the impact of diversity is directly related to the organization’s ability to walk their talk and can have a negative impact if not followed. For example, the Witt/Kieffer’s 2011 national survey of 454 health care professionals, with 54 percent representing senior executives, provides a deeper understanding of how diversity is connected to measurable business benefits: Patient satisfaction: Nearly two-thirds (62 percent) believe cultural differences improve patient satisfaction. • Successful decision-making: More than half (57 percent) believe that cultural differences support successful decision-making. • Strategic goals: More than half of these respondents (54 percent) acknowledge that diversity recruiting enables the organization to reach its strategic goals. • Clinical outcomes: Nearly half (46 percent) believe diversity improves clinical outcomes. • Dreachslin (2007) reinforces the need for mass customization of diversity practices to be inclusive of disparities that are represented within the communities that health care organizations serve. In order to actively support business strategy, organizations will need to provide employees with skills that are inclusive of conflict-management skills, self-awareness, understanding of cultural differences, validation of alternative points of view, and methods to manage bias through effective human resource training and development. For health care managers to transform their organizations into an inclusive culture where all employees fee...
Purchase answer to see full attachment