Health & Medical Healthy Conflict Resolution Case Study Questions

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:

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
JONES & BARTLETT
LEARNING
World Headquarters
Jones & Bartlett Learning
5 Wall Street
Burlington, MA 01803
978-443-5000
info@jblearning.com
www.jblearning.com
Jones & Bartlett Learning books and products are
available through most bookstores and online
booksellers. To contact Jones & Bartlett Learning
directly, call 800-832-0034, fax 978-443-8000, or
visit our website, www.jblearning.com.
Substantial discounts on bulk quantities of Jones
& Bartlett Learning publications are available to
corporations, professional associations, and
other qualified organizations. For details and
specific discount information, contact the special
sales department at Jones & Bartlett Learning
via the above contact information or send an
email to specialsales@jblearning.com.
Copyright © 2021 by Jones & Bartlett Learning,
LLC, an Ascend Learning Company
All rights reserved. No part of the material protected
by this copyright may be reproduced or utilized in
any form, electronic or mechanical, including
photocopying, recording, or by any information
storage and retrieval system, without written
permission from the copyright owner.
The content, statements, views, and opinions herein
are the sole expression of the respective authors
and not that of Jones & Bartlett Learning, LLC.
Reference herein to any specific commercial
product, process, or service by trade name,
trademark, manufacturer, or otherwise does not
constitute or imply its endorsement or
recommendation by Jones & Bartlett Learning, LLC
and such reference shall not be used for advertising
or product endorsement purposes. All trademarks
displayed are the trademarks of the parties noted
herein. Organizational Behavior in Health Care,
Fourth Edition is an independent publication and
has not been authorized, sponsored, or otherwise
approved by the owners of the trademarks or
service marks referenced in this product.
There may be images in this book that feature
models; these models do not necessarily endorse,
represent, or participate in the activities represented
in the images. Any screenshots in this product are
for educational and instructive purposes only. Any
individuals and scenarios featured in the case
studies throughout this product may be real or
fictitious, but are used for instructional purposes
only.
Production Credits
VP, Product Management: Amanda Martin
Director of Product Management: Laura Pagluica
Product Manager: Sophie Fleck Teague
Product Assistant: Tess Sackmann
Project Specialist: David Wile
Digital Project Specialist: Angela Dooley
Senior Marketing Manager: Susanne Walker
Production Services Manager: Colleen Lamy
Manufacturing and Inventory Control Supervisor:
Therese Connell
Composition: codeMantra U.S. LLC
Project Management: codeMantra U.S. LLC
Cover Design: Michael O’Donnell
Text Design: Kristin E. Parker
Senior Media Development Editor: Troy Liston
Rights Specialist: Maria Leon Maimone
Cover Image (Title Page, Part Opener, Chapter
Opener): © Valex/Shutterstock
Printing and Binding: Sheridan Books
Library of Congress Cataloging-in-Publication
Data
Library of Congress Control Number: 2020933339
6048
Printed in the United States of America
25 24 23 22 21 10 9 8 7 6 5 4 3 2
© Valex/Shutterstock
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.
Frey, W. (2018). US white population declines and Generation ‘ZPlus’ is minority white, census shows. Brookings Institution.
Available from https://www.brookings.edu/blog/theavenue/2018/06/21/us-white-population-declines-andgeneration-z-plus-is-minority-white-census-shows/
Graham, R., Berkowitz, B., Blum, R., Bockting, W., Bradford, J.,
de Vries, B. … Makadon, H. (2011). The health of lesbian,
gay, bisexual, and transgender people: Building a 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
settings. Family and Community Health, 23(4), 36–49.
Howden, L. M., & Meyer, J. A. (2011). Age and sex composition:
2010. U.S. Department of Commerce, Economics and
Statistics Administration, U.S. Census Bureau, Washington,
DC.
Human Rights Campaign. (2019). Healthcare equality index.
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.
Joplin, A., & Kunitz, D. (2018). Can you change implicit bias?
Washington Post. Available from
https://www.washingtonpost.com/video/national/can-youchange-implicit-bias/2018/05/29/e1d28542-604d-11e8b656-236c6214ef01_video.html
Kapila, M., Hines, E., & Searby, M., (2016, October 16). Why
diversity, equity, and inclusion matter. Retrieved from
https://independentsector.org/resource/why-diversityequity-and-inclusion-matter/
Kates, J. Ranji, U., Beamesderfer, A., Salganicoff, A., & Dawson,
L. (2018). Health and access to care and coverage for lesbian,
gay, bisexual, and transgender (LGBT) individuals in the U.S.
Kaiser Family Foundation. Retrieved from
https://www.kff.org/disparities-policy/issue-brief/healthand-access-to-care-and-coverage-for-lesbian-gaybisexual-and-transgender-individuals-in-the-u-s/
Meyers, V. (2017). The Verna Meyers company. Available from
https://learning.vernamyers.com/pages/about-vern-myers
Orgera, K., & Artiga, S. (2018). Disparities in health and health
care: five key questions and answers. Kaiser Family
Foundation. Available from https://www.kff.org/disparitiespolicy/issue-brief/disparities-in-health-and-health-carefive-key-questions-and-answers/
Perry, D. (2012). Entrenched ageism in healthcare isolates,
ignores and imperils elders. Aging Today, 33(2), 1.
Project Implicit. (2019). Explore the data: Implicit association test.
Available from https://pi-liz.shinyapps.io/explore-iat/
Traxler, A. J. (1980). Let’s get gerontologized: Developing a
sensitivity to aging. The multi-purpose senior center concept:
A training manual for practitioners working with the aging.
Springfield, IL: Illinois Department of Aging.
United Nations, Department of Economic and Social Affairs,
Population Division. (2019). World population prospects 2019:
Highlights (ST/ESA/SER.A/423). Available from
https://population.un.org/wpp/Publications/Files/WPP2019_Highlights.pdf
University of Michigan. (2018). Defining DEI. Diversity, equity and
inclusion. Available from

Defining DEI

U.S. Census Bureau. (2010). DP-1 – United States: Profile of
General Population and Housing Characteristics: 2010
Demographic Profile Data: U.S. Census Bureau 2000 Census
Data as shown I the 2009 Population Estimates table: U.S.
Census Bureau: National Population Estimates; Decennial
Census.
U.S. Census Bureau. (2017). Educational Attainment in the United
States: 2017. 2017 National population projections tables.
Available from
https://www.census.gov/data/tables/2017/demo/educationattainment/cps-detailed-tables.html
U.S. Census Bureau. (2018). 2017 National population projections
tables. Available from
www.census.gov/data/tables/2017/demo/popproj/2017summary-tables.html
Vespa, J., Armstrong, D. M., & Medina, L. (2018). Demographic
turning points for the United States: Population projections for
2020 to 2060 (Current Population Reports, P25-1144). U.S.
Census Bureau, Washington, DC.
Warshaw, G. A. (2002). Academic geriatrics programs in US
allopathic and osteopathic medical schools. Journal of the
American Medical Association, 288, 2313–2319.
Warshaw, G. A., Bragg, E. J., Thomas, D. C., Ho, M. L., &
Brewer, D. E. (2006). Are internal medicine residency
programs adequately preparing physicians to care for the
Baby Boomers? A national survey from the Association of
Directors of Geriatric Academic Programs Status of Geriatrics
Workforce Study. Journal of the American Geriatrics Society,
54(1), 1603–1609.
Weinstein, J. N., Geller, A., Negussie, Y., & Baciu, A. (2017).
Communities in action: Pathways to health equity.
Washington, DC: National Academies Press.
Other Suggested 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, …

Order an Essay Now & Get These Features For Free:

Turnitin Report

Formatting

Title Page

Citation

Outline

Place an Order