Imagine that you have been charged with transforming the performance of a team at your workplace. Specifically, it is under-performing, and your supervisor wants the team to be high-performing within six months. Based on the information in Chapter 18 of Organizational Behavior in Health Care and your own research develop a presentation for your supervisor that addresses the following:
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
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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.
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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
______
______
______
______
______
______
______
______
______
______
______
______
______
______
process, some individuals see a specific situation as a threat,
whereas other individuals see the same situation as a
challenge or opportunity.
16. Managers are under the constraints of limited time and
resources, personal bias and other factors, which make
rational decision-making unrealistic.
17. Conflict is inevitable and unavoidable.
18. Individuals join groups to satisfy their need for safety and
social needs.
19. 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.
20. 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. False
2. True
3. False
4. False
5. True
6. True
7. True
8. True
9. False
10. True
11. False
12. True
13. True
14. False
15. False
16. True
17. True
18. True
19. True
20. 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?
_____
_____
•
•
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?
_____
_____
• 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?
_____
_____
•
•
•
•
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 feel the opportunity to reach their full
potential, Guillory (2004, pp. 25–30) recommended a 10-step process:
1.
Development of a customized business case for diversity for your
organization. In other words, how does diversity relate to the overall
success of the organization?
2. Education and training for your staff to develop an understanding of
diversity, its importance to your organization’s success, and diversity
skills to apply on a daily basis.
3. Establishment of a baseline by conducting a comprehensive cultural
survey that integrates performance, inclusion, climate, and work/life
balance.
4. Selection and prioritization of the issues that lead to the greatest
breakthrough in transforming the culture.
5. Creation of a three- to five-year diversity strategic plan that is tied to
organizational strategic business objectives.
6. Leadership’s endorsement of and fina…
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