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Health & Medical Healthy Conflict Resolution Case Study Questions

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April 4th, 2024
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First, read “Case Study 15-8, Healthy Conflict Resolution”, of Organizational Behavior in Health Care.

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

  • What are the five conflict modes?
  • What is the basis/cause of the conflict in the case described?
  • What conflict style/handling-mode should be use to resolve the conflict?
  • Why is the chosen approach preferable to other approaches?
  • What are the advantages and disadvantages of your choice?

    • Case Study 15-8 Healthy Conflict Resolution
    “Cindy, please reschedule my afternoon clinic; I am going to be out for the rest of the day,” says
    Dr. Jones, a senior physician in a hospital-owned multispecialty group.
    “But, Dr. Jones,” Cindy says, while whipping off her telephone headset and turning away from
    the open patient registration window, “you are double booked for most of the afternoon
    because you canceled your clinic twice this month already. Many of these patients have been
    waiting more than three months to see you!”
    Jones glances furtively at the waiting room, and already half turned and heading toward the
    clinic exit, says, “I’m sure you will be able to smooth things over. Just tell them that I got called
    to an emergency.”
    Cindy has a suspicion that, because the weather is nice, Jones is taking off with a couple of
    colleagues to go sailing or play a round of golf. After all, he always sports a darn tan, comes to
    clinic late, and often leaves early. Cindy does not relish having to call and reschedule these
    patients, some of whom have already been rescheduled at least once in the past couple of
    months.
    Cindy decides enough is enough. She calls her manager and requests a meeting as soon as
    possible. Her manager can sense that Cindy is upset and offers to have someone cover for Cindy
    so that they can talk privately.
    Cindy tells the manager about the situation with Jones that happens “all the time,” and how she
    is “sick of it,” and will not “work another day under these conditions.” After calming Cindy
    down, the manager promises to bring the matter up with the chief of the department.
    To make a long story shorter, suffice it to say that this conflict continues to mushroom to involve
    several more individuals (the chief medical officer, the executive director of the clinic, the
    director of human resources, and the union representative) before Jones is ever
    made aware that Cindy has filed a formal complaint about him. When he is finally confronted, in
    a meeting with the chief medical officer and the director of human resources, he is caught
    completely off guard.
    After all, the incident happened several weeks ago, and Cindy did not mention anything to him
    about it. They have continued to work together, in his opinion, as if nothing were wrong. He is
    also surprised to find out that Cindy has been keeping a tally of the number of times that he has
    canceled his clinic, left early, or started clinic late.
    Jones goes from astonishment to red-faced anger in a few minutes. It is clear to all that the
    relationship between Cindy and the doctor is irreparable. Jones is labeled as a disruptive
    physician. Cindy is not welcome in any department because the other physicians are fearful of
    being targeted. Cindy eventually resigns, and Jones feels betrayed and unappreciated by his
    staff and his employer.
    If you were the manager in this case, how would you have handled the situation?
    FOURTH EDITION
    Organizational Behavior
    in HEALTH CARE
    Nancy Borkowski, DBA, FACHE,
    FHFMA
    Professor
    Department of Health Services Administration
    School of Health Professions
    University of Alabama at Birmingham
    Birmingham, AL
    Katherine A. Meese, PhD
    Assistant Professor
    Department of Health Services Administration
    School of Health Professions
    University of Alabama at Birmingham
    Birmingham, AL
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    Brief Contents
    Preface
    About the Authors
    PART I Introduction
    CHAPTER 1
    Overview and History
    of Organizational
    Behavior
    CHAPTER 2
    Diversity, Equity, and
    Inclusion in Health
    Care
    CHAPTER 3
    Diversity
    Management and
    Cultural Competency
    in Health Care
    CHAPTER 4
    Attitudes and
    Perceptions
    CHAPTER 5
    Workplace
    Communication
    PART II Understanding Individual
    Behaviors
    CHAPTER 6
    Content Theories of
    Motivation
    CHAPTER 7
    Process Theories of
    Motivation
    CHAPTER 8
    Attribution Theory
    and Motivation
    PART III Leadership
    CHAPTER 9
    Power, Politics, and
    Influence
    CHAPTER 10 Trait and Behavioral
    Theories of
    Leadership
    CHAPTER 11 Contingency Theories
    and Situational
    Models of Leadership
    CHAPTER 12 Contemporary
    Leadership Theories
    PART IV Intrapersonal and
    Interpersonal Issues
    CHAPTER 13 Stress in the
    Workplace and Stress
    Management
    CHAPTER 14 Decision Making
    CHAPTER 15 Conflict Management
    and Negotiation Skills
    PART V Groups and Teams
    CHAPTER 16 Overview of Group
    Dynamics
    CHAPTER 17 Groups
    CHAPTER 18 Work Teams and
    Team Building
    PART VI Managing Organizational
    Change
    CHAPTER 19 Organization
    Development
    CHAPTER 20 Managing Resistance
    to Change
    Index
    © Valex/Shutterstock
    Contents
    Preface
    About the Authors
    PART I Introduction
    CHAPTER 1 Overview and History of
    Organizational Behavior
    Overview
    Why Study Organizational Behavior in Health
    Care?
    The Health Care Industry
    History of Organizational Behavior
    The Hawthorne Studies
    Theories X and Y
    Related Disciplines
    Discussion Questions
    What Do You Know About Organizational
    Behavior?
    Scoring
    Interpretation
    References
    CHAPTER 2 Diversity, Equity, and
    Inclusion in Health Care
    Overview
    Diversity, Equity, and Inclusion Defined
    Changing U.S. Population
    Race/Ethnicity
    Age
    Gender
    Sexual Orientation, Gender Identity, and Gender Expression
    Implications for the Health Care Industry
    Summary
    Discussion Questions
    Exercise 2-1
    Exercise 2-2
    Exercise 2-3
    References
    Other Suggested Readings
    CHAPTER 3 Diversity Management
    and Cultural Competency in Health
    Care
    Diversity Management
    The Future Workforce
    Diversity in Health Care Leadership
    Cultural Competency
    Summary
    Discussion Questions
    Exercise 3-1
    Exercise 3-2
    Exercise 3-3
    References
    CHAPTER 4 Attitudes and
    Perceptions
    Overview
    Attitudes
    Cognitive Dissonance
    Formation of Attitudes
    Measurement of Attitudes
    Changing Attitudes
    Perception
    Attribution Theory
    Social Perception
    Halo Effect
    Contrast Effects
    Projection
    Stereotyping
    Pygmalion Effect
    Impression Management
    Employee Selection
    Summary
    Discussion Questions
    Case Study and Exercises
    References
    Other Suggested Readings
    CHAPTER 5 Workplace
    Communication
    Overview
    Communication Process
    Feedback
    The Johari Window
    Communication Channels
    Verbal Communication
    Electronic Communication
    Nonverbal Communication
    Barriers to Communication
    Environmental Barriers
    Personal Barriers
    Overcoming Barriers to Improve
    Communication
    Effective Communication for Knowledge
    Management
    Strategic Communication
    Flows of Intraorganizational Communication
    Upward Flow
    Downward Flow
    Horizontal Flow
    Diagonal Flow
    Communication Networks
    Informal Communication
    Cross-Cultural Communication
    Communicating with External Stakeholders
    Summary
    Discussion Questions
    Case Studies
    References
    PART II Understanding Individual
    Behaviors
    CHAPTER 6 Content Theories of
    Motivation
    Overview
    Maslow’s Hierarchy of Needs Theory
    Alderfer’s ERG Theory
    Herzberg’s Two-Factor Theory
    Job Design
    McClelland’s Three-Needs Theory
    Achievement
    Power
    Affiliation
    Summary
    Discussion Questions
    Case Studies and Exercises
    References
    Other Suggested Readings
    CHAPTER 7 Process Theories of
    Motivation
    Overview
    Expectancy Theory
    Equity Theory
    Satisfaction–Performance Theory
    Goal-Setting Theory
    Reinforcement Theory
    Summary
    Discussion Questions
    Case Studies
    References
    CHAPTER 8 Attribution Theory and
    Motivation
    Overview
    Attribution Theory
    Attribution Style
    Attributions and Motivational States
    Learned Helplessness
    Aggression
    Empowerment
    Resilience
    Promoting Motivational Attribution Processes
    Screening for Resilience
    Attributional Training
    Immunization
    Increasing Psychological Closeness
    Multiple Raters of Performance
    Conclusion
    Discussion Questions
    Case Studies and Exercise
    References
    Other Suggested Reading
    PART III Leadership
    CHAPTER 9 Power, Politics, and
    Influence
    Overview
    Sources of Power
    Other Sources of Power in an Organization
    Uses of Power
    Developing a Power Base
    Organizational Politics
    Upward Influence
    Conclusion
    Discussion Questions
    Case Studies
    References
    CHAPTER 10 Trait and Behavioral
    Theories of Leadership
    Overview
    Trait Theory
    Lewin’s Behavioral Study
    Ohio State Leadership Studies
    University of Michigan Studies
    Blake and Mouton’s Leadership Grid
    Conclusion
    Discussion Questions
    Case Study and Exercises
    Exercise 10-1
    Exercise 10-2
    Exercise 10-3
    Exercise 10-4
    Exercise 10-5 Leadership Questionnaire
    References
    CHAPTER 11 Contingency Theories
    and Situational Models of Leadership
    Overview
    Fiedler’s Contingency Theory
    House’s Path–Goal Leadership Theory
    Tannenbaum and Schmidt’s Continuum of
    Leadership Behavior
    Hersey and Blanchard’s Situational Leadership
    Model
    Leader–Member Exchange Theory
    Conclusion
    Discussion Questions
    Exercise 11-1
    References
    CHAPTER 12 Contemporary
    Leadership Theories
    Overview
    Transformational Versus Transactional
    Leadership
    Transactional Leadership
    Transformational Leadership
    Transformational Leadership: A Contradictory
    View
    The Implications of Transformational
    Leadership for the Health Care Industry
    Other Contemporary Leadership Approaches
    The Charismatic Leader
    Servant Leadership
    Collaborative Leadership
    Another Look at Traits and Behavior
    Big Five Personality Factors
    Emotional Intelligence
    Behavioral Competencies
    Summary
    Discussion Questions
    Exercise 12-1
    Exercise 12-2 Are You a Charismatic Leader?
    Exercise 12-3 What Is Your EQ?
    Exercise 12-4
    Appendix 12-A Traits and Skills of Collaborative
    Leaders
    Appendix 12-B Six Key Practices and Necessary
    Steps for Leaders to Guide Successful
    Collaborations
    References
    Other Suggested Readings
    PART IV Intrapersonal and
    Interpersonal Issues
    CHAPTER 13 Stress in the Workplace
    and Stress Management
    Overview
    Work-Related Stress
    Workplace Violence
    Stressors
    Positive and Negative Stressors
    Internal or External Stressors/Acute or Chronic
    Individuals and Stress
    Personalities
    Underrepresented Populations
    Gender
    Beliefs About Stress
    Burnout
    Presenteeism
    Causes of Workplace Stress
    Coping with Stress
    Organizational Coping Strategies
    Joy in Work
    Job Design
    Individual Coping Strategies
    Learned Optimism
    Stress Management Programs
    Summary
    Discussion Questions
    References
    Other Suggested Readings
    CHAPTER 14 Decision Making
    Overview
    Rational Approach
    Bounded Rationality Model
    Intuition
    Heuristics or Biases Approach
    Escalation of Commitment and Framing Heuristics
    Decision-Style Model
    Vroom-Yetton Decision-Making Model
    Conclusion
    Discussion Questions
    Exercise 14-1
    Exercise 14-2
    Exercise 14-3
    References
    Other Suggested Readings
    CHAPTER 15 Conflict Management
    and Negotiation Skills
    Overview
    Types of Conflict
    Levels of Conflict
    Intrapersonal Conflict
    Interpersonal Conflict
    Intragroup Conflict
    Intergroup Conflict
    Interorganizational Conflict
    Conflict Management
    Conflict Negotiation Models
    Distributive Model
    Integrative Model
    Interactive Model
    Benefits of Skilled Conflict Resolution and
    Negotiation
    Conclusion
    Discussion Questions
    Case Studies
    References
    Other Suggested Readings
    PART V Groups and Teams
    CHAPTER 16 Overview of Group
    Dynamics
    Overview
    What Is a Group?
    Group Interaction
    Why Do People Join Groups?
    Roles of Group Members
    Group Norms
    Cohesiveness
    Size of the Group
    Social Loafing
    Experience of Success
    Group Status
    Outside Threats to the Group
    Conformity
    Groupthink
    Conclusion
    Discussion Questions
    Exercise 16-1
    Exercise 16-2
    Be the Best We Can Be Team Norms
    Exercise 16-3
    References
    CHAPTER 17 Groups
    Overview
    Types of Groups
    Primary Groups
    Secondary Groups
    Reference Groups
    Informal or Formal Group Structure
    Informal Groups
    Formal Groups
    Group Development
    Group Decision Making
    Rational Decision-Making Processes
    Brainstorming
    Nominal Group Technique
    The Delphi Technique
    Irrational Decision-Making Processes
    The “Garbage Can” Decision-Making Process
    Conclusion
    Discussion Questions
    Exercise 17-1
    Exercise 17-2
    References
    CHAPTER 18 Work Teams and Team
    Building
    Overview
    Teams and Teaming
    Types of Teams
    Virtual Teams
    Building Team Performance
    Common Characteristics of Successful Teams
    Barriers to Effective Teamwork
    Conclusion
    Discussion Questions
    Exercise 18-1
    Exercise 18-2
    Exercise 18-3
    References
    Other Suggested Readings
    PART VI Managing Organizational
    Change
    CHAPTER 19 Organization
    Development
    Overview
    Organization Development
    The Organization Development Professional
    Action Research
    Steps in the Organization Development Process
    Entering and Contracting
    Diagnosis
    Planning and Implementing Change
    Evaluating and Institutionalizing Change
    Organization Development Interventions
    Appreciative Inquiry
    Conclusion
    Discussion Questions
    References
    CHAPTER 20 Managing Resistance
    to Change
    Overview
    Drivers of Change
    Resistance to Change
    Individuals’ Barriers to Change
    Discomfort with Uncertainty
    Perceived Negative Effects on Interests
    Perceived Breach of Psychological Contract
    Lack of Clarity as to What Is Expected
    Excessive Change
    Lewin’s Change Model
    Transformation of Health Care Organizations
    Summary
    Discussion Questions
    Case Study
    References
    Other Suggested Readings
    Index
    © Valex/Shutterstock
    Preface
    In the first edition of this book, Chapter 1 stated that
    “the U.S. health care industry has grown and
    changed dramatically over the past twenty-five
    years.” That was an understatement! Since that
    time, the industry has experienced some of the most
    dynamic changes that health care managers have
    seen. In the coming years, more system-wide
    changes will occur as we continue our push forward
    to achieve patient-centered, value-based health
    care. Health care managers are quickly learning that
    what worked in the past might not work in the future.
    This was the compelling reason 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 we 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,
    health care employs more than 16 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 our goal to give you a
    greater understanding of why and how people and
    groups behave as they do in the workplace. With
    this knowledge, you will be able to predict and
    effectively influence the behavior of the people you
    lead. Please let me know if we accomplish our goal!
    You can reach us at nborkows@uab.edu or
    kameese@uab.edu.
    We have tried to ensure that we referenced all the
    individuals whose work contributed to the
    development of this book. However, if by chance we
    failed to give credit to someone along the way,
    please contact us so that we can make the
    necessary correction.
    At this time, we wish to thank our families for their
    patience, understanding, and support over the
    years. Finally, we wish to thank the many wonderful
    and caring people employed throughout the health
    care industry with whom we have had and will
    continue to have the opportunity to work with. Our
    lives continue to be blessed by these dedicated
    individuals!
    Thank you for purchasing (and reading) our book.
    We welcome your comments and suggestions, and
    we wish you the best on your health care
    management and leadership journey.
    With personal regards,
    Nancy Borkowski, DBA, FACHE, FHFMA
    Katherine A. Meese, PhD
    © Valex/Shutterstock
    About the Authors
    Nancy Borkowski, DBA, 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 25 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 board certified in health management and is 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 the
    professional development of health management
    students.
    Over the past three decades, Dr. Borkowski has
    served in various leadership roles for the
    Association of University Programs in Health
    Administration, 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, the Alabama 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 Frederick T. Muncie Gold Award from the
    Healthcare Financial Management Association
    (2017).
    Katherine A. Meese, PhD, is an Assistant
    Professor in the Department of Health Services
    Administration at the University of Alabama at
    Birmingham. She earned her PhD in Health
    Services Administration with a specialization in
    strategic management from the University of
    Alabama at Birmingham in 2019. Dr. Meese has
    seven years of industry experience, encompassing
    work in ten countries on four continents, including
    management positions for a large academic medical
    center. Her work has been published in Anesthesia
    & Analgesia, Health Services Management
    Research, Journal of Health Administration
    Education, and various other journals. Her research
    interests are in wellness, burnout, quality and
    safety, and delivery models that enhance
    organizational learning.
    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 focuses specifically on
    cultural competency and the skills that managers
    need to adapt to the changing environment explored
    in Chapter 2. Chapter 4 deals with attitudes and
    perceptions, which are the foundation for
    understanding organizational behavior. You will find
    the terms “attitude” and “perception” frequently
    referred to in the various organizational behavior
    theories. Finally, Chapter 5 discusses the
    importance of communication. Recent surveys have
    revealed that 70% of small- to medium-sized
    businesses claim that ineffective communication is
    their primary problem. Sentinel event data from The
    Joint Commission estimated that communication
    failure was the root cause for patient harm 70% of
    the time in 2400 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 differences 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 in an organizational
    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
    have lunch together regularly)?
    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.
    OB has three goals. First, OB attempts to explain
    why individuals and groups behave the way they do
    in organizational settings. 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 that 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 20 million individuals. The
    industry will account for almost a third of the nation’s
    projected job growth through 2026, adding over 2
    million jobs. The projected 1.9% per year growth
    rate is the fastest among all industry sectors
    (Bureau of Labor Statistics, 2019).
    Each segment of the health care industry (e.g.,
    hospitals, home health, rehabilitation facilities)
    comprises a different mix of health-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). Therefore, today’s health care
    managers need to have 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 in 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 therefore influence the behavior of
    employees to achieve organizational goals.
    Given the service-related intensity of the health care
    industry, understanding individuals’ behavior and
    group dynamics within health service organizations
    is critical to a health care manager’s success.
    Research indicates that the primary reasons why
    managers fail stem from difficulty in handling
    change, not being able to work well in teams, and
    having 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. Because readers are probably familiar
    with most of these changes either from 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 affect
    tomorrow’s health care industry.
    Past changes and future trends are interrelated
    forces that have shaped or will shape tomorrow’s
    health care organizations at both the system level
    and the organizational level. Declining
    reimbursement and changes in payment schemes
    for services have 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,
    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 and
    substantial legislative changes, such as the
    Medicare Prescription Drug, Improvement, and
    Modernization Act of 2003; the American Recovery
    and Reinvestment Act of 2009; the Patient
    Protection and Affordable Care Act of 2010 (ACA)
    and subsequent legislation to repeal portions of the
    act; and the Medicare Access & Chip
    Reauthorization Act of 2015 (MACRA). With an
    increased focus on chronic disease management,
    patients are living longer, and requiring more longterm 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 have increasingly high
    expectations of health care professionals. This trend
    has changed the way in which health care services
    are delivered, with a focus on patient satisfaction
    and safety as well as on the quality and value of
    services provided. Physician–patient relationships
    have changed because patients are beginning to
    understand that much of the responsibility for
    wellness lies with them and have easy access to
    health-related information. A growth in highdeductible insurance plans places a larger financial
    responsibility on patients to manage their own
    health and reduce unnecessary health spending.
    The economics of health care are 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 well-qualified people. Changes are
    also 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 that are 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
    which can contribute to the overuse and misuse of
    hospital emergency departments.
    To deal with these changes, a number of health
    care organizations have adapted their
    organizational forms by restructuring 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, longterm 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, numerous hospitals were
    acquired 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.
    Consolidation in health care began to rise rapidly in
    2009 and doubled between 2011 and 2015 (Health
    Care Financial Management Association, 2017).
    In addition, not-for-profit hospitals have merged with
    for-profit health systems as a result of competition
    and the need to reduce cost through 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 had to change the ways in which they and
    other employees carry out their job responsibilities.
    These changes have been forced on 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 to balance. 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 to maximize their
    ability to motivate staff and lead their organizations
    effectively.
    ▶ History of Organizational
    Behavior
    The beginnings of OB can be found in 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) well-known 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 timeand-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 included a concern for workers in
    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. The Hawthorne Studies had
    four phases: the illumination experiments, the relayassembly group experiments, the bank-wiring
    observation-room group studies, and the
    interviewing program. 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 in 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, the improvement
    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 5 years. During the
    first part of the experiment, the employees’ working
    conditions 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 the workers’ physical health and wellbeing. 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 high
    level that had occurred under 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 relay-assembly experiment. A group of
    workers were segregated so that their productivity
    and group dynamics could be studied. The workers
    were paid at 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 a result, 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 their
    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 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 on (1) the personal social
    conditioning (values, hopes, fears, expectations,
    etc.) that they brought to the workplace, formed
    from their previous family or group associations, and
    (2) the human satisfaction that 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. 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 (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),
    which, in modern society, were mostly satisfied and
    therefore no longer acted as motivators 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 about 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 employee behavior was nothing more than
    a self-fulfilling prophesy. The manager’s
    assumptions caused the staff’s “unmotivated”
    behavior.
    At the opposite end of the spectrum from Theory X,
    McGregor proposed Theory Y, which suggested
    productivity increased when managers created
    opportunities, removed obstacles and encouraged
    growth and learning for their employees. McGregor
    stated that participative (Theory Y) managers
    supported decentralization and delegation of
    decision making, job enlargement, and participative
    management because these allowed employees
    some 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
    ▶ Related Disciplines
    Before we conclude this chapter, we 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 was noted at the
    beginning of the chapter, OB is the study of
    individual and group dynamics within an
    organization setting and therefore is a micro
    approach. OT analyzes the entire organization and
    is a macro perspective, since the organization is the
    unit examined. The field of OD describes 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 the like for personnel management and is
    usually housed in a functional unit within an
    organization.
    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 team-building.
    Part VI provides an overview of managing
    organizational change within the context of
    organizational development.
    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.
    6. What Do You Know About Organizational
    Behavior?
    What Do You Know About
    Organizational Behavior?
    1.
    Questions
    True/False
    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;
    ___________
    therefore, we do not currently have ways to
    measure employees’ attitudes about their jobs.
    4.
    Extroverts do best in quiet, nonsocial 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 toward 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 that the
    behavior may be influenced if necessary.
    8.
    An employee’s degree of job satisfaction is
    ___________
    proportional to the actual amount of rewards
    the employee 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 in opposition.
    15. Because stress is a complex and highly
    ___________
    personalized process, some individuals see a
    specific situation as a threat, whereas others
    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 interaction.
    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.
    False
    9.
    True
    10.
    False
    11.
    True
    12.
    True
    13.
    True
    14.
    True
    15.
    True
    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 represent only a very
    small part of organizational behavior. If you didn’t
    score high, don’t be concerned. 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. (2019).
    Employment projections to 2016–2026. Available from
    https://www.bls.gov/emp/
    Daft, R. L. (2004). Organization theory and design (8th ed.).
    Mason, OH: Thomson South-Western.
    Health Care Financial Management Association. (2017, March 8).
    Mergers and acquisitions: Strategy takes precedence over
    scale. HFMA Buyer’s Resource Guide. Available from
    www.hfma.org
    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, Equity, and
    Inclusion in Health
    Care*
    LEARNING OUTCOMES
    After completing this chapter, the student should
    be able to:
    Define diversity, equity, and inclusion.
    Understand major trends in U.S
    demographics.
    Understand why changes in U.S.
    demographics affect the health care industry.
    Understand the unique challenges facing
    different groups of people.
    *
    We would like to thank Dr. Justin Lord for his contribution to this
    chapter. We wish to acknowledge and thank Dr. Jean Gordon,
    who was the contributing author of an earlier version of this
    chapter, which appeared in Organizational Behavior in Health
    Care (2014), Jones & Bartlett Learning.
    ▶ Overview
    Demographics of the U.S. population have changed
    dramatically in the past three decades. These
    changes directly affect the health care industry in
    regard to the patients we serve and our workforce.
    Over the next 40 years, there is expected to be a
    fundamental shift in which demographic groups
    represent majority and minority percentages of the
    U.S. population. According to the U.S. Census
    Bureau, by midcentury the White, non-Hispanic
    population will make up less than 50% of the
    nation’s population. The health care industry needs
    to change and adopt new ways to meet the diverse
    needs of our current and future patients and
    employees.
    This chapter is presented in three parts. First, we
    define the terms “diversity,” “equity,” and “inclusion.”
    Second, we discuss the changing demographics of
    the nation’s population. Last, we examine how these
    changes are affecting the delivery of health services
    from both the patient’s and the employee’s
    perspectives. Because diversity challenges faced by
    the health care industry are not limited to quality-ofcare 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.
    ▶ Diversity, Equity, and
    Inclusion Defined
    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)
    provides a more specific definition of 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). Therefore, diversity
    can mean a great many things, from differences in
    education, language, and background to race and
    gender identity. For our discussions, we will focus
    on the following characteristics: (1) race/ethnicity,
    (2) age, (3) biological sex at birth, and (4) sexual
    orientation, gender identity, and gender expression.
    Equity is providing fair treatment, access,
    opportunity, and advancement for all people while at
    the same time striving to identify and eliminate
    barriers that have prevented the full participation of
    some groups. Improving equity involves increasing
    fairness of the procedures and processes within the
    organization as well as in their distribution of
    resources. Tackling equity issues requires an
    understanding of the root causes of outcome
    disparities within our society and organizations
    (Kapila, Hines, & Searby, 2016).
    Inclusion refers to the act of creating environments
    in which any individual or group can feel welcomed,
    respected, and supported and can fully participate.
    An inclusive and welcoming climate embraces
    differences and offers respect in words and actions
    to all people (Kapila et al., 2016). Inclusion allows
    people to have a sense of belonging.
    A diverse environment with many different types of
    people might not be equitable or inclusive.
    Therefore, just increasing diversity is not enough.
    For example, if a manager does not offer the same
    mentorship and coaching to employees from
    underrepresented populations and therefore these
    employees do not get the same opportunities for
    promotion as nonminority employees do, that is not
    an equitable environment. An environment can be
    diverse and equitable but not inclusive. For
    example, maybe all employees have access to the
    same coaching and career development
    opportunities, but the manager plans a celebratory
    lunch during an important Jewish religious holiday.
    This lunch would not be inclusive because Jewish
    employees could not attend as a result of their
    religious obligations. One way to remember the
    differences between diversity, equity, and inclusion
    is by thinking about going to a dance. Diversity
    means that everyone is invited to the dance. Equity
    means that each person gets to contribute to the
    playlist. Inclusion means everyone gets asked to
    dance (Meyers, 2017; University of Michigan,
    2018; see Case 2-1).
    CASE STUDY 2-1 Diverse but
    Not Inclusive
    Jill, a young White female, was hired to work
    at a health care consulting firm. The team was
    very diverse, with people from all over the
    world who had a variety of educations and
    backgrounds. Jill’s coworkers had different
    religious and cultural beliefs, races,
    languages, and countries of origin. Jill felt that
    she connected well with all of her colleagues
    and really appreciated the unique
    perspectives they all brought to the team.
    However, she started to notice that the senior
    vice president, Mark, had a small group of
    favorites. The only people whom he would
    invite to lunch or have coaching sessions with
    were the younger White employees. In fact, as
    individuals started to get promoted, the White
    employees were promoted much higher and
    more quickly than anyone else. Although
    these employees’ promotions were usually
    deserved, other employees seemed to have a
    harder time gaining promotion even if they had
    performed equally well. When Jill had been at
    the company for almost a year, Mark
    scheduled a team lunch at an expensive
    restaurant to thank the entire team for
    surpassing productivity targets. The lunch was
    scheduled during Ramadan, which is an
    important religious time for Muslims, and
    involves fasting during the day. Jill overhead
    one of her Muslim coworkers whispering to
    another coworker, “Doesn’t he know how
    insulting it is to invite us knowing that we can’t
    eat anything? I mean if he had just waited one
    more week to schedule the lunch, we could all
    enjoy it.” Jill thought that Mark might have
    been unaware of the poor timing, so she
    brought it to his attention at their next one-onone meeting. When Jill raised the issue, Mark
    replied, “Well, I’ve got to keep the numbers
    down somehow if I want us to go somewhere
    expensive. They are invited. It’s not my
    problem if they choose not to eat.”
    Was this environment diverse, equitable, and
    inclusive? Why or why not?
    Unfortunately, we all have implicit or unconscious
    biases that can affect how we treat people of certain
    genders, gender identities, sexual orientations,
    races, ethnicities, and ages. Despite our best
    intentions, these implicit biases are often unknown
    even to ourselves, and they can lead us to create or
    accept environments in which certain people are
    treated poorly or are discriminated against. “Think of
    implicit bias as the thumbprint of the culture on our
    brain,” says Harvard University social psychologist
    Mahzarin Banaji (Joplin & Kunitz, 2018). Harvard
    University’s Project Implicit provides a series of free
    online implicit association tests to help people
    determine what implicit biases they hold. An
    analysis of almost 8000 participants found that
    people tend to demonstrate a moderate implicit
    preference for Whites over Blacks and for
    heterosexuals over homosexuals and a strong
    implicit preference for young over old people.
    People also have a stronger implicit association with
    men and science than with women and science
    (Project Implicit, 2019; see Case 2-2). It is only by
    recognizing our unconscious and implicit biases that
    we can hope to change them. Instead of denying
    their existence—we all have them—we must
    actively work to eliminate our own blind spots that
    might be leading us to treat certain types of people
    differently.
    CASE STUDY 2-2 You Don’t
    Look Like a Doctor
    Tamika Cross, a young African American
    physician who worked in Houston, was flying
    home from a wedding in Detroit. When the
    flight attendants asked for any physicians on
    board to help a passenger who had become
    unresponsive, Dr. Cross raised her hand and
    offered to help. The flight attendant
    responded, “Sweetie, put [your] hand down.
    We are looking for actual physicians or nurses
    or some type of medical personnel, we don’t
    have time to talk to you.”
    When Dr. Cross tried to inform the flight
    attendant that she was a physician, she was
    repeatedly dismissed and asked to show
    credentials. When she insisted that she was a
    doctor, the flight attendants responded with
    surprise and disbelief. The crew continued to
    ask any physicians on board to press their call
    buttons. A few moments later, a white male
    physician told the flight attendant that he was
    a physician, and Dr. Cross was sent back to
    her seat.
    Dr. Cross posted the account to her Facebook
    page, which then went viral on a number of
    social media sites and news outlets, sparking
    the #WhataDoctorLooksLike movement.
    What implicit biases do you think the flight
    attendant held about what a physician should
    look like?
    Reproduced from
    https://www.washingtonpost.com/national/healthscience/tamika-cross-is-not-the-only-black-doctor-ignored-in-anairplane-emergency/2016/10/20/3f59ac08-9544-11e6-bc79af1cd3d2984b_story.html accessed September 2, 2019.
    ▶ Changing U.S. Population
    To better appreciate the need for more diverse,
    equitable, and inclusive environments, it is important
    to understand how our population is changing. The
    demographic profile of the U.S. population is
    projected to undergo significant alterations over the
    next 40 years in age, gender, and ethnicity (see
    Table 2-1).
    Table 2-1 Projected Population of the United States by
    Age, Gender, and Race/Ethnicitya (in Millions)
    In 2016, 323.1 million people resided in the United
    States, an increase of 41.7 million people, or 14.8%,
    between 2000 and 2016. The 2016 census data
    showed a decline in the White, non-Hispanic
    population for the first time in history since the first
    census in 1790. This decline was almost a decade
    ahead of earlier projections. Additionally, there are
    currently more non-White children than White
    children under 10 years old for those born after
    2007 (Frey, 2018). This means that as the youngest
    generation ages, we are on the verge of a
    fundamental shift in the diversity of both patients
    and workers in the United States. In addition to the
    changing ethnic and racial composition of America,
    another trend is the aging population. The
    percentage of the population over age 65 is
    projected to increase from 15% to 23% by the year
    2060, an increase of 45.5 million people (see Table
    2-1). Finally, by the year 2030, international
    migration is projected to outpace the natural
    increase (excess of births over deaths) as the main
    cause of population growth (Vespa, Armstrong, &
    Medina, 2018).
    Males and females are almost evenly divided in the
    total population, representing 49.2% and 50.8%,
    respectively (see Table 2-1); however, in the
    population under age 25 years, males outnumber
    females. Among older adults, the male–female ratio
    reverses, with women outnumbering men, typically
    due to longer life spans (Vespa, Armstrong, &
    Medina, 2018). This imbalance is expected to
    persist through 2060 and beyond. However, the gap
    between males and females over age 65 is
    narrowing as men are living longer than men in
    previous generations.
    Race/Ethnicity
    The U.S. population continues to diversify racially as
    minority populations continue to increase at a faster
    rate than the White population. Although the nonHispanic White population still represents the
    largest group (61.3%) of the U.S. population, this
    number is expected to decrease by almost 10% by
    2060 (see Table 2-1).
    In 2016, the Hispanic or Latino population
    represented the largest minority in the United
    States, at almost 18% of the population. By 2060,
    Hispanics are expected to make up over a quarter
    of the U.S. population (27.5%), almost doubling in
    number. The remaining population is composed of
    13% Black or African American, 6% Asian and
    Pacific Islanders, 1% American Indians and Alaska
    Natives, and 3% people who identify 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
    people who identified themselves as being Asian
    (either alone or in combination with another race)
    grew 43.3%, while the total population grew only
    9.7% (U.S. Census Bureau, 2010). After people
    identifying as more than one race, the Asian
    population is expected to be the fastest-growing
    segment, doubling in size by 2060 (see Table 2-1).
    In addition to the resident population in the United
    States, health care organizations may encounter an
    even more diverse patient population, due to the
    strong reputation of U.S. health care and its
    popularity as a destination for medical travel and
    medical tourism. The United States is a highly
    desirable destination for health care for people
    around the world who might not be able to access
    various types of procedures or treatments in their
    home countries. Hundreds of thousands of visits
    from international patients from almost every
    country occur at U.S. hospitals every year
    (Johnson & Garman, 2010). As the middle class
    expands in countries such as China and India, this
    trend is expected to continue as more patients
    around the world are able to afford to travel for
    treatment. This means that health care workers will
    need additional skills and tools for dealing with a
    vastly more diverse population of patients coming
    from other countries in addition to the growing
    diversity in the domestic population.
    Unfortunately, people from underrepresented racial
    and ethnic groups often face additional challenges
    when they interact with the U.S. health care system.
    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 that 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% versus 16%)
    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% of Black non-Hispanics
    experience similar communication difficulties.
    Age
    The world’s population is aging at unprecedented
    rates. Slow population growth brought about by
    reductions in fertility leads to population aging; that
    is, it produces populations in which the proportion of
    older persons increases while that of younger
    persons decreases. For the first time in history, in
    2018 the number of people over age 65 in the world
    outnumbered the number of children under age 5.
    By 2050, the number of people over age 65 is
    projected to be double the number of people under
    age 5 (United Nations, 2019).
    The United States is experiencing the same trend.
    Between 2016 and 2060, the U.S. population under
    age 18 is expected to grow by 8%, and the
    population aged 45–64 is expected to grow by
    almost 15%. In stark contrast, the country is
    experiencing substantially faster growth rates for
    older ages. For example, the population over age 65
    is expected to almost double (U.S. Census Bureau,
    2018, see Table 2-1). The large growth in this age
    group is primarily attributable to the aging of the
    Baby Boom population and longer life spans due to
    disease control and advances in medical
    technology.
    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 rates for men and women, in that
    women tend to live longer than men. For example,
    life expectancy for men in the United States is 76.1
    years, whereas women’s life expectancy is 81.1
    years.
    While the elderly population is not as racially and
    ethnically diverse as younger generations, its racial
    and ethnical makeup is projected to diversify over
    the next four decades. As in the past, the largest
    proportion of the U.S. population age 65 and over is
    White. However, the racial composition of the older
    population is changing; the percentage of Whites is
    projected to decrease by 2060, and the percentages
    of all other race groups will increase (Vespa et al.,
    2018).
    Technology and other medical advances have given
    us the ability to increase longevity. As our citizens
    grow older, more services are required for the
    treatment and management of both acute and
    chronic health conditions. Health care professionals
    must devise strategies to care for the growing
    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 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, MD, a pioneer in geriatric medicine and a
    founding director of the National Institute on Aging
    (NIA). Butler (1969) 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”
    (p. 12).
    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 3-year residency
    training programs, only 9% required 6 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 continues
    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, as a result of 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 rehospitalizations, and
    improved care coordination, as well as annual
    screening for cognitive impairment, will assist in
    changing attitudes toward elderly patients.
    Gender
    As was previously noted, according to the U.S.
    Census Bureau, in 2016, 50.8% of the U.S.
    population was female and 49.2% was male—
    almost identical to percentages in the 2000 Census.
    That translates to 96 men for every 100 women.
    However, the ratio of men to women varies
    significantly by age group. There were about 105
    males for every 100 females under age 25 in 2010
    (U.S. Census Bureau, 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. Among
    older adults, the male–female ratio falls as women
    increasingly outnumber and outlive men. When we
    look at education, it appears that females and males
    are somewhat equal. Among the population age 25
    and older, 90% of both men and women were high
    school graduates, with 34% of men and 35% of
    women graduating from college (U.S. Census
    Bureau, 2017).
    Sexual Orientation, Gender Identity,
    and Gender Expression
    Another important aspect of diversity to consider in
    health care is sexual orientation, gender identity,
    and gender expression. The last decade has led to
    an increased focus on disparities that exist in the
    lesbian, gay, bisexual, transgender, and questioning
    community (LGBTQ). Various surveys estimate that
    people over age 18 who identify as LGBT make up
    2.8%–4.1% of the total population, or 5–10 million
    individuals in the United States, according to a
    Kaiser Family Foundation Report (Kates, Ranji,
    Beamesderfer, Salganicoff, & Dawson, 2018).
    The term “LGBTQ” may encompass elements of
    sexual orientation, gender identity, and gender
    expression. Sexual orientation is defined by the
    Institute of Medicine report as “an enduring pattern
    of or disposition to experience sexual or romantic
    desires for, and relationships with, people of one’s
    same sex, the other sex, or both sexes” (Graham et
    al., 2011, p. 27). For many people, sexual
    orientation does not fall neatly into any specific
    category and may be better described as belonging
    somewhere along a spectrum. Gender identity
    refers to one’s internal sense of being male, female,
    or something else (Kates et al., 2018). Because
    gender identity is internal, it is not necessarily visible
    to others. Gender expression refers to the outward
    and external portrayal of gender. Gender expression
    may include clothing, hairstyles, mannerisms, and
    taking on gender roles that are defined by one’s
    culture. Both gender identity and gender expression
    may be different from one’s biological sex at birth.
    These aspects of identity and orientation can span
    all ages, races, and biological genders. According to
    the Kaiser Family Foundation report, “while sexual
    orientation and gender identity are important
    aspects of an individual’s identity, they interact with
    many other factors, including sex, race/ethnicity,
    and class. The intersection of these characteristics
    helps to shape an individual’s health, access to
    care, and experience with the health care system”
    (Kates et al., 2018, p. 2).
    Individuals who identify as LGBTQ may experience
    unique health challenges that cannot be explained
    by differences in race/ethnicity, age, or gender
    alone. Because of discrimination and a variety of
    other factors, research has shown that self-identified
    lesbian, gay, and bisexual individuals are more
    likely to rate their health as poor and have higher
    prevalence of many chronic diseases such as
    cancer and cardiovascular disease, as well as
    asthma, allergies, headaches, and disabilities. In
    addition to concerns about physical health, studies
    have found that people who identify as LGBT are at
    a higher risk for mental health conditions, often as a
    result of prejudice, discrimination, and stigma.
    Various studies show that LBGT individuals are 2.5
    times more likely to suffer anxiety, depression, and
    substance misuse; are more likely to have
    experienced both sexual and physical violence; and
    have a substantially higher rate of suicidal ideation
    or attempts. In addition to stigma and discrimination,
    LGBTQ individuals may face additional health
    disparities resulting from practices that pose barriers
    to accessing health services. For example, some
    insurance companies will not pay for mental health
    services for transgender individuals. Additionally,
    between 6% and 15% of employers reported not
    offering same-sex spousal benefits to workers.
    Although these numbers are improving, there is still
    a substantial disparity in this area (Kates et al.,
    2018).
    However, there has been some progress in this
    area. Since 2007, the Healthcare Equality Index
    (HEI) of the Human Rights Campaign (HRC)
    Foundation has been available for use by hospitals
    and other organizations. This survey is a resource
    for health care organizations that are seeking to
    provide equitable, inclusive care to LGBTQ
    Americans and for LGBTQ Americans who are
    seeking health care organizations that have a
    demonstrated commitment to their care (HRC,
    2019). In 2018, 680 facilities across the country
    participated in the HEI survey, with 60% designated
    as leaders and 22% as top performers
    demonstrating that they have varying inclusive
    LGBT patient and employment policies. 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. 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. Additionally, patient forms
    should reflect diverse gender identities, allowing
    patients to identify both their biological sex at birth
    and their gender identity. 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.
    Table 2-2 Healthcare Equality Index’s Core Four Leader
    Criteria
    Criteria
    Non-discrimination and
    Patient non-discrimination
    staff training
    Equal visitation
    Employment non-discrimination
    Staff training
    Patient services and
    LGBTQ patient services & support
    support
    Transgender services and support
    Patient self-identification
    Medical decision making
    Employee benefits and
    Equal benefits
    policies
    Additional support for LGBTQ employees
    Healthcare benefits impacting
    transgender Employees
    Patient and community
    LGBTQ community engagement and
    engagement
    marketing
    Understand the needs of LGBTQ
    patients and community
    © 2019 by the Human Rights Campaign Foundation.
    ▶ Implications for the Health
    Care Industry
    The changing demographics of the U.S. population
    affect the healthcare industry significantly. Health
    care organizations need to work to reduce
    disparities in care and treatment provided to
    underrepresented populations as well as ensuring
    that our health care systems are diverse, equitable,
    and inclusive places for both patients and
    employees.
    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 had come 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 Maria would get
    through this fine. The young interpreter told Maria,
    “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!”
    At first glance, these might seem rather humorous
    misunderstandings, but there is nothing funny about
    a diabetic coma or the possibility of undergoing
    unneeded surgery, and real-life experiences such
    as these happen every day in the United States
    (Howard, Andrade, & Byrd, 2001). 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 their
    daughter 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, which
    recognized only the scientific necessities but
    ignored the family’s personal beliefs 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 in which 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. Health and health care
    disparities in the United States have been
    documented for many decades (see Exhibit 2-1).
    Kaiser Family Foundation and the Institute of
    Medicine both note that although many
    improvements in population health have occurred,
    numerous disparities have persisted and, in some
    cases, widened across many dimensions, including
    race/ethnicity, socioeconomic status, age, location,
    gender, disability status, and sexual orientation
    (Orgera & Artiga, 2018; Weinstein, Geller,
    Negussie, & Baciu, 2017). As noted by Orgera and
    Artiga (2018), there is a complex and interrelated
    set of not only individual and provider factors, but
    also a broad array of social and environmental
    factors both inside and outside of the health care
    system that affect individuals’ health and ability to
    engage in healthy behaviors, such as economic
    status, neighborhood/physical environment,
    educational levels, and access to healthy food.
    Exhibit 2-1 Unequal Treatment
    A 2002 study by the Institute of Medicine titled
    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 in
    the United States, members of
    underrepresented racial and ethnic groups
    receive fewer routine medical procedures and
    experience a lower quality of health services
    than the majority of the population. For
    example, members of 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 be subjected to
    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.
    ▶ Summary
    Health care organizations need to build
    environments that are diverse, equitable, and
    inclusive for the well-being of their patients and
    employees. The slower growth of the younger
    population of the United States will have a direct
    effect on the health care industry’s ability to recruit
    professionals to provide sufficient services in the
    future for a large elderly population. Young people
    of all races, ethnicities, and genders must be
    attracted to the health care industry as a career
    choice to meet the health care needs of the
    country’s growing, aging, and increasingly diverse
    population.
    Discussion Questions
    1. Discuss what the terms “diversity,” “equity,”
    and “inclusion” mean.
    2. Explain why and how changes in U.S.
    demographics affect the health care industry.
    3. What are the differences between diversity,
    equity, and inclusion?
    4. Describe a situation that is diverse but not
    equitable or inclusive.
    5. Describe a situation that is diverse and
    equitable but not inclusive.
    Exercise 2-1
    In 2012, the Alliance of Aging Research established
    the Healthspan Campaign, a coalition of
    organizations committed to solving the challenges
    brought about by the aging of the American
    population. With each passing year, the percentage
    of people in the United States—and much of the
    world—over age 65 increases. This “Silver
    Tsunami” is expected to bring a flood of chronic
    disease and disabilities due to aging that could
    overwhelm the health care systems of many
    nations. Watch the films The Healthspan Imperative
    and What Is the Silver Tsunami? at
    www.healthspancampaign.org. Discuss the effect
    of the aging population on our health system, and
    present recommendations for how these challenges
    could be addressed.
    Exercise 2-2
    In December 2012, the American College of
    Healthcare Executives released its fifth report in a
    series of research surveys designed to compare the
    career attainments of male and female health care
    executives. View this report, titled A Comparison of
    the Career Attainments of Men and Women
    Healthcare Executives: 2012, at www.ache.org. In
    small groups, discuss the changes (if any) regarding
    women advancing to senior leadership positions
    that have occurred in the health care industry since
    the previous report in 2006.
    Exercise 2-3
    In 2019, Modern Healthcare published its biennial
    recognition of the Top 25 Women in Healthcare.
    The previous lists appeared in 2017 and 2015 and
    can be found by searching for the list on the website
    modernhealthcare.com. In small groups, discuss
    the changes (if any) over the past 9 years of the
    selected awardee population (i.e., employment in
    what sectors of the health industry, the positions
    they do or did hold, race/ethnicity groups, and so
    on).
    References
    Alliance for Aging Research. (2003). Ageism: How healthcare fails
    the elderly. Available from www.agingresearch.org
    Bowling, A. (2007). Honour your father and mother: Ageism in
    medicine. British Journal of General Practice, 57(538), 347–
    348.
    Butler, R. (1969). Ageism: Another form of bigotry. The
    Gerontologist, 9, 243–246.
    Commonwealth Fund. (2002). International health policy survey of
    adults with health problems. Available from www.cmwf.org
    Dreachslin, J. L. (1998). Conducting effective focus groups in the
    context of diversity: Theoretical underpinnings and practical
    implications. Qualitative Health Research, 8(6), 813–820.
    Fadiman, A. (1998). The spirit catches you and you fall down.
    New York, NY: Farrar, Straus and Giroux.
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    Graham, R., Berkowitz, B., Blum, R., Bockting, W., Bradford, J.,
    de Vries, B. … Makadon, H. (2011). The health of lesbian,
    gay, bisexual, and transgender people: Building a foundation
    for better understanding. Washington, DC: Institute of
    Medicine.
    Howard, C., Andrade, S. J., & Byrd, T. (2001). The ethical
    dimensions of cultural competence in border healthcare
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    DC.
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    Available from https://www.hrc.org/hei/about-the-hei
    Johnson, T. J., & Garman, A. N. (2010). Impact of medical travel
    on imports and exports of medical services. Health Policy,
    98(2–3), 171–177.
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    Washington Post. Available from
    https://www.washingtonpost.com/video/national/can-youchange-implicit-bias/2018/05/29/e1d28542-604d-11e8b656-236c6214ef01_video.html
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    diversity, equity, and inclusion matter. Retrieved from
    https://independentsector.org/resource/why-diversityequity-and-inclusion-matter/
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    Defining DEI


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    Brewer, D. E. (2006). Are internal medicine residency
    programs adequately preparing physicians to care for the
    Baby Boomers? A national survey from the Association of
    Directors of Geriatric Academic Programs Status of Geriatrics
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    Communities in action: Pathways to health equity.
    Washington, DC: National Academies Press.
    Other Suggested Readings
    Institute of Medicine. (2004). In the nation’s compelling interest:
    Ensuring diversity in the healthcare workforce. Available from
    http://www.nap.edu/catalog/10885.html
    Lantz, P. (2008). Gender and leadership in healthcare
    administration: 21st century progress and challenges. Journal
    of Healthcare Management, 53(5), 291–304.
    Information relating to Anne Fadiman’s book The Spirit Catches
    You and You Fall Down may be viewed at
    www.spiritcatchesyou.com
    CHAPTER 3
    Diversity Management
    and Cultural
    Competency in Health
    Care
    LEARNING OUTCOMES
    After completing this chapter, the student should
    be able to:
    Define diversity management.
    Define cultural competency.
    Understand the importance of a culturally
    competent workforce in meeting the needs of
    patients.
    The population of the United States is changing
    rapidly and is becoming increasingly diverse. In
    response to the growing diversity of the general
    population, health care organizations must be
    prepared to handle the unique needs of a changing
    population in two key ways. First, organizations
    must ensure that diversity management programs
    are in place to provide an environment where
    people of all demographic types have the
    opportunity to succeed within the organization and
    to feel a sense of belonging. Second, health care
    organizations must ensure that their workforce is
    equipped to handle the needs of an increasingly
    diverse patient population by developing cultural
    competency. Diversity management strategies and
    cultural competency are the focus of this chapter.
    Health care organizations need to be flexible to
    change and meet diversity challenges. The greatest
    barrier to the industry’s success may be its inability
    to understand and appreciate the increasing
    diversity within our population, whether relating to
    patients or employees. As Kochan and colleagues
    (2003, p. 18) related,
    Diversity is a reality in labor markets and “customer”
    markets today. To be successful in working with and
    gaining value from this diversity requires a sustained,
    systemic approach and long-term commitment.
    Success is facilitated by a perspective that considers
    diversity to be an opportunity for everyone in an
    organization to learn from each other how better to
    accomplish their work and an occasion that requires a
    supportive and cooperative organizational culture as
    well as group leadership and process skills that can
    facilitate effective group functioning. Organizations that
    invest their resources in taking advantage of the
    opportunities that diversity offers should outperform
    those that fail to make such investments.
    ▶ Diversity Management
    Diversity management is a challenge for 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; WeechMaldonado, Dreachslin, Dansky, DeSouza, &
    Gatto, 2002). In 2004, the National Urban League
    published its first study on employees’ perceptions
    of the effectiveness of their companies’ diversity
    programs. The results of the organization’s 2009
    follow-up survey showed progress in certain areas.
    However, leadership commitment to diversity and
    companies clearly communicating their platform on
    how they value diversity are still lagging (see Figure
    3-1).
    Figure 3-1 American Workers’ Perceptions
    Data from National Urban League. (2009). Diversity practices that
    work: The American worker speaks II.
    As reflected in Figure 3-1, 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
    U.S. workers. As the National Urban League (2009)
    reported, 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 increasing
    diversity in the field of health care management,
    recent studies 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, disclosed in a 1992 study, that minorities
    held fewer than 1% of top management positions in
    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% of health care workers in six
    Midwestern hospitals thought that their institutions
    had a program to improve employee skills in dealing
    with people of different cultures, and only 38.9%
    thought that management realized that cultural
    factors were sometimes the cause of conflicts
    among employees. Weech-Maldonado et al. (2002)
    found that hospitals in Pennsylvania had been
    relatively inactive in employing diversity
    management practices and that equal employment
    requirements were the main driver of diversity
    management policy. Five years later, WeechMaldonado and colleagues (Weech-Maldonado et
    al., 2007; Weech-Maldonado, Elliott, Schiller,
    Hall, & Hays, 2007) continued to find low levels of
    diversity management activity in California hospitals.
    Since that time, the Institute for Diversity in Health
    Management, in collaboration with other
    organizations, has 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.
    ▶ The Future Workforce
    For the first time in modern history, the U.S.
    workforce consists of four separate generations
    working side by side, and the differences among
    generations are one of the greatest challenges
    facing managers today (Wasserman, 2007). Bonnie
    Clipper (2012, p. 45), author of The Nurse
    Manager’s Guide to an Intergenerational Workforce,
    provides a humorous example for understanding the
    generations’ differences.
    A nurse manager desperate for more staff, telephones
    four nurses to ask whether they will pull an extra shift:
    The first nurse says, “What time do you need
    me?”
    The second nurse says, “Call me back if you
    can’t find anyone else.”
    The third nurse says, “How much will you pay
    me?”
    The fourth nurse says, “Sorry, I have plans.
    Maybe next time.”
    Stokowski, L. A. (2013). The 4-generation gap in
    nursing. Medscape. Available from
    www.medscape.com/viewarticle/781752.
    These different responses are typical of the four
    generations of nurses currently working side by side
    at the bedside. The first response is from the
    traditionalist generational cohort. This generation,
    born between 1925 and 1942, is typically
    characterized as dedicated, hardworking, …

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