Leadership competence essay assignment papers: professional competencies, and personal skills and responsibilities

This chapter presents the personal competencies a leader must develop, build, and maintain to be successful. It also discusses leadership knowledge, skills, and abilities and the ability–job fit a leader has with his or her organizational environment. Emphasis is placed on the understanding that health leaders work in a highly complex environment with a very educated and interdisciplinary workforce. Based on the complexity and diversity of the health industry workforce, leadership competence in leading people begins with understanding the elements of motivation, influence, and power as combined with the ability to communicate to those diverse audiences. Leadership success is often based on the leader’s capabilities in terms of motivation, influence, power, interpersonal relationships, communication, and inspiring teams. The chapter begins with a summary of leadership competencies from experts in the industry.

LEARNING OBJECTIVES 1. Describe the complexity of the healthcare industry in terms of workforce, environment, and societal expectations, and explain how a health leader’s mastery of competencies, influence processes, motivation, interpersonal relationships, and communication capabilities is necessary to successfully navigate that complexity. 2. Explain how the complexity of the health workforce may lead to communication failure and conflict, and summarize the use of quality communication and conflict management skills to successfully motivate subordinates, build interdisciplinary teams, and lead a health organization based on commitment rather than compliance or resistance. 3. Predict the outcomes of continuous use of the avoiding and competing strategies in a health organization, as compared to the compromising, accommodating, and problem-solving strategies; predict the outcomes of face-to-face communication as compared to use of the memoranda communication channel and media to disseminate ambiguous and urgent messages. 4. Analyze the health leader competencies in terms of the knowledge, skills, and abilities discussed in this chapter, differentiating the competencies described here with those not discussed; support your assessment. 5. By combining several theories and models, design an influence, power, and motivation leadership model for use in health organizations focused on subordinate commitment; modify this model for use with an interdisciplinary health team or group, and explain why this modification was necessary. 6. Evaluate competencies (knowledge, skills, and abilities) found in leadership practice concerning situational assessment, interpersonal relationships, influence processes, motivation, and communication necessary to successfully lead healthcare organizations; support your evaluation.


COMPETENCIES IN THE HEALTH PROFESSION As noted by Dr. Mary Stefl, a forerunner in academic education and a leading author in competency development in health care, “health executives in all professional settings must navigate a landscape influenced by complex social and political forces, including shrinking reimbursements, persistent shortages of health professionals, endless requirements to use performance and safety indicators, and prevailing calls for transparency.”1 Furthermore, she notes that leaders and managers are expected to continually do more with less. Developing competencies that are specific to the role an individual plays in the health setting aids healthcare organizations in communicating to executives the skills necessary for leading in these changing times. Baldrige National Quality Award criteria also hold leadership competencies and the application of sound, moral, and effective leadership in high regard. Today’s healthcare executives and leaders must have management talent sophisticated enough to match the increased complexity of the healthcare environment.1 Competencies in health care are important because they set professional standards by adding to the value of health education. Competencies are skills, knowledge, and attitudes that allow a health professional to perform to standards set within the profession. Establishing and implementing these competencies are based on education, training, and professional development. The health administration profession began to explore the concept of competency-based education to produce qualified healthcare executives in the 1990s. Early careerists in the health professions were taught that competencies in the health profession were composed of four key points that would assist graduates in achieving competence in executive positions: technical skills such as finance and human resources; a perceptive view of the industrial aspects in health care such as clinical process and various healthcare institutions; the explanation of analytic and conceptual concepts; and the interpretation of and acknowledgment of emotional intelligence.2,3 Calhoun, Vincent, Calhoun, and Brandsen also have been leaders in the health education process for developing competencies. They have suggested that “during the last decade there has been a growing interest in adopting a competency-based system in various areas of education, training, and professional development.”4 As a result, they list a number of competency initiatives that include calls for the following: 1. both curricular content and process review in health administration and related training programs; 2. rethinking and reform of current educational practices; and 3. evidence-based, outcomes-focused education in health management; and policy education.4 They also suggest that competencies in healthcare administration optimize organizational effectiveness by better equipping students with more than just the textbook information needed to succeed in the industry. However, they have suggested that in spite of governmental mandates and accrediting body specifications for education’s improvement, the debate about the use of competency models, the competencies themselves, and competency-based education (CBE) still continues in a number of postsecondary educational settings—both within and outside the professions.4,5 Competencies can also be described as a characteristic of a person that results in effective performance on the job. As a result, professionals are better prepared for excellence in the working world of the health professions. Competencies can also be thought of in terms of actual performance. A person can have the education and training to be a hospital administrator, but actually performing the job involved is another matter altogether. Mastery of specific competencies related to healthcare administration is the true measure of performance in the workplace. In health care, competencies are used to define discipline and specialty standards as well as expectations.6 The competency validation process should begin in the academic setting. Setting formal standards as a profession will give leaders clear direction on what they should be doing to be a successful leader within their organization. However, it is important to note that both the academic world and healthcare organizations need to be on the same page in terms of accepted competencies and expectations. The need for competencies has been an issue throughout the healthcare industry for decades. During the twentieth and twenty-first centuries there has been a growing interest in competency-based systems in various areas of education, training, and professional development. As a result, a number of competency initiatives have been undertaken across the health professions, including administration and medicine. Organizations that are able to hire leaders with competencies in healthcare management benefit from the ability of a leader to more quickly tackle the specifics of his or her job, retain staff who thrive under leadership that has the skills of collaboration and team building, and maintain a ready pool of exemplary employees competent to move up and through an organization, strengthening its quality of service as well as operations. The reason competency is important in healthcare administration is that health care continues to change and require a highly skilled workforce that readily adapts for lifelong learning. A prerequisite for ensuring this is the identification and specification of skill sets or competencies that accommodate those transformation processes. Additionally, leaders should recognize the development of competencies as a continual process that results in continual improvement. The focus on individual leadership competencies in health care is a continuation—and product—of earlier work by dozens of healthcare icons, including Abraham Flexner, Dr. Ernest A. Codman, Avedis Donabedian, and John R. Griffith (to name only a small handful). ABRAHAM FLEXNER Abraham Flexner is credited with shepherding in the scientific age of medicine. In 1910 he wrote Medical Education in the United States and Canada. This seminal piece of healthcare literature was used at that time as the basis to close more than 60 of the United States’ 155 operating medical schools that were still basing medical education on anachronistic practices. Flexner found that some medical schools were still awarding medical degrees based on apprenticeships and teaching students with woefully outdated and irrelevant curricula, and that none of the medical schools based their education on any one particular standard. As a result, Flexner recommended that all physicians needed formal didactic education, that this education be conducted in a university setting by skilled medical educators, that it conform to a recognized curriculum, and that standards and practices (early terms for competencies) be developed that would allow for uniform learning outcomes regardless of where any medical student earned a degree. Flexner’s report also recommended that physician education be based on both a scientific foundation and empirical knowledge. Using this methodology, it may be suggested that medical students of the era were the first of their generation to be taught to think critically; that is, to transcend the gaps between knowledge and abilities in the development of new skills.7,8

ERNEST A. CODMAN In 1917, Dr. Ernest A. Codman wrote A Study in Hospital Efficiency as Demonstrated by the Case Report of the First Five Years of a Private Hospital. Codman practiced medicine in the early 1900s during the start of the industrial revolution, and the U.S. healthcare system’s burgeoning interest in standardization (another early precursor term for competence). Today, Codman is credited with developing the “end results” methodology, which was a precursor to outcomes assessment. Codman’s end results methodology involved studying the delivery of patient care practices that resulted in more favorable outcomes (such as lower morbidity and mortality). However, unlike his contemporary Abraham Flexner, Codman’s efforts to improve patient outcomes in the Boston hospital in which he practiced were not met with approbation from peers. In fact, Codman was eventually asked to resign his medical position from the Massachusetts Medical Society for advocating policies and practices that none of his colleagues thought prudent or necessary. However, there was a growing trend within U.S. health care to meet the quality demands of a rapidly growing and more discerning patient base. As a result, the American College of Surgeons (an early precursor to the American Medical Association) eventually adopted Codman’s end result methodology as an early quality process to deliver better care. Today, we refer to this collective process of a population of providers all evaluating and treating patients in a similar way that results in the most favorable outcomes as standards of practice.9,10 AVEDIS DONABEDIAN Avedis Donabedian’s work in health care is most commonly associated with the construct of quality. Donabedian published three volumes on healthcare quality and divided quality assessment into three focal areas: structure, process, and outcome. Since the 1960s there have been numerous efforts at measuring and improving quality by assessing the clinical process by way of the Healthcare Effectiveness Data and Information Set (HEDIS) measure and the Institute for Healthcare Improvement’s (IHI’s) 100,000 Lives Campaign, which was promoted to spur healthcare organizations to systematically use evidence-based guidelines for specific medical issues. Other quality improvement efforts have led to the employment of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, which is a general healthcare satisfaction survey of care, and the Hospital Based Inpatient Psychiatric Services (HBIPS), which is a set of core psychiatric measurements developed in concert with the Joint Commission, the National Association of Psychiatric Health Systems (NAPHS), the National Association of State Mental Health Program Directors (NASMHPD), and the NASMHPD Research Institute.11,12 Although the aforementioned may seem like an alphabet soup of professional organizations and jargon, the key for early careerists is to recognize that these professional organizational metrics do, in fact, flow from the current knowledge, best practices, standards, and outcomes assessment within the field. As such, these professional organizations provide the “variables, measures, and operationalization” that competencies are evaluated through. JOHN R. GRIFFITH John R. Griffith has been an educator and scholar in the health professions for over 50 years. He is a past chair of the Association of University Programs in Health Administration (AUPHA), and has previously served as a commissioner for the Accrediting Commission on Education in Health Services Administration (now called the Commission on Accreditation Healthcare Management Education [CAHME]). His textbook, The Well-Managed Health Care Organization, is necessary reading for those candidates wanting to take the Board of Governors exam in order to become Board Certified in Healthcare Management through the American College of Healthcare Executives (ACHE). Finally, the material developed by the Griffith Leadership Center is strongly considered by a variety of professional organizations, university programs, and other entities as practical guidance from research and as advisory/best practices for the profession.13 COMPETENCY ASSESSMENT TOOLS AMERICAN COLLEGE OF HEALTHCARE EXECUTIVES The American College of Healthcare Executives (ACHE) has developed a Competencies Assessment Tool that healthcare executives can use in assessing their expertise in critical areas of healthcare management. The competencies are derived from the Healthcare Leadership Alliance (HLA), and the self-assessment is designed to help identify areas of strengths and weaknesses to develop a personal development plan. The competencies in this self-assessment tool comprise a subset relevant to management and leadership tasks typically performed by affiliates of the ACHE, regardless of work setting or years of experience. ACHE suggests its competency self-assessment can be a powerful tool in facilitating feedback about gaps in skills necessary for optimizing performance.14 HEALTHCARE LEADERSHIP ALLIANCE The Healthcare Leadership Alliance (HLA)—a consortium of six major professional membership organizations—used the research from and experience with its individual credentialing processes to posit five competency domains common among all practicing healthcare managers. The organizations of the HLA are the American College of Healthcare Executives (ACHE), American College of Physician Executives (ACPE), American Organization of Nurse Executives (AONE), Healthcare Financial Management Association (HFMA), Healthcare Information and Management Systems Society (HIMSS), Medical Group Management Association (MGMA), and its educational affiliate, the American College of Medical Practice Executives (ACMPE). The necessary competencies they have developed are: 1. Communication and relationship management 2. Professionalism 3. Leadership 4. Knowledge of the healthcare system 5. Business skills and knowledge NATIONAL CENTER FOR HEALTHCARE LEADERSHIP The Robert Wood Johnson Foundation created the Health Research and Development Institute, which revolves around creating a foundation for qualified leadership within U.S. health systems. To align initiatives with current shortcomings in the healthcare administration field, a group of 200 professionals gathered in 2001 at the National Summit on the Future of Education and Practice in Health Management and Policy. This group also identified specific facets of the overall healthcare administration problems. Deficiencies in expenditures, cost, quality, and patient satisfaction; difficulty attracting young professionals and leaders; lack of clear collegiate accreditation in health care administration; insufficient practical experience; lack of support for young managers; failure to provide opportunities for advancement for women and minorities in management positions; and a shortage of individuals being prepared for senior management positions of healthcare systems were the main focuses on improvement in education and training that came out of this summit. In response to this, the Robert Wood Johnson Foundation funded two grants, one of which established the National Center for Healthcare Leadership (NCHL). This center was seen as a formal structure to carry out the mission of encouraging stronger managerial leadership in the healthcare field. This group encourages broad participation throughout various career stages, establishes baseline data for the industry, identifies core competencies for superior performance, identifies best means for career preparedness, and strengthens values and diversity levels within the talent pool for executive management throughout the country. The NCHL succeeded in developing a protocol for evaluating organizational culture, aligning human resource systems with the organization’s competency model, creating the most widely used health leadership competency model (the Lifelong Learning Inventory [LLI]), and other projects to develop graduate students in health management education programs.15 The LLI can assist leaders in self-assessing their stage of professional competence.16,17 ASSOCIATION OF UNIVERSITY PROGRAMS IN HEALTH ADMINISTRATION The Association of University Programs in Health Administration (AUPHA) lists five core competencies of healthcare professionals: communication and relationship management, leadership, professionalism, knowledge of health care, and business skills. These are defined as follows: 1. Communication and relationship management: A healthcare executive should be able to communicate clearly and respectfully with patients, customers, industry leaders, partners, department heads, and hospital workers. He or she should be able to create meaningful relations with peers, and promote constructive interaction between individuals and groups in all situations. 2. Leadership: For obvious reasons, a healthcare leader needs to have the ability to create a shared vision for and inspire his or her entire team. He or she must also be able to create and implement a strong organizational plan for his or her hospital or institution. 3. Professionalism: A hospital executive must maintain the utmost professional, ethical, and moral conduct at all times, thereby setting a high standard of excellence for his or her team members. 4. Knowledge of health care: A good healthcare executive is on top of healthcare system policies, the latest innovations in healthcare technology, and the ever-changing political landscape of the industry. 5. Business skills: Business skills are needed to run a hospital like a business. Healthcare leaders need to have a good grasp of business principles, systems thinking, and business management in order to reach the higher levels of healthcare employment.

THE COMPLEX AND DYNAMIC HEALTH ENVIRONMENT The health industry exists in a very dynamic environment. If the environment were static (i.e., not changing), the workforce homogenous and consistent, and the technology of health simple, the need for and the value of leaders would be much lower than they are in reality. In effect, the real dynamic and complex environment of health necessitates competent and motivated leaders. Because the environment, workforce, technology, and systems are complex and dynamic, leadership in the health realm is essential. Also, societal expectations for health organizations and health professionals are very high; in truth, the expectations are for these organizations and professionals to be error free or flawless. How long would a pharmacy director keep his or her job if even 5%, or 3%, of that section’s work was erroneous? How successful would a physical therapy director or branch chief of the clinic be if new therapies and technologies were adopted 5 or 10 years after a competitor had adopted them? Would the director of the supply chain for a hospital be successful if that person did not keep up with the new medical and surgical items needed for the hospital to meet the professional or national standard of care? Of course, the responses in these scenarios would not be favorable; in fact, failure in these areas would be career minimizing for these hypothetical individuals. Clearly, the dynamic environment of the health industry requires competent leaders throughout the organization, from chief executive officer to section or branch director. In today’s health industry, the need for professionalization and competence are especially important. Competence means recognizing and having the ability to utilize the capabilities associated with leadership. It requires mastery of the special skills and learning from experiences that are required to become a “professional.” Many organizations in the United States focus on increasing the competence of professionals of health organizations. Many of these organizations or associations are populated by executives in the profession who are committing their time and resources for the causes that are important to them. Without this kind of interdisciplinary exchange, increasing competence levels of the industry, one leader at a time, might not be achievable. THE COMPLEX AND HIGHLY EDUCATED WORLD OF THE HEALTH WORKFORCE The health workforce is a complex assortment of individuals characterized by different backgrounds, educational experiences, certifications, specialties, and work locations. Reviewing the workforce reports from the federal government’s Health Resources and Services Administration, Bureau of Health Professions division,18 provides some appreciation of the diversity and heterogeneity of the health workforce. As a whole, the health workforce accounts for nearly 12 percent of the total U.S. workforce.19 Leaders in the health sector must be able to foster a culture that is conducive to change and growth as well as develop the full potential of their staff members and volunteers. Understanding culture is a big part of this effort. Put simply, a major component of culture is the human element. Culture includes the sum total of knowledge, beliefs, art, morals, laws, customs, and shared patterns of behaviors, interactions, cognitive constructs, and affective understanding that are acquired by a particular society through socialization.20 These shared patterns distinguish the members of one group from the members of another group. Studies have found that the values that vary from one culture to another significantly influence the constitutional effectiveness of the organization. Each of these groups has its own specialized training, norms, beliefs, and values, which may differ from those espoused by other groups. In stable times, such individual dynamics may be masked and subgroups submissive; in contrast, in turbulent times, these internal groups may seek some degree of autonomy. Moreover, the training, education, and experience of health administrators, doctors, nurses, allied health professionals and other paraprofessionals may result in the presentation of certain cultural concepts that are unique and may be expressed in different ways, such as aggressive needs for autonomy or increased advocacy for patient care versus financial survivability of the healthcare organization.21 Mechanisms that reinforce norms and behaviors arise when the leader focuses attention on specific, high-priority goals and objectives. These characteristics are taught by the leaders and, in turn, adopted by the staff and the supporters of the organization. In a reciprocal relationship, the culture influences leadership as much as leadership influences culture. The adroit leader in a health organization has a direct impact on the culture, which can affect how decisions are made with respect to fundraising, volunteers, and placement within the organization.22 For a leader in this complex world, the important issues are threefold: (1) the leader’s ability to focus a diverse group of individuals toward the mission, vision, and tasks of the organization; (2) the leader’s ability to determine which individuals, with their unique sets of knowledge, skills, and abilities, should be employed, where, and how they should be utilized to the greatest value of the organization; and (3) the leader’s use of the skills of communication and motivation, as well as culture development and maintenance to create systems and processes that are effective, efficient, and efficacious so that the organization can be successful within the environment in which it performs its mission. These leadership challenges are salient for leaders throughout the industry regardless of their level in a specific organization. As leaders progress upward in responsibility and accountability in a health organization, the complexity widens and deepens. Those are rather large leadership tasks! The myriad of specialties in the health workforce underline the advancement and specialization of the application of knowledge, skills, abilities, and technologies of the industry. Multidisciplinary teams, whether in clinical, administrative, or allied health, are becoming more prevalent in the delivery of care, administration of health organizations, and improvement of health status of communities. Understanding the different knowledge, skills, abilities, and perspectives each health professional brings to an issue, opportunity, or challenge that the organization faces is important for leaders. Effective handling of this need is essential so that the proper mix of professionals can be formed into a team, proper resources can be provided, and appropriate expectations can be set for the multidisciplinary team. Learning about each discipline and knowing which capability each type of health professional can competently perform will allow the leader to make the most efficient use of the most valuable resource—people. Table 5-1 presents a simple summary of a current snapshot of the health workforce. These various specialties and disciplines all have different education, licensure, credentialing, and licensure maintenance requirements. Therefore, different professional associations and societies, and credentialing and accreditation associations, have been developed to provide a set of standards for each distinct profession. These associations and societies also provide valuable connections and updates concerning the macro- and micro-environmental forces that are changing the health industry. A recent collaboration of five professional associations has created five domains that encompass a total of 300 competencies for the health leader and manager. An extract of competencies, focusing on leadership and management from Domain 2: Leadership, is provided in Table 5-2. Although this table focuses on the Leadership domain, leaders should possess the competencies identified in each domain. The professional associations involved in the collaboration to create this list of competencies are essential to leaders and managers in the health industry. The associations’ mission or charter (a reason to exist, a purpose), taken as a whole, is to keep their membership—that is, the leaders, managers, and stakeholders of the health industry—current on changing environmental forces. One of the many ways they perform this mission is to maintain close relationships with the legislative, judicial, and political entities of U.S. society. Health industry leaders should seek membership in these associations and certification as appropriate to their career track and personal career goals. This is a sincere and strong recommendation. Table 5-3 lists some of these associations, as well as provides contact information for the National Center for Healthcare Leadership and the Association of University Programs in Health Administration. Health leaders should become members and earn the appropriate certification from a professional association of the health industry. The associations and societies listed in Table 5-3 are the best known in the industry for leadership careers. For example, the NCHL provides essential services and information for the health leader. AUPHA and CAHME provide instructors of health industry leadership and management students with the standards and specialty certification for their programs. In addition, specialty associations exist to serve women, Asian, and African American health leaders and managers. Of note, recognized universities may be regionally accredited as institutions of higher learning, whereas specific colleges and specific programs are specialty accredited, such as with health administration regarding CAHME. Other specialty accrediting bodies for health industry leadership and management programs include the Council on Education for Public Health (CEPH)32 and the Association to Advance Collegiate Schools of Business (AACSB).33 Many leaders come from clinical or technical programs, backgrounds, and practical experiences. These leaders include, but are not limited to, physicians, physical therapists, pharmacists, occupational therapists, audiologists and speech pathologists, optometrists, and nurses. For would-be health leaders, maintaining membership and certification for your clinical or technical specialty is important, but securing membership in one of the professional leadership and management health associations—the one that provides the best fit for you—is also important for your personal growth, professional development, and upward career mobility. Not only are your leadership knowledge, skills, and abilities important, and not only is the environmental scanning support important, but the broader network of similar leaders that you will develop can also assist you and your organization greatly throughout your career. Table 5-1 Health Workforce Specialty Categories and Disciplines Category Specialties Medicine • Physicians of medicine (MD) and physicians of allopathic medicine (DO) • Many specialties, such as neurology, pathology, radiology, psychiatry, and surgery (e.g., thoracic, cardiac, orthopedic) • Many specialties, such as pediatrics, family medicine, obstetrics and gynecology, internal medicine, ophthalmology, and cardiology Nursing • Registered nurses (RN) • Advance practice nurses (NP or APN) • Licensed practical and vocational nurses (LPN) Dentistry • Dentists of surgery (DDS) and dentists of medical dentistry (DMD) • Dental hygienists • Dental assistants Nonphysician clinicians • Physician assistants (PA) and podiatrists (DPM) • Chiropractors • Optometrists and opticians Pharmacy • Doctors of pharmacy (PharmD) • Pharmacists • Pharmacy technicians and aides Mental health • Psychologists • Social workers • Counselors Allied health • Physical therapy, occupational therapy, speech-language pathology and audiology, and respiratory therapy • Various technicians and technologists (laboratory, emergency medical, radiology), paramedics, medical and clinical technologists, and nuclear medicine technologists • Medical records and health information technologists and technicians, dieticians and nutritionists, home health aides and nursing aides, orderlies and attendants Health administration • Health system and hospital administration, nursing home/long-term care administration, home health administration, health insurance, and integrated system administration • Medical practice administration, clinical practice administration, and technical area administration • Public health administration as a whole and/or, for example, in environmental health science, epidemiology, community and social behavior, health policy, maternal women and children, and biostatistics Industry segment associations are valuable assets not just to the health industry as a whole, but also to your organization. These associations include the American Hospital Association, American Medical Association, American Dental Association, and American Nurses Association, among many others. Maintaining connections and good relationships with these organizations will assist your organization in environmental scanning and situational assessment activities as well. As a health leader, you are responsible for maintaining your competence and your subordinate team’s competence, and for striving for and achieving organizational success. Leaders should regularly seek out continuing education—much of which is provided by the health professional associations—not just for themselves, but also for their subordinates. Most certifications you earn as a health leader, or as a clinician or technician for that matter, require regular continuing education credits or units. The next section expands on the topic of learning and competence.


LEADERSHIP KNOWLEDGE, COMPREHENSION, SKILLS, AND ABILITIES Knowledge focuses on recalling information with familiarity gained through education, experience, or association, whereas comprehension is the understanding of the meaning of the information such as of a science, an art, or a technique so as to interpret and translate that information into action. A skill is the effective and timely utilization of knowledge that is comprehended; it is the learned power of doing something competently through a developed aptitude. Ability is the physical, cognitive, or legal power to competently perform through natural aptitude or learned or acquired proficiency and competence. In essence, knowledge, comprehension, skills, and abilities are sequential, and the notions of “competence” and “proficiency” are critical to these definitions. Leaders grow in knowledge, comprehension, skills, and abilities through education, study, experience, mentoring, and observation. Most, if not all, of these capabilities are learned. Table 5-2 Leadership Domain: Health Professional Associations’ Collaborative Competency Directory Table 5-3 Professional Associations for Health Leaders and Managers Health Professional Association (Web Address) Mission American College of Healthcare Executives (ACHE) www.ache.org ACHE is an international professional society of more than 40,000 health executives who lead hospitals, healthcare systems, and other healthcare organizations. ACHE is known for its prestigious FACHE credential, signifying board certification in healthcare management, and its educational programs, including the annual Congress on Healthcare Leadership, which draws more than 4,500 participants each year. ACHE’s established network of more than 80 chapters provides access to networking, education, and career development at the local level.23 Medical Group Management Association (MGMA) www.mgma.com The mission of MGMA is to continually improve the performance of medical group practice professionals and the organizations they represent. MGMA serves 22,500 members who lead and manage 13,600 organizations in which almost 280,000 physicians practice. Its diverse membership comprises administrators, chief executive officers (CEOs), physicians in management, board members, office managers, and many other management professionals. They work in medical practices and ambulatory care organizations of all sizes and types, including integrated systems and hospital- and medical school-affiliated practices. Three related organizations, and their boards of directors and committees, help MGMA fulfill its commitment to members. • American College of Medical Practice Executives (ACMPE): The standard-setting and certification organization for group practice professionals • MGMA Center for Research: The research and development companion to MGMA that conducts quantitative and qualitative research to advance the art and science of medical group management • MGMA Services Inc.: A wholly owned, for-profit subsidiary of MGMA that was established to further the provision of high-quality medical management services and assist medical group practices in delivering efficient and effective health care24 American Organization of Nurse Executives (AONE) www.aone.org AONE is the national organization of nurses who design, facilitate, and manage care. With more than 6,500 members, AONE is the voice of nursing leadership in health care. Since 1967, this organization has provided leadership, professional development, advocacy, and research to advance nursing practice and patient care, promote nursing leadership excellence, and shape public policy for health care. AONE’s 48 affiliated state and metropolitan chapters and its alliances with state hospital associations give the organization’s initiatives both regional and local presences. AONE is a subsidiary of the American Hospital Association.25 Healthcare Financial Management Association (HFMA) www.hfma.org HFMA is the United States’ leading membership organization for healthcare financial management executives and leaders. Its more than 39,000 members—ranging from CFOs to controllers to accountants—consider HFMA a respected thought leader on top trends and issues facing the healthcare industry. HFMA members can be found in all areas of the healthcare system, including hospitals, managed care organizations, physician practices, accounting firms, and insurance companies. At the chapter, regional, and national levels, HFMA helps healthcare finance professionals meet the challenges of the modern healthcare environment in the following ways: • Providing education, analysis, and guidance • Building and supporting coalitions with other healthcare associations to ensure accurate representation of the healthcare finance profession • Educating a broad spectrum of key industry decision makers on the intricacies and realities of maintaining fiscally healthy healthcare organizations • Working with a broad cross-section of stakeholders to improve the healthcare industry by identifying and bridging gaps in knowledge, best practices, and standards Vision: To be the indispensable resource for healthcare finance Purpose statement: To define, realize, and advance the financial management of health care by helping members and others improve the business performance of organizations operating in or serving the healthcare field26 Healthcare Information and Management Systems Society (HIMSS) www.himss.org HIMSS is the healthcare industry’s membership organization exclusively focused on providing global leadership for the optimal use of healthcare information technology (IT) and management systems for the betterment of health care. Founded in 1961, and with offices in Chicago; Washington, D.C.; Brussels; Singapore; and other locations across the globe, HIMSS represents nearly 50,000 individual members and more than 570 corporate members who collectively represent organizations employing millions of people. HIMSS frames and leads healthcare public policy and industry practices through its advocacy, educational, and professional development initiatives designed to promote information and management systems’ contributions to ensuring quality patient care. Vision: Advancing the best use of information and management systems for the betterment of health care. Mission: To lead change in the healthcare information and management systems field through knowledge sharing, advocacy, collaboration, innovation, and community affiliations27 National Center for Healthcare Leadership (NCHL) www.nchl.org NCHL is a not-for-profit organization that works to assure that high-quality, relevant, and accountable leadership is available to meet the challenges of delivering quality patient health care in the twenty-first century. Its goal is to improve health system performance and the health status of the entire country through effective healthcare management leadership.28 Association of University Programs in Health Administration (AUPHA) www.aupha.org Commission on Accreditation of Healthcare Management Education (CAHME) www.cahme.org AUPHA is a global network of colleges, universities, faculty, individuals, and organizations dedicated to the improvement of healthcare delivery through excellence in health administration education. Its membership includes the premier baccalaureate and master’s degree programs in health administration education in the United States and Canada. The association’s faculty and individual members represent more than 230 colleges, universities, and healthcare organizations. When asked what they value most highly about AUPHA membership, these members cite the opportunity to meet and network with colleagues who share similar interests, learning about the issues facing the field, and witnessing the latest products and services for the healthcare industry.29 Vision: Improve health by promoting excellence and innovation in healthcare management education. Mission: AUPHA fosters excellence and innovation in healthcare management education, research, and practice by providing opportunities for member programs to learn from one another, by influencing practice, and by promoting the value of healthcare management education.30 Program certification and Accreditation: Programs seeking full membership in AUPHA must have achieved proven excellence as indicated by undergraduate certification or graduate accreditation. Certification and accreditation are processes of external peer review through which programs are examined to determine quality of the curriculum, infrastructure, and outcomes. Certification of undergraduate programs is available through AUPHA. Accreditation of graduate programs is carried out by the CAHME.31 Leaders may find the taxonomies developed by Benjamin Bloom useful as they reflect on their own capabilities and as they evaluate and develop subordinates whom they lead. Bloom’s theory is based on three types of learning or three learning domains (categories): • Cognitive: Mental skills (knowledge) • Affective: Growth in feelings or emotional areas (attitude) • Psychomotor: Manual or physical skills (skills) Trainers often refer to these three domains as KSAs (knowledge, skills, and attitudes [abilities]). Thus this taxonomy of learning behaviors can be thought of as “the goals of the training process.” That is, “after the training session, the learner should have acquired new skills, knowledge, and/or attitudes [and abilities].”34 “Bloom’s Taxonomy is a way to classify instructional activities or questions as they progress in difficulty. The lower levels require less in the way of thinking skills. As one moves down the hierarchy, the activities require higher-level thinking skills.”35 Table 5-4 describes the cognitive domain within Bloom’s Taxonomy.36 The cognitive domain involves knowledge and the development of intellectual skills. This includes the recall or recognition of specific facts, procedural patterns, and concepts that develop intellectual abilities and skills. There are six major categories in Table 5-4, which move from the simplest behavior to the most complex. The categories can be thought of as degrees of difficulties; that is, the first one must be mastered before the next one can be tackled. A revision of the cognitive domain in 2001 updated the terminology and uses active verbs. 1. Remembering: Retrieving, recognizing, and recalling relevant knowledge from long-term memory 2. Understanding: Constructing meaning from oral, written, and graphic messages through interpreting, exemplifying, classifying, summarizing, inferring, comparing, and explaining 3. Applying: Carrying out or using a procedure through executing or implementing 4. Analyzing: Breaking material into constituent parts, determining how the parts relate to one another and to an overall structure or purpose through differentiating, organizing, and attributing Table 5-4 Bloom’s Taxonomy of the Cognitive Domain (Original Version) Category and Example Key Words and Actions Knowledge: Recall of data or information Example: Defines leadership; identifies items from a list Defines, describes, identifies, knows, labels, lists, matches, names, outlines, recalls, recognizes, reproduces, selects, states Comprehension: Understands the meaning, translation, interpolation, and interpretation of instructions and problems; states problem in own words Example: Explains the steps and sequence of willful choice decision making; translates information and equations into a spreadsheet Comprehends, converts, defends, distinguishes, estimates, explains, extends, generalizes, gives examples, infers, interprets, paraphrases, predicts, rewrites, summarizes, translates Application: Uses a concept in a new situation or unprompted use of an abstraction; applies what was learned in the classroom to novel situations in the workplace Example: Uses quantitative methods to determine employee performance outliers; uses a policy to determine an employee’s merit raise increase or bonus Applies, changes, computes, constructs, demonstrates, discovers, manipulates, modifies, operates, predicts, prepares, produces, relates, shows, solves, uses Analysis: Separates material or concepts into component parts so that their organizational structure may be understood; distinguishes between facts and inferences Example: Determines sequential work process steps and transition points of a larger work system; gathers information and assessments to identify training needs in a department or unit Analyzes, breaks down, compares, contrasts, deconstructs, diagrams, differentiates, discriminates, distinguishes, identifies, illustrates, infers, outlines, relates, selects, separates Synthesis: Builds a structure or pattern from diverse elements; puts parts together to form a whole while emphasizing a new meaning or structure Example: Composes an organizational policy, operations, or process manual; organizes, plans, and leads a process improvement project Categorizes, combines, compiles, composes, creates, designs, devises, explains, generates, modifies, organizes, plans, rearranges, reconstructs, relates, reorganizes, revises, rewrites, summarizes, tells, writes Evaluation: Makes judgments about the value of ideas or materials Example: Selects the most effective, efficient, and efficacious solution to a health delivery problem; explains and justifies a project or annual budget Appraises, compares, concludes, contrasts, criticizes, critiques, defends, describes, discriminates, evaluates, explains, interprets, justifies, relates, summarizes, supports Source: Adapted from Bloom, B. S. (1956). Taxonomy of educational objectives. Handbook I: The cognitive domain. New York: David McKay. Retrieved from http://www.nwlink.com/~Donclark/hrd/bloom.html#cognitive 5. Evaluating: Making judgments based on criteria and standards through checking and critiquing 6. Creating: Putting elements together to form a coherent or functional whole; reorganizing elements into a new pattern or structure through generating, planning, or producing37 Next, we turn to the affective domain within Bloom’s Taxonomy. This domain includes the manner in which we deal with things emotionally, such as feelings, values, appreciation, enthusiasms, motivations, and attitudes. The five major categories are listed in Table 5-5 from the simplest behavior to the most complex. The psychomotor domain includes physical movement, coordination, and use of the motor-skill areas. Table 5-5 Bloom’s Taxonomy of the affective Domain (Original version) Category and Example Key Words and Actions Receiving Phenomena: Awareness, willingness to hear, selective attention. Example: Listens to others with respect; listens for and remembers name of newly introduced person Asks, chooses, describes, erects, follows, gives, holds, identifies, locates, names, points to, selects, sits, replies, uses Responding to Phenomena: Active participation in activities; learns from stimulus; attends and reacts to particular phenomenon; shows compliance in responding, willingness in responding, or satisfaction in responding (motivation) Example: Participates in discussions; gives presentations; questions new ideas, concepts, and models to understand them; knows rules and follows them Answers, aids, assists, complies, conforms, discusses, greets, helps, labels, performs, practices, presents, reads, recites, reports, selects, tells, writes Valuing: The worth or value a person attaches to a particular object, phenomenon, or behavior; ranges from simple acceptance (compliance) to commitment; based on the internalization of a set of specified values; clues often expressed in overt behavior and are often identifiable Example: Demonstrates belief in the democratic process; is sensitive to individual and cultural differences; speaks up appropriately on matters one feels strongly about Completes, demonstrates, differentiates, explains, follows, forms, initiates, invites, joins, justifies, proposes, reads, reports, selects, shares, studies, works Organization: Organizes values into priorities by contrasting different values; resolves conflicts between those values and creates new (or modified) value system; emphasis is on comparing, relating, and synthesizing values Example: Recognizes the need to balance freedom with responsible behavior; accepts responsibility for own behavior; explains role of systematic planning to solve problems; accepts professional ethical standards; balances abilities, interests, and beliefs as well as organization, family, and self Adheres, alters, arranges, combines, compares, completes, defends, explains, formulates, generalizes, identifies, integrates, modifies, orders, organizes, prepares, relates, synthesizes Internalizing Values: Has a value system that controls one’s behavior; behavior is pervasive, consistent, predictable, and characteristically that of a learner Example: Shows self-reliance when working alone; cooperates in group activities (teamwork); uses an objective approach to problem solving; displays professional commitment to an ethical framework and moral practice at all times; revises judgments and behaviors in light of new evidence; values people for what they are and how they behave, not on appearance Acts, discriminates, displays, influences, listens, modifies, performs, practices, proposes, qualifies, questions, revises, serves, solves, verifies Source: Adapted from Krathwohl, D. R., Bloom, B. S., & Masia, B. B. (1973). Taxonomy of educational objectives, the classification of educational goals. Handbook II: Affective domain. New York: David McKay. Retrieved May 12, 2009 from http://www.nwlink.com/~Donclark/hrd/bloom.html#affective Development of these skills requires practice, and achievement in this domain is measured in terms of speed, precision, distance, procedures, or techniques in execution. Table 5-6 lists the seven major categories in the psychomotor domain in order from the simplest behavior to the most complex. Understanding and utilizing these taxonomies will assist health leaders in evaluating their own progress in learning about leadership and applying leadership capabilities; moreover, it will assist leaders in structuring the development of their subordinate team members. Motivating and inspiring to focus the collective energy of a diverse workforce toward the mission and vision of the health organization is paramount to leadership success. The next section provides an overview of motivation and inspiration theories, models, and applications. Table 5-6 Bloom’s Taxonomy of the Psychomotor Domain (Original Version) Category and Example Key Words and actions Perception: The ability to use sensory cues to guide motor activity; ability ranges from sensory stimulation to translation. Example: Detects nonverbal communication cues; estimates where a ball will land after it is thrown; adjusts height of forklift forks in relation to pallet Chooses, describes, detects, differentiates, distinguishes, identifies, isolates, relates, selects Set: Readiness to act; includes mental, physical, and emotional sets; these three sets are dispositions that predetermine a person’s response to different situations. Example: Knows and acts upon a sequence of steps in a care delivery process; recognizes one’s abilities and limitations; shows desire to learn a new process (motivation) Begins, displays, explains, moves, proceeds, reacts, shows, states, volunteers Guided Response: The early stages of learning a complex skill, which include imitation and trial and error; adequacy of performance is achieved by practice. Example: Solves a financial or mathematical equation as demonstrated; follows instructions to conduct an activity Copies, follows, reacts, reproduces, responds, traces Mechanism: The intermediate stage of learning a complex skill; learned responses have become habitual and the movements can be performed with some confidence and proficiency. Example: Uses a personal computer and software program; drives a car Assembles, calibrates, constructs, dismantles, displays, fastens, fixes, grinds, heats, manipulates, measures, mends, mixes, organizes, sketches Complex Overt Response: The skillful performance of motor acts that involve complex movement patterns. Proficiency is indicated by a quick, accurate, and highly coordinated performance, requiring a minimum amount of energy; performs without hesitation, an automatic response. Note: Same as Mechanism but performed more quickly, better, and more accurately. Example: Operates a computer and software program quickly and accurately; displays confidence while addressing a group Assembles, calibrates, constructs, dismantles, displays, fastens, fixes, grinds, heats, manipulates, measures, mends, mixes, organizes, sketches Adaptation: Skills are well developed and the person can modify movement patterns to fit special situations and requirements. Example: Responds effectively and efficiently to unexpected situations and experiences; modifies instruction to meet the needs of the learners; uses a machine or medical instrument in a new way (not as intended) successfully Adapts, alters, changes, rearranges, reorganizes, revises, varies Origination: Creates new movement patterns to fit a particular situation or specific problem. Learning outcomes emphasize creativity based on highly developed skills. Example: Constructs a new theory or model; develops a new and comprehensive training program Arranges, builds, combines, composes, constructs, creates, designs, initiates, makes, originates Source: Adapted from Simpson, E. J. (1972). The classification of educational objectives in the psychomotor domain. Washington, DC: Gryphon House. Retrieved May 12, 2009 from http://www.nwlink.com/~Donclark/hrd/bloom.html#psychomotor MOTIVATION AND INSPIRATION In the health leader’s array of knowledge, skills, and abilities, motivation and inspiration rank high on the list. Carnevale states that “creating a climate that enhances motivation, with the commensurate increase in productivity, is a requirement.”38 Motivation is all about getting a person to start and persist on a task or project. Inspiration is the emotive feeling of value a person experiences while performing a worthy task or project. Motivation and inspiration in the present day are rooted in the concepts of influence and, to some degree, power. Leaders use motivation and inspiration to influence subordinate actions. Traditionally, leadership thinking rested in the concepts of power and influence. However, the modern-day art of leadership requires a more subtle approach to the misconception of aggressive power and “arm-twisting” influence. The well-educated and complex health workforce will resist the use of errant influence and positional power. Perhaps not surprisingly, many leaders, academics, and scholars disagree about the best use of power and influence. “There is more conceptual confusion about influence processes than about any other facet of leadership.”39 First this section presents a brief discussion of where influence “exists” for a person; it is followed by a discussion on group affiliation, and then influence as a concept is explored. Subordinates in health organizations look to leaders, and especially senior executives, as champions and sources of inspiration. Inspirational motivation in health organizations can be achieved when the leader passionately believes in the vision and is able to motivate others through this passion. The leadership team plays an important role in ensuring the success of the organization. This team determines the direction of the organization, while also ensuring that the details behind each event are managed well. Leaders have the responsibility of being concerned about the task of the organization and the support of the organization’s stakeholders. Successful health organizations have leaders who not only provide the overall vision for the organization, but also step in and play a pivotal role by motivating and recognizing the efforts of subordinates that contribute to success.40 Ethics and morality play a key role in motivating others as well; collectively, they represent a crucial characteristic for a leader to possess. The success of the organization may rise and fall on the perception of the community regarding the morals of the organization. Subordinates and the community expect leaders to use their best judgment and to do what is right. Although leadership distinctions may depend on the execution of skills and abilities, such as charisma, the distinction of authentic leadership rests heavily on perceptions of morality.41 To gain widespread support, the organization must demonstrate the sincerity of its mission and stay true to the values it supports as an organization. LOCUS OF CONTROL To understand where or how people are motivated and inspired, it is important to recognize each person’s perspective on influence. Rotter used a personality scale that measured locus of control orientation as a means of assessing influence.42 People with a strong internal locus of control orientation (a belief that they control their own destiny and success) believe that events in their lives are determined more by their own actions than by chance or uncontrollable forces. (Leaders and managers tend to be “internals.”) In contrast, people with a strong external control orientation believe that events are determined mostly by chance or fate and that they can do little to improve their lives. Research by Miller and Toulouse associated effective management (leadership) with managers (leaders) with an internal locus of control orientation.43,44 According to this research, some people are influenced inside themselves (internalizers) and some are influenced outside of themselves (externalizers). In reality, both an internalizer and an externalizer are present inside each person. As a health leader, it is important to understand those people you lead—specifically, to understand which subordinates are more internally oriented and which are more externally oriented. GROUP AFFILIATION Schutz’s theory of affiliation suggests that individuals form groups in response to three kinds of needs: • Inclusion need: The need to be included • Control need: The need for status and power • Affection need: The need to give and receive warmth and closeness These needs are cyclical; groups pass through observable phases of inclusion, control, and affection.45 When a leader balances a subordinate’s need for inclusion with his or her needs for control and affection within a group environment, the seeds of a powerful organizational or group culture are planted. In a study published in the research literature in 2007, charismatic leadership attributes used by leaders positively contributed to social identification processes and to social identity applied to the workplace.46 This suggests that leaders can positively influence group affiliation. Ideally, the leader’s subordinate group will be formed into a cohesive team. The health leader’s understanding and active use of the insight provided by Schutz’s theory could prove very valuable in developing a high-performing, effective, and efficacious team. INFLUENCE In the simplest terms, leader influence on one or more subordinates may have one of three possible outcomes: • Commitment: The person internally agrees with a decision or request from the leader and makes a great effort to carry out the request or implement the decision effectively. • Compliance: The person is willing to do what the leader asks but is apathetic rather than enthusiastic about it and will make only a minimal effort. The leader has influenced the person’s behavior but not the person’s attitudes. • Resistance: The person is opposed to the proposal or request, rather than merely indifferent about it, and actively tries to avoid carrying it out.47 Clearly, commitment is what every leader desires from each team member or members. The reason motivation is linked with inspiration is that leaders should communicate how the task, project, or action is integrated with a subordinate’s job activities and provide individualized consideration and concern for that subordinate. SELF-DETERMINATION THEORY Self-determination theory (SDT) is a motivation theory that focuses on human motivation, personality, and well-being.48 This macro theory assists in investigating people’s inherent growth and psychological needs and the conditions that promote self-motivation and personality integration.49 SDT begins with the assumption that people are active organisms that have only three basic psychological needs: autonomy, competence, and relatedness.50 Autonomy concerns the feeling of choice, and having the ability to initiate one’s own behavior, whereas relatedness is associated with respecting others, and the sense of relying on others.51 Competence is related to the ability of the individual to complete a challenging task and achieve a desired outcome.52 When these needs are supported and satisfied within a social context, people experience more vitality and self-motivation, as well as enhanced well-being.53 To create an environment that is conducive to satisfying the three basic psychological needs—autonomy, relatedness, and competence—leadership must first develop an interpersonal environment and appropriate relationships with their subordinates. Leaders should allow subordinates to participate in the decision-making and planning processes. This will encourage autonomy and self-empowerment. To promote relatedness and competence, health leaders should equip employees with the fundamental information needed to complete challenging tasks; they should set obtainable goals and encourage staff to use problem solving to formulate solutions. This will give team members or employees the satisfaction of achieving a desired outcome and allowing them to depend on each other to achieve a mutual goal. To promote intrinsic motivation and intrinsic goals, team members or employees should be rewarded with positive praise, public praise, achievement certificates, and other rewards, not just increased pay or salary. Team members should be allowed to choose their own goals, as long as the goals are in alignment with the organization’s goals. This will also promote autonomy. If the goals or tasks are interesting to the employee, intrinsic motivators will be used, and the task would be performed for the satisfaction of completing the task. To create an environment that promotes autonomy orientation, leaders should limit unnecessary rules, thus promoting workers’ empowerment. This will give subordinates a sense of authority, by having the ability to make decisions based on the value of their work environment. Employees will then tend to be self-regulated and orient towards the values of the organization when deciding how to behave and perform. This macro theory is the applied expression of social exchange–based theories, discussed next. MOTIVATION BASED IN SOCIAL EXCHANGE THEORY: EXCHANGE AND EXPECTANCY THEORIES Social exchange theory requires that leaders give something in exchange (e.g., higher salary, bonus, increased status) for improved or additional performance by subordinates. Under this theory, relationships can be described in terms of their rewards, costs, profits, and losses. As long as rewards exceed costs (group membership is profitable), group membership is attractive. In social exchange theory, cohesiveness of group members becomes a salient issue. Exchange theory, as developed by Graen, emphasizes the interaction of the leader with the subordinate or supervised group. The leader exchanges resources, such as increased job or task choices and latitude, influence on decision making, and open communication, for members’ commitment to higher involvement in organizational functioning.54 Under this theory, the leader categorizes followers into two groups: (1) the cadre or in-group and (2) the hired hands or out-group. With the in-group, the leader allows greater subordinate choices and decision making that contribute to higher performance, lower propensity to quit, greater supervisory relationships, and greater job satisfaction. The out-group receives less latitude and, therefore, has poorer performance outcomes. Social exchange theory and the application of Graen’s exchange theory are both salient factors in leadership. With a basic understanding of exchange theory, Vroom’s expectancy theory of motivation can be studied. According to Vroom’s expectancy theory,55 motivation depends on a person’s belief that effort will lead to performance, and performance will lead to rewards that are valued. If any of these three variables (expectancy, instrumentality, and valence) decreases in value, then motivation decreases. Likewise, as the variables increase in value, motivation increases. Expectancy is the subordinate’s belief that effort will result in quality performance; it focuses on how the employee perceives the relationship between his or her effort and performance. Instrumentality is the belief in the reward for quality performance; it refers to the perceived relationship between performance and outcome. Valence is the level of self-satisfaction in the reward and in the quality performance. In other words, how valuable is the outcome? Does the person think if he or she tries hard, the individual can achieve the outcome, and does the person think he or she can really achieve the outcome? Social exchange theories and models are closely integrated with goal setting, the subject of the next subsection. GOAL-SETTING THEORY: A MOTIVATIONAL THEORY Goal-setting theory,56–58 which was originally developed by Edwin Locke, is an effective motivational and inspirational leadership approach. Goals are the aim of an action or behavior. They can be set for any verifiable or measurable outcome. “Goals provide order and structure, measure progress, give a sense of achievement, and provide closure.”59 Locke’s basic assumption is that goals are immediate regulators of human action. An individual synthesizes direction, effort, and persistence to accomplish goals (Figure 5-1). To maximize the effectiveness of goal setting, specific and challenging goals should be established to focus action and effort over time so as to accomplish tasks. From 1968 to 1980, 90% of all studies conducted in this area showed that specific, well-defined, and challenging goals led to greater improvements in performance as compared to vague and easy goals.60 Individuals must commit to setting goals to produce results; the more difficult (challenging yet reasonable) the goal, the better the individual will perform. FIGURE 5-1 Locke’s goal-setting theory constructs and application. Individuals need leadership support (feedback, reward mechanisms, and required resources [time, training, and material goods]) to maximize performance when applying goal setting. “Goal setting and regular communication increase the challenge of the job, make it clear to workers precisely what they are expected to do, and deliver a sense of pride and achievement.”61 Locke suggests seven steps to follow to apply and optimize goal setting: 1. Specify objectives or tasks to be done. 2. Specify how performance will be measured. 3. Specify the standard to be reached. 4. Specify the time frame involved. 5. Prioritize goals. 6. Rate goals as to difficulty and importance. 7. Determine the coordination requirements.62 Leaders must ensure that the goals they set do not conflict with one another or with organizational goals. For groups, every group member should have verifiable specific goals, as well as an overall group goal to counter social loafing. Smaller groups (three to eight people) are more effective than larger ones in goal setting.63 The use of management by objectives (MBO) is an approach for leaders to utilize goal setting,64 whereby mutually acceptable goals can be developed with subordinates.65 Locke’s model coupled with SMART goals is an excellent model; SMART is an acronym for specific, measurable, attainable, relevant, and time-bound.66 Leaders should be cognizant of the risks of goal setting, which include excessive risk taking and excessive competitiveness. Indeed, goal failure can reduce subordinate confidence and create unwanted stress. However, the benefits of goal setting outweigh the negative potential aspects of applying the theory. “Goal-setting theories provide specific explanations for why people are motivated. Difficult, specific, and mutually developed goals will assist individuals in being motivated. Although goal setting is extremely useful, many individuals are motivated more by climate [current atmosphere or ‘feeling’ of the workplace; an easily changed phenomenon], culture, and affiliation.”67 Goal setting integrates well with other motivational theories. Although goal setting is a principal component of many motivational and performance theories, research in this genre has largely focused on locus of control influences and expectancy theory relationships. For the health leader, the merging or synthesis of related theories provides a powerful repertoire for utilization in a multitude of situations. Following are some examples of results from the evaluation of merged theories: • Considering the theory of locus of control, internalizers tend to have better performance than externalizers with regard to goal setting and applying goal setting.68 • In the merger of expectancy theory and goal-setting theory, goal setting is negatively related to valence (setting low-level goals does not satisfy individuals as well as setting high-level goals), and instrumentality is positively related to goal setting (difficult goals give the individual a greater sense of achievement, self-efficacy, and skill improvement than do easy goals).69 Clearly, motivation and influence are critical to leadership success. The understanding, application, and enhanced skill and ability a leader gains by using applied theories such as goal setting are invaluable.

POWER, INFLUENCE, AND THE BASIS OF POWER Power is a leader’s or agent’s capacity to influence another person’s, group’s, or organization’s values, beliefs, attitudes, and behaviors. Using power to influence a change of behaviors is less difficult than changing attitudes; attitudes are less difficult to change than either beliefs or values. Power and influence can be characterized in several ways; the two methods presented here are the most universal. Power can be discussed in terms of Kelman’s social influence theory70,71 and the process of social influence. Power and influence, serving as a catalyst, prompt three responses to varying degrees; that is, the subordinate or target of a leader’s power- and influence-based request or requirement may demonstrate instrumental compliance, internalization, and/or identification. • Instrumental compliance is defined as a subordinate’s or target person’s fulfillment of the leader’s requested action for the purpose of obtaining a tangible reward or avoiding a punishment controlled by the agent. This is an example of transactional leadership in action from a foundation of the social exchange theory. • Internalization is defined as a subordinate or target person’s commitment to support and implement requests (and actions required to fulfill the request) made by the leader because they are perceived to be intrinsically desirable and correct in relation to the target’s values, beliefs, attitudes, and self-image. In this response, the request or proposal becomes integrated with the target person’s underlying values and beliefs. It is an example of transformational leadership in action. • Identification is defined as a subordinate’s or target person’s imitation of the leader’s behavior and/or adoption of the same attitudes to please the leader. This is an example of social learning theory in action, closely linked to role modeling. Another method to consider in terms of the use of power and influence on subordinates, peers, stakeholders, and possibly superiors results in three possibilities: commitment, compliance, or resistance. • Commitment occurs when the person, group members, or organizational members who are the focus of power and influence from the leader internally agree with a decision or request from the leader; they then implement an approach to fulfill the request or implement the decision effectively, efficiently, and efficaciously. Commitment implies attitude change in the subordinates. • Compliance occurs when the person, group members, or organizational members are willing to do what the leader desires but in a mechanical or apathetic manner, applying only moderate to minimal effort. Compliance implies that the subordinate’s behavior, but not his or her attitude, has changed due to the leader’s influence. • Resistance happens when organizational members are opposed to the leader’s request and actively avoid carrying it out, perhaps even taking steps to block actions to fulfill the leader’s request. The most recognized basis of power and influence comes from French and Raven’s Power Taxonomy. Table 5-7 is presented in tandem with Kelman’s model for purposes of synthesis and comparison. Agenda power—the authority and control of agenda items—is similar to information power but can be recognized as a source of power as well: Consider the secretary’s or assistant’s control of meeting agenda items on behalf of the leader (superior). Moreover, health leaders have power from legitimate or formal power, also called position power: “Position power includes potential influence derived from legitimate authority, control over resources and rewards, control over punishments, control over information, and control over the organization of the work and the physical work environment.”72 Power is maintained, if not increased, by wise use of power. The use of power is particularly important in organizational culture; who controls resources, who receives those resources, and how resources are used contribute to the cultural disposition of the organization. Bolman and Deal, in their reframing organizational leadership model (specifically, under the “political” construct), overtly suggest that leaders must use power and resource distribution wisely. Again, consistent and predetermined leadership actions, when using power and distributing resources, are paramount to ensure leader success. Table 5-7 French and raven’s Power Taxonomy and Kelman’s Power and Influence Outcomes French and raven’s Power Taxonomy Description Kelman’s Influence Processes Reward Person complies to obtain rewards controlled by the agent. Instrumental compliance Coercive Person complies to avoid punishment by the agent. Instrumental compliance Legitimate (also called formal) Person complies because the agent has the right to make the request; person is under the chain of authority. Instrumental compliance, internalization, and identification Expert Person complies because the agent has special knowledge. Internalization Referent Person complies because he or she admires or identifies with the agent and wants the agent’s approval. Identification Information* Control of information by agent is a source of power. *Added by Yukl. Source: Adapted from French, J. R. P., & Raven, B. H. (1959). The bases of social power. In D. Cartwright (Ed.), Studies of social power (pp. 150–167). Ann Arbor, MI: Institute for Social Research; Kelman, H. C. (1958). Compliance, identification and internalization: Three processes of attitude change. Journal of Conflict Resolution, 2, 51–56; Kelman, H. C. (1974). Further thoughts on the process of compliance, identification, and internalization. In J. T. Tedeschi (Ed.), Perspectives on social power (pp. 125–171). Chicago: Aldine; Yukl, G. (1994). Leadership in organizations (3rd ed.). Englewood Cliffs, NJ: Prentice Hall, p. 202. Power and influence, and the basis of power, change in all organizations. “Power is not static; it changes over time due to changing conditions and the actions of individuals and coalitions.”73 Subcultures in health organizations have also been shown to create and build resistance to power, influence, and change.74 Controlling your emotions is “power’s crucial foundation”75 across all professional situations. Health leaders who control their emotional “self,” are cognizant of their sources and level of power, and are sensitive to subcultures in the organization and to sources and level of power in others will best navigate amid coalitions and groups in moving the health organization forward in a positive direction. Of course, as in motivation, influence and power, competence, network building, interpersonal relationship building, and communication competencies are also vital to leadership. Next, concepts of leadership network building, interpersonal relationships, personal development, and communication are discussed. FORMING RELATIONSHIPS, NETWORKS, AND ALLIANCES Leaders are rarely successful in any organization without the assistance of positive relationships and networks. Knowledge and education can only help an individual achieve certain levels of success. The ability to build relationships and networks is critically important at early stages of leadership development. However, as the junior leader emerges from initial leader development jobs into more responsible and complex positions in dynamic organizations, his or her success is no longer a function of skills and tools as much as the ability to influence the behaviors of those outside the organization; outside stakeholders form the basis for networks and alliances in the organizational environment.76,77 In support of this notion, Mintzberg found that leaders spend 44% of their time dealing with outside agents and stakeholders, and the rest of their time talking to internal (or other) elements associated with organizational survival.78,79 For health organizations, policies are official expressions and, at least, implied guidelines of expected behavior, decision making, and thinking within the organization. Because policies help organizations attain objectives, they must be consistent with the health organization’s mission. However, when determining policies, health organizations must take into account the needs of the stakeholders who make up outside networks and alliances. These external stakeholders include the community, patients, providers, and insurers. Stakeholders are constituents with a vested interest in the affairs and actions of health organizations. They include individuals, groups, and organizations affected by the health organization’s decisions and actions. A well-thought-out and implemented philosophy about stakeholders is a prerequisite to a health organization’s strategic planning effort, resource allocation and utilization, customer service strategies, and ability to cope with the external environment in general. Stakeholders can be classified into three groups: • Internal stakeholders “operate entirely within the bounds of the organization and typically include management and professional and nonprofessional staff.”80 • Interface stakeholders “function both internally and externally to the organization” and include medical staff, the governing body, and stockholders in the case of for-profit health organizations. • External stakeholders, such as suppliers, patients, and third-party payers, including government entities and officials, interact with the organization, provide resources, or use services of the organization. The health organization needs this stakeholder group to survive. Other external stakeholders include competitors, special-interest groups, local communities, labor organizations, and regulatory and accrediting agencies. Health organizations must assess stakeholders to determine which ones are most important, which ones pose potential threats, and which ones have the potential to cooperate with the health organization. Such an assessment suggests appropriate health organization behavior toward stakeholders, ranging from ignoring to negotiating to co-opting and cooperating. Asking a stakeholder group that the health organization has previously ignored to assist the organization with significant influence or resources would be futile. The assessment of stakeholders should also capture conflicting priorities, needs, demands, incentives, and political and financial pressures as related to the association with the health organization. Balancing the demands of multiple stakeholders with different interests is a major challenge. Levey and Hill suggest that the need for health organization managers (leaders) to balance demands can pose “moral dilemmas arising from responsibilities to patients, governing boards, (professional) staff, and community.”81 Balancing these demands maintains ethical values and social responsibility and prevents inappropriate demands made by single-interest stakeholders from predominating. The stakeholder philosophy should be consistent with continuous quality improvement. “For example, patients as consumers were passive stakeholders until this decade.”82 Patients are major stakeholders, as are third-party payers; both aggressively seek to influence the health organization. External stakeholders are a fact of life; responding to their legitimate interests while minimizing the effects of inappropriate demands is necessary. Health organizations are dynamic, heterogeneous entities composed of numerous suborganizations and interdependent processes. These linkages, when changed, affect other internal departments as well as the external environment. Various types of health organizations are found in both the private (owned by private individuals or groups) and public (owned by government) sectors. Health organizations may be institutions, the most prominent of which are hospitals and nursing facilities, or they may be programs and agencies such as public health departments and visiting nurse associations. All interact with, influence, and depend on their internal environments to provide the range of health services that, in turn, interact with, influence, and depend on the external environment that the organization serves. In earlier eras, traditional approaches to leadership development were based on the notion that an individual’s formal education prior to employment would provide enough learning to span an entire career. Today, however, restructuring efforts, coupled with continuous environmental and technological change, have contributed to rapid job obsolescence at all organizational levels; as a result, leaders need to rely more on outside relationships to ensure organizational success.83 This emerging focus on managing alliances and networks mandates that leadership development efforts concentrate as much on networking across the entire organization with stakeholders as on the technical requirements of leadership. Networks can be seen as living systems that adapt and change over time. As more individuals and groups join the network, they become dependent on one another for “group” survival and future growth.84 If one area of a network is threatened, other partners in the alliance may be less likely to abandon “one of their own” and move off to recruit new replacements if there is a friendship in place. Although relationship and network building may be difficult for many early careerists to understand and embrace, the practical reality of working and operating in the health environment requires a formal and informal network to achieve results. This need usually becomes apparent during the first few months of a new position. The application of the knowledge, skills, and abilities presented in this text will assist you in dealing with these kinds of real-world situations as they arise in the workplace. Health organizations establish supply chains; such a chain is both a network and an alliance between two or more organizations. In today’s collaborative, customer-driven, networked economy, forming and sustaining strategic business relationships with customers, suppliers, and partners has become a mission-critical imperative. If done well, the creation of collaborative relationships will lead to greater success and profitability for the organizations involved. As with all other aspects of business, specific steps are followed in forming these relationships—namely, planning, preparing, interaction, and analysis and refinement. These relationships are complex and require investigation and consideration of what each party wants out of the relationship.85 FORMAL AND INFORMAL NETWORKS The support of formal and informal networks—that is, groups of individuals connected in some way—is important for the leader to perform his or her duties. Formal professional networks include peers and superiors at the health organization as well as professional links to members of associations to which the leader belongs. Informal networks tend to be associated with friendship and longevity. Internal networks in the health organization assist leadership to accomplish goals and objectives as well as to move the organizational culture toward the desired state. External networks within the health professions and in the community are also important for career progression and health organization integration and acceptance in the communities served. The basis of building networks, whether internal or network, is interpersonal relationships. Formal networks in the workplace tend to mirror an organizational wire diagram or organizational structure diagram. These relationships are generally supervisory in nature and carry with them an annual performance appraisal of some sort. Health leaders in the higher positions can be great leaders—or, unfortunately, not-so-great leaders. If you encounter great leaders, learn from them. With not-so-great leaders, look to them to learn what not to do. Some leaders in the upper echelons of the hierarchy may not lead through charisma, motivation, and values-driven philosophies, but rather use coercion and legitimacy of position to manipulate their subordinates. Leaders of this sort do not care about or know the feelings of those under them. They focus only on organizational outcomes and lead through a bottom-line mentality. It may be difficult to work for such leaders; however, for those in job-lock situations with few options for employment elsewhere, the legitimate and coercive boss can dominate a formal network of subordinates for years, with his or her power going unchecked.86,87 What is important, when working under a not-so-good leader, is to be a great leader to those who follow you and are subordinate to you. You can be a great leader at whatever level you hold a position. Informal networks are relationships with others within or outside the health organization that exist through mutual understanding. They are based on the strengths and values of each member of the informal group and the shared aspiration of members’ success. Such may be the case with the local community hospital or health organization and the local entity itself. For example, the president of a local health organization cooperative or association benefits from the wide participation of local affiliated hospitals. The larger the network, the more legitimacy and creditability the cooperative or association may have among its peers in the community when it comes time to lobby local government for changes in policy or recognition of its members. In turn, the chief executive officers (CEOs) of the local hospitals and healthcare networks benefit from the opportunity to ally with a large assortment of peers and stakeholders in the local community and establish alliances to achieve various economies of scales on issues, resulting in better outcomes for both parties.88,89 From an individual perspective, the same lesson may be applied to the personal level within an organization. The locally elected union representative may have formal reporting relationships within the vertically integrated facility itself; however, if the internal union leader and the legitimately appointed CEO do not have a positive relationship, contract negotiations and employee complaints may result in less than cordial and collegial discussions. In the worst-case scenario, risk management issues may evolve into lawsuits and litigation rather than leading to open discussion, problem solving, arbitration, and mediation.90,91 From a more pragmatic perspective, the essential tasks of many leaders in nonprofit health organizations may include fundraising and lobbying state and local officials for funding. Although a CEO may be able to justify needs and budget expenses to outside agents and stakeholders, many CEOs of these types of organizations find that it is their ability to influence and leverage personal relationships that result in the advantageous distribution of funds and the personal contributions of charitable donors.92 Given this factor, organizational survival may depend as much on the CEO’s informal professional network as on the development of strategic plans and leadership of internal subordinates. INTERPERSONAL RELATIONSHIPS 93 Building relationships while in a leadership role is not always easy. Nevertheless, you can build relationships in a professional manner while maintaining your position of power and authority. If honesty, inclusion, and sincerity (the building blocks of trust) are the basis of your quality communication, and if that communication is culturally competent, then you can maintain your role while building relationships. You can gauge the nature of each relationship based on disclosure levels; leaders must consciously draw the line when determining their personal level of disclosure. Disclosing too much or too soon or too often can reduce your position power and authority; being personally “disclosure conservative” is a good initial approach when building new relationships. For health leaders (or any other leaders, for that matter), interpersonal relationships are required, are beneficial, and enhance leadership capability and success. Certain elements or factors facilitate improved, positive, and mutually beneficial relationships. In 1989, Yukl proposed a taxonomy of managerial behaviors in which one of the four major domains of managerial life was “building relationships”; in this construct, managing conflict, team building, networking, supporting, developing, and mentoring were the actual behaviors and activities leaders were recommended to engage in to strengthen relationships.94 A health organization leader should establish, enhance, and grow relationships with a myriad of organizational stakeholders both internal and external to the organization. There is no better method to build relationships than going to visit people in their own environment or location; this kind of “management by walking around” is a powerful approach. The next section provides an overview of four key factors that will enhance relationships. Each factor described has monumental importance, though many factors play a role in forging and maintaining solid relationships. FACTORS TO STRENGTHEN RELATIONSHIPS A relationship encompasses the feelings, roles, norms, status, and trust that both affect and reflect the quality of communication between members of a group.95 Relational communication theorists assert that every message has both a content and relationship dimension: • Content contains specific information conveyed to someone. • Relationship messages provide hints about whether the sender/receiver likes or dislikes the other person. Communicating with someone in a manner that provides both content and positive relationship information is important. Language, tone, and nonverbal communication all work together to provide communicative meaning that is interpreted by another person. Consider the following points about nonverbal communication:96,97 • Nonverbal communication is more prevalent than verbal communication and consists of the following elements: • Eye contact • Facial expressions • Body posture • Movement • People believe nonverbal communication more than verbal communication. • Sixty-five percent of meaning is derived from nonverbal communication. • People communicate emotions primarily through nonverbal communication. • Ninety-five percent of emotions are communicated nonverbally. Frequent communication that is timely, useful, accurate, and in reasonable quantity is needed to reinforce and validate the relationship. Thus one important factor in developing quality interpersonal relationships is quality communication of sufficient and desired frequency. A second factor is disclosure, which was mentioned briefly earlier in this chapter. Disclosure relates to the type of information you and the other person in the relationship share with each other; disclosure is one factor that can help you “measure” or evaluate the depth and breadth of a relationship. The “deeper” the information disclosed, the closer the bond of the relationship. Also, the broader the topics of information and experience sharing (e.g., family, work, fishing together, or playing golf) between people, the closer the bond of the relationship. Disclosure or self-disclosure is strongly and positively correlated with trust; that is, more trust means more disclosure. Again, trust starts with quality communication. Self-disclosure can be categorized and measured. In Powell’s model,98 level 5 illustrates a weak relationship bond, whereas level 1 shows a strong relationship bond: • Level 5: Cliché communication • Level 4: Facts and biographical information • Level 3: Personal attitudes and ideas • Level 2: Personal feelings • Level 1: Peak communication (rare; usually with family or close friends) Self-disclosure can be summarized as having the following characteristics:99 • A function of ongoing relationships • Reciprocal • Timed to what is happening in the relationship (contextual/situational/relational) • Should be relevant to what is happening among people present • Usually moves in small increments A third factor in building strong interpersonal relationships is trust (mentioned briefly in relation to self-disclosure). Trust is built and earned over time through honest interaction (communication and experiences). It is an essential component of a quality, positive relationship. Honesty, inclusion, and sincerity are directly linked to building trust. Honesty means being truthful and open concerning important pieces of information that you share with another person. Inclusion entails including the other person in the relationship in activities and experiences that are important to the other person, to you, and to both of you. Inclusion is also about making sure the other person is part of the “group” in the organization. Sincerity is meaning what you say, meaning what you do, and not keeping record or account of the relationship (not keeping score). Over time, if honesty, inclusion, and sincerity are the basis of your interactions with others, positive and quality relationships will begin to grow. A fourth factor in forging successful relationships is cultural competence. This factor is based not only on ethnic or national dimensions, but also on socioeconomic factors. For instance, consider the cultural differences in surgeons as opposed to nurses as opposed to facility technicians or linen staff or consultants. Every stakeholder group, and every individual, has a varying culture of uniqueness. Understanding those cultural issues—“walking a mile in someone else’s shoes”—is a factor important to building solid interpersonal relationships. Understanding and modifying your approach to relationship building and enhancement based on cultural differences will serve you well in leadership positions. COMMUNICATION AND CULTURE Health leaders need to have exceptional communication skills. They must learn the techniques for clarifying what someone else is saying and for being clear in their own communication. Mintzberg’s study on managerial work revealed that managers’ activity was characterized by “brevity, variety, and fragmentation”; managers were continually seeking information, preferring oral communications to written reports.100,101 This finding applies to leaders as well. The preference for oral communication may be difficult for health leaders to enact, but nonetheless is important. As an example of personal preference for oral communication, it has been noted that within the first 7 months of President Barack Obama’s administration, he had more White House Press conferences than George W. Bush did in his 8 years in the same position.102 Although verbal communication may be time consuming, given employees’, and the public’s, need for such communication, it is a very valuable tool that is essential to achieve success. Simply put, communication is the process of acting on information.103 Communication contributes tremendously to the culture and climate of the health organization. A response—feedback—is an essential aspect of the communication process. Obstacles to communication, called noise, either in the channel or in the mind of the receiver, may contribute to an inaccurate understanding of the intended message. Communication is the main catalyst behind the motivation efforts and strategies utilized by leaders.104 “Various management [leadership] practices, including goal setting, reinforcement, feedback, and evaluation, require communication.”105 There are three goals of communication: • Understanding • Achieving the intended effect • Being ethical (moral) Communication is a process of active transaction (transactive), which means messages are sent and received simultaneously. Everything you do or do not do, say or do not say, communicates something. You cannot not communicate. Communication media, which encompass what and how to communicate, is discussed next. MEDIA RICHNESS THEORY Media richness theory,106–108 which was originally developed by Daft and Lengel and then later updated with the inclusion of computer-mediated communication109 by D’Ambra and Rice, explains and predicts why certain types of technologies, called media channels or media, are effective (or not effective) in communication efforts. This theory is important to health leaders, in that selecting the appropriate communication media channel, such as a face-to-face meeting, a telephone call, or an email, can predict the likelihood of successful communication to others, such as superiors, subordinates, and peers. Today, it is all too easy to send off an email. In many situations, however, email, as a media channel, is not a good choice to have your communication understood as you meant and, therefore, receivers of your message may not take the proper action you expect. In media richness theory, various media are placed on a “richness” continuum based on the following factors (Figure 5-2): • Potential for instant feedback • Verbal and nonverbal cues that can be processed by senders and receivers • Use of natural language versus stilted or formal language • Level of focus on individual versus a group or mass of people FIGURE 5-2 Media richness theory media channel continuum. This theory indicates that ambiguous or potentially ambiguous messages should be sent with richer media to reduce the level of potential (or actual) misunderstanding. Ambiguity—also called equivocality—is based on the ability of the receiver, in this context, to ask questions. In other words, does the receiver know which questions to ask and how to get started? Different from ambiguity is uncertainty, although these two constructs complement each other. Uncertainty is “having the question answered” and having the appropriate information to proceed with an action, task, or project. “Uncertainty is a measure of the organization’s ignorance of a value for a variable in the [information] space; equivocality is a measure of the organization’s ignorance of whether a variable exists in the [information] space.”110 More information reduces uncertainty.111 In the workplace, the more similar the work performed by subordinates (or the workforce in general) is, the more ambiguity exists, whereas the more dependent each segment of the work process or work flow is on other segments, the more uncertainty exists (Figure 5-3). It is vital for leaders to reduce ambiguity and uncertainty to the greatest extent possible. The richer the media utilized, the greater the chance of leader communication success, the greater the chance of reducing ambiguity, and the greater the chance of reducing uncertainty. Unfortunately, richer media, such as face-to-face communication, cost more in terms of resources (e.g., time, travel, meeting space) than less rich media. Health leaders will be more effective if they master the basics of the media richness theory. Following are some important points to reflect on for leadership success: • Select media channels to reduce ambiguity. • Select media channels to reduce uncertainty. • The more complex the issues, the more group members like face-to-face meetings. • Computer-mediated communication (CMC) deals more with tasks but less with group relationships. • CMC may increase polarization. • CMC works best with linear, structured tasks. • CMC increases individual “information processing” requirements. • People with technological skills gain more power in CMC group communication. • More cliques and coalitions form with CMC than with face-to-face communication. SYMBOLIC CONVERGENCE THEORY Bormann developed symbolic convergence theory112 which explains how certain types of communication function to shape a group’s identity and culture, which in turn influence other dynamics such as norms, roles, and decision making. As part of this process, a group develops “fantasy” themes and stories. The key points are that groups develop a unique “group identity” (culture, personality) built on shared symbolic representations related to the group, and that these cultures evolve through the adoption of fantasy themes or group stories. Stories provide insight into a group’s culture, values, and identity.113 FIGURE 5-3 Ambiguity and uncertainty in health organization work process. COMMUNICATION ENVIRONMENTS Health organizations function best in communication environments that are open and honest, are free of fear and unnecessary anxiety, and support diverse teams of professionals. Gibb suggests that organizational communication environments promote either a defensive or a supportive communication climate. According to Beebe and Masterson, the following behaviors used by leaders, as well as by others (because subordinates tend to follow the leader’s example), contribute to defensive or supportive communicative environments: • Evaluative versus descriptive communication. Evaluation is “you” language; description is “I” language. Descriptive language leads to more trust and greater group cohesiveness. • Problem orientation. Such an orientation is more effective in reducing defensiveness than attempting to control communication. • Strategic versus spontaneous communication. Strategic communication (controlling) suggests manipulation, creating distrust, whereas spontaneous communication is inclusive. • Superiority versus equality in communication. Supportive climates occur when participative and equity-based communication is used. • Certainty versus provisionalism. Flexible, open, and genuine thinking fosters a more supportive climate than “knowing it all.114 The health organization’s leader and leadership team—from the smallest unit leader all the way to the top of the hierarchy of the organization—set the example and develop the communication environment. The communication environment is a major foundational element of organizational culture. Which type of communication environment do you want to foster as a leader? Is one environment better at enabling more quality and productivity in the health organization than another environment? Another communication environmental model suggests that a culture may be either disconfirming or confirming based on communicative responses. In essence, a confirming communicative response causes people to value themselves more. A disconfirming communicative response causes people to value themselves less. Health leaders should work to be much more confirming than disconfirming, an effort that takes practice and work. Think about which responses are confirming and which responses are disconfirming. Listening is yet another valuable leadership skill. Listening contributes to a supporting and confirming communication environment to build a culture of achievement. It encompasses the following aspects of communication: • Hearing: Receiving the message as sent • Analyzing: Discerning the speaker’s purpose • Empathizing: Seeing and understanding the speaker’s viewpoint “People seen as good leaders are also seen as good listeners.”121 A simple, yet effective listening model to practice and master has been summarized as follows: “1) stop, 2) look, 3) listen, 4) ask questions, 5) paraphrase content, and 6) paraphrase feelings.”122 Sometimes, despite the best efforts at communication, conflict may arise. A leader’s wise use of conflict management knowledge, skills, and abilities is essential for effectiveness, efficiency, and efficacy in a health organization, as discussed next. CONFLICT MANAGEMENT 115 Conflict is both inevitable and necessary for a vibrant organization. Health leaders will surely meet with situations of conflict and, therefore, must master conflict management styles and techniques. Five frameworks form the basis of modern conflict management theory and application: psychodynamic theory, field theory, experimental gaming theory, human relations theory, and intergroup conflict theory. Conflict that is channeled and managed effectively is a rational route to change, improvement, thought creation, and organizational longevity, if not outright survival. The existence of conflict means there are opportunities to find improved alternative solutions to the current state of affairs. Of course, conflict can negatively affect the organization; even so, pessimism should not be the overriding default attitude assumed by leadership, management, or human existence for that matter. Leaders and managers can manage conflict and train others to apply skills and tools of conflict to achieve successful and improved outcomes in their professional lives. Leaders communicate meaning in everything they do. If messages are incongruent, goal conflicts and inconsistencies soon become part of the organizational culture.116–118 Hand-in-hand with conflict management are interpersonal relationships. Learning, as an organization, to constructively manage and succeed in conflict situations is a foundational construct of leadership and management. Conflict occurs wherever interdependent people or groups (i.e., people or groups who depend on one another in some fashion for some need) have different goals119 or aspirations of achievement amid an environment of scarce resources. Simply put, conflict arises when people, individually or in groups, must work together with other individuals or groups who have different goals, needs, or desires in an environment where a full complement of resources is not available to satisfy those goals, needs, or desires. We all live, work, and socialize with other people and share the limited resources available (rarely, if ever, are resources not limited), so conflict will happen and does happen to varying degrees of intensity. At one end of the spectrum, conflict can be a situation identified by two parties, such that those parties identify the problem and work together to solve it (problem-solving style). At the other end of the spectrum is violence (competing style) that inflicts bodily harm, such as in a war, which is the failure of conflict management. Conflict is both an individual and a group phenomenon. Western society tends to teach children to “smooth over” conflict. For example, you may remember a parent saying, “Play nice” or “You have to learn to share.” Fairness, morals, social norms, and mores, along with the application of any of the multiple distributive justice methods, contribute to conflict situations when one party believes that a less than equitable distribution of resources has occurred. Quality conflict management should produce the following outcomes: • A wise agreement if an agreement is possible • An efficient solution • A potentially innovative solution • Movement toward positive change in the organization • A better relationship between the conflicting parties (or at least not damage the relationship) Given these expectations, how can the health leader manage conflict? Basically, different situations require different styles; training organizational stakeholders on the effective use of conflict styles is also imperative. Conflict occurs due to differing preferences and nuances, over resources, differing values, difficult relationships, and differing perceptions. Primary tension (initial conflict over an issue or difference) is followed by secondary tension (conflict over the process for actually dealing with the issue of difference), and both require leadership intervention, conflict management, and conflict styles training of the conflicting parties. (The preference is to train all subordinates and staff.) “Groupthink,” a negative group decision, occurs when there is no conflict (Figure 5-4). Conflict Styles Six basic conflict management styles have been identified.120,123–127 Although each person has a dominant or primary style and a secondary style that are relatively stable (like personality style), all six styles can be learned, applied, and mastered. Conflict styles are a learning skill set. The more you learn and practice, the more flexible you will be in conflict situations. Later in this chapter, a decision tree is shown that can help you select which conflict style to use based on the situation (by answering several yes/no questions). It is imperative to understand and be able to apply different conflict styles because situations will differ daily. FIGURE 5-4 Conflict illustrated. The six styles presented here represent an amalgam of multiple scholars’ work created for the purpose of expanding your knowledge: 1. Accommodating 2. Avoiding 3. Collaborating 4. Competing 5. Compromising 6. Problem solving The best style to use in any case depends on the situation. It is important to note that during conflict situations, one party may select (knowingly or unknowingly) one style and the other party may select a different style. Only in problem solving do both parties knowingly choose that style and work together. The following summaries identify the situational context associated with each conflict management style. Accommodating • When you find you are wrong; to allow a better position to be heard, to learn, and to show your reasonableness • When issues are more important to others than to you; to satisfy others and maintain cooperation • To build social capital for later issues • To minimize your losses when you are outmatched and losing the conflict • When harmony and stability are especially important • To allow subordinates to develop by learning from their mistakes Avoiding • When an issue is trivial or more important issues are pressing • When you perceive no chance of satisfying your needs • When the potential disruption outweighs the benefits of resolution • To let people cool down and regain perspective • When gathering information supersedes immediate decision making • When others can resolve the conflict more effectively • When issues seem a result of other issues Collaborating • To find an integrative solution when both sets of concerns are too important to be compromised • When your objective is to learn • To merge insights from people with different perspectives • To gain commitment by incorporating concerns into a consensus • To work through feelings that have harmed an interpersonal relationship Competing • When quick, decisive action is vital (e.g., emergency situations such as a disaster or terrorism incident or accident) • On important issues where unpopular actions need implementing (e.g., cost cutting, enforcing unpopular rules, discipline) • On issues vital to company welfare and survival when you know you are right • Against people who take advantage of noncompetitive behavior Compromising • When goals are important, but not worth the effort or potential disruption of competing • When opponents with equal power are committed to mutually exclusive goals • To achieve temporary settlements to complex issues • To arrive at expedient solutions under time pressure • As a backup when collaboration or competition is unsuccessful Problem Solving • May not always work (it takes two to make this style work) • Requires the identification of a broader range of strategies • Points for problem solving: • Both parties have a vested interest in the outcome (the resolution). • Both parties believe a better solution can be achieved through problem-based collaboration. • Both parties recognize that the problem is caused by the relationship, not the people involved. • The focus is on solving the problem, not on accommodating differing views. • Both parties are flexible. • Both parties understand that all solutions have positive and negative aspects. • Both parties understand each other’s issues. • The problem is looked at objectively, not personally. • Both parties are knowledgeable about conflict management. • Allowing everyone to “save face” is important. • Successful outcomes are celebrated openly. The various conflict management styles should be used contingently based on the situation that presents itself in conflict environments. The dynamic nature of healthcare organizations requires leaders to become competent in using each conflict style. Again, training organizational stakeholders is also critically important. To show the contingent nature of conflict styles, a merging with a well-known leadership model is highlighted in Figure 5-5. From a leadership contingency perspective, it might be helpful to review the results of the Ohio State and Michigan Leadership studies, where conflict management styles can be arrayed as shown in the figure, similar to leadership styles. Essential steps for leaders in conflict management follow. When you are in the early stages of conflict, you should take these steps: • Stay calm and rational. • Use facts (do your homework). • Understand the resource implications and limitations surrounding the conflict. • Listen to how you feel and know what you want or need. • Try to imagine what the other(s) feel, want, and need. • Use a process to select a strategy such as the decision tree method (discussed later). • Rehearse your strategy. • Be prepared to modify your approach if necessary. When you are in the midst of conflict, keep these tenets in mind: • Separate the people from the problem or conflict as much as possible. • Focus on interests, not positions. • Avoid always having a “bottom line.” • Think about the worst and best solutions and know what you can “live with.” • Generate several possibilities before deciding what to do. • Insist that the result (resolution) be based on some objective standard. Negotiation is similar to conflict resolution. In fact, Fisher, Ury, and Patton’s 1991 work, Getting to Yes: Negotiating Agreement Without Giving In, Second Edition, contains some especially salient points for conflict management. These recommendations reinforce guidelines presented earlier in this chapter and lean toward the problem-solving style of conflict:128 • Do not bargain over positions. • Separate the people from the problem. • Focus on interests, not positions. • Invent options for mutual gain. • Insist on using objective criteria to resolve the issue. • Use your “best alternative to a negotiated agreement.” (What is the worst-case scenario if nothing is resolved?) • Get the other party to negotiate. FIGURE 5-5 Conflict styles regarding concern for self and others. Source: This figure is an aggregation of multiple scholars’ work115–120 and a modification of the leadership studies at Ohio State and Michigan University accredited to Stogdill and Likert. For the leadership component, Concern for Task was replaced by Concern for Others. Next, we turn our attention to the process of selecting a conflict style based on the situation. With six styles to select from, it is important to study all of them and become familiar with the styles so that the selection method—a decision tree—becomes understandable. Remember that five styles are under your “control,” whereas the sixth style, problem solving, requires that both parties consciously agree to select that style. Conflict Style Selection Selecting a conflict style depends on several factors, including the interpersonal relationship with others (that is, those in the conflict against you), resources available (such as time), resources not available, and importance of the issues at hand. In the decision tree model, these factors take the form of high/yes or low/no answers to the following questions: 1. Is (are) the issue (issues) important to you? 2. Is (are) the issue (issues) important to the other party? 3. Is the relationship with the other party important to you? 4. How much time is available and how much pressure/stress is there to come to resolution? (With this question, an answer of “high” means high pressure.) 5. How much do you trust the other party? To obtain an overview of the decision tree process, examine Figure 5-6, noting the questions at the top of the graphic and the associated high/yes and low/no answers to each of these questions. Follow the path until you come to a conflict management style that is recommended given the conflict situation. An example illustrating two points—use of the decision tree and cautionary notes associated with each style—is provided here. In this scenario, you are in a conflict situation with another employee at the hospital. You have prepared yourself by reviewing all the points made previously in this chapter. Now you answer the questions based on the decision tree model (follow along on the decision tree in Figure 5-6): FIGURE 5-6 Conflict management style decision tree (modified). Source: Adapted from Folger, J. P, Poole, M. S., & Stutman, R. K. (1997). Working through conflict: Strategies for relationships, groups, and organizations (3rd ed.). New York: Addison-Wesley Educational Publishers, p. 201. 1. Is the issue important to you? You determine the answer is “low.” 2. Is the issue important to the other party? You determine the answer is “high.” (Why else would this person make such a big deal out of it?) 3. Is the relationship with the other party important to you? You determine the answer is “low.” (Caution: How does this equate to using the avoiding style? Eventually, the avoiding style will cause the relationship with the other person or party to deteriorate.) 4. How much time is available and how much pressure/stress is there to come to resolution? You determine there is “high pressure” to come to resolution. 5. How much do you trust the other party? You determine you do not really trust the other person, so the answer is “low.” 6. Outcome: The style recommended is the avoiding style. Conflict management is a critical and necessary skill that includes both technical (styles and decision tree) and relationship (communication and trust building) components. Conflict is a state of nature; hence the application of conflict styles requires good judgment on the leader’s part. OVERVIEW OF CULTURE Culture is a learned system of knowledge, behavior, attitudes, beliefs, values, and norms that are shared by a group of people.129,130 Culture is a difference that makes a difference.131 Cultural differences have been classified (initially from the work of Hofstede) into the following categories (four categories are presented here, though several more are possible): • Language • Context (high versus low) • Contact (high versus low) • Time (monochronic versus polychronic) Language is the structure, rules, and enunciation of symbols. Spanish, English, Mandarin Chinese, German, and Flemish are examples of language. High-context cultures place more emphasis on nonverbal communication; physical context is important in interpreting the message, and the stress is on the receiver of a message to understand the intended meaning (Figure 5-7). Low-context cultures place more emphasis on verbal expression; the sender is responsible for relaying meaning to the receiver verbally. Sometimes, people from a high-context culture will find those from a low-context culture less credible or trustworthy. Someone from a low-context culture may be more likely to make explicit requests for information (“Talk to me,” “Do you know what I mean?”). In contrast, a person from a high-context culture expects communication to be more indirect and relies on more implicit cues132 People from high-context cultures may consider a low-context person overbearing, dominant, and talkative. FIGURE 5-7 High- versus low-context cultures continuum. Source: Adapted from Beebe, S. A., & Masterson, J. T. (1997). Communicating in small groups: Principles and practices (5th ed.). New York: Addison-Wesley Educational Publishers, pp. 152–158. Contact preferences among cultures differ as well. People from some cultures are more comfortable being touched or being in close proximity to others (high contact), whereas some people want more personal space, typically have less eye contact, and are uncomfortable with being touched by others (low contact). Contact, as a variable, is similar to the notion of personal and social space. Some people want larger areas of space, whereas others are comfortable with less space. Monochronic and polychronic cultures differ with perceptions and use of time. Monochronic cultures are precise; time is to be used and manipulated. Polychronic cultures are not as precise on time; time is what it is, events flow in their intended pattern as they happen. It is not unusual to have a monochronic culture person arrive at a scheduled meeting 5 minutes early, only to be irritated and upset by the time a polychronic culture person arrives 30 minutes past the scheduled time. Although organizational rules such as adherence to schedules (organizational coupling) are important, some understanding of time perception differences can reduce potential anger when people from differing cultural perspectives understand the perceptions of one another. Thus, strategies to bridge cultural differences, specifically for communicative purposes, are important, as discussed next. BRIDGING CULTURAL DIFFERENCES IN COMMUNICATION Individuals hold cultural assumptions when engaged in work within the health organization; this is particularly apparent when involved in group problem solving and decision making. “All communication, problem-solving, decision making, etc. . . . is filtered through the cultural perspective group members hold.”133 Beebe and Masterson recommend the following strategies to bridge cultural differences: • Develop mindfulness. Be consciously aware of cultural differences; your assumptions and other people’s assumptions may be (and probably are) different. • Be flexible. You may have to adapt and change according to the perceptions and assumptions others hold. • Tolerate uncertainty and ambiguity. Be patient and tolerant. • Resist stereotyping others and making negative judgments about others. Do not be ethnocentric; ethnocentrism leads to defensive (not open or confirmatory or supportive) communication environments. • Ask questions. Develop common ground rules and ask for additional meaning (paraphrase and paraphrase feelings). • Be other oriented. Be empathetic and sensitive to others where the key is to bridge cultural differences.134 Just as there are global cultural differences, so there may be unit or discipline or location differences within the same industry and organization. The next section discusses this phenomenon. COORDINATED MANAGEMENT OF MEANING At the organizational or unit level, individuals and groups embody their own cultural identity; this is certainly true in health organizations. Coordinated management of meaning (CMM) is an interactional theory that focuses on how individuals organize, manage, and coordinate their meanings and actions with one another. This theory was developed by Pearce in 1976 and updated by Pearce and Cronen in 1980. “The theory proposes that the interpretation of a conversation or message will be shaped by the context or nature of the relationship between the interactants as well as the self-concept and culture of each individual.”135 Consider the cultural differences of operating room nurses and technicians and surgeons relative to physical therapists and therapy aides relative to pharmacists and pharmacy technicians while you review the constructs of this theory. At the highest and deepest level, cultural patterns provide a person’s unique view of the world and how they fit into that world through their various roles, behaviors, and beliefs; this level is very stable and difficult to change. The next construct level is life scripts, which expands on cultural patterns by “holding” a person’s self-identity, self–efficacy, and expectations of rewards and punishments based on that identity; this level is stable and nearly as difficult to change as compared to the cultural patterns construct. The following quote sheds light on constructs in the model that are more likely, although not easy, to modify, subject to influence and change. Contracts define and specify expectations of the particular relationship based on the kinds of episodes that occur within the relationship. Episodes define the kind of activity that occurs between individuals based on the kinds of and sequencing of messages being exchanged. Speech acts identify the intent of the speaker and content is the decoding of the substance of the message. Raw sensory data concern the audio and visual signals that reach the brain.136 This logical relationship between levels produces constitutive rules for determining meaning. Constitutive rules stipulate how meanings at one level determine meanings at another level. Regulative rules specify what is appropriate given the nature of the relationship, the episode, and what the other person has said. Thus the CCM theory may be connected to Rokeach’s values–beliefs–attitudes model in the following way: (1) values link to cultural patterns and life scripts; (2) beliefs link to life scripts and contracts; and (3) attitudes link to contracts, episodes, and speech acts. The CMM theory brings into focus practical elements of Shutz’s theory of affiliation, communication environments and culture, media richness theory, and interpersonal relationships. It also has strong links to Bolman and Deal’s reframing organizational leadership model. Health leaders who understand motivation and influence and apply culturally sensitive communication approaches can effectively use motivation based theories and models, such as goal setting, to focus a multidisciplinary team of health professionals on the mission and vision of the organization in an effective, efficient, and efficacious manner. Figures 5-8 and 5-9 graphically illustrate the CMM model and the hierarchy of how meaning impacts people from low (raw data) to high (cultural patterns within the model’s continuum). FIGURE 5-8 Coordinated management of meaning: hierarchy. Source: Adapted from Folger, J. P, Poole, M. S., & Stutman, R. K. (1997). Working through conflict: Strategies for relationships, groups, and organizations (3rd ed.). New York: Addison-Wesley Educational Publishers, p. 58. FIGURE 5-9 Coordinated management of meaning: impact. Source: Adapted from Beebe, S. A., & Masterson, J. T. (1997). Communicating in small groups: Principles and practices (5th ed.). New York: Addison-Wesley Educational Publishers. SUMMARY A leader has personal responsibility to maintain—if not advance—relevancy in his or her environment. To ensure that he or she does so, leadership competencies and the ability–job fit between a leader and his or her organizational environment are key considerations. Health leaders work in a highly complex environment with a very educated and interdisciplinary workforce. Leadership success is often based on the leader’s capabilities related to motivation, influence, interpersonal relationships, communication, situational assessment, and inspiring teams. Networks and alliances are key ways to expand the leader’s sphere of influence. Health leaders must take into account the various factors that play roles in interpersonal relationship building, communication as an environment for leadership effectiveness, communication culture, and conflict management. For the beginning careerist, using the applications, ideas, and principles presented in this chapter both for your leadership model and for practice will serve you well. Additionally, seeking out a mentor who clearly has earned the respect of others by establishing many quality relationships will benefit you for many years; learn from your mentor in the areas of motivation and inspiration, forming networks and alliances, developing interpersonal relationships, and managing conflict. DISCUSSION QUESTIONS 1. How would you describe the complexity of the health industry in terms of workforce, environment, and societal expectations? How would a health leader’s mastery of competencies, including interpersonal relationship building, influence processes, motivation, power, and communication capabilities, enable the leader to successfully navigate this complexity? 2. Explain how the complexity of the health workforce may lead to communication failure and conflict. Summarize ways to use quality communication and conflict management skills to successfully motivate subordinates, build interdisciplinary teams, and lead a health organization based on commitment rather than compliance or resistance. 3. Can you predict the outcomes of continuous use of the avoiding and competing strategies as compared to the compromising, accommodating, and problem-solving strategies in a health organization? What might be the outcomes of use of face-to-face meetings as compared to use of memoranda communication channel/media for ambiguous and urgent messages? 4. How would you analyze the health leader competencies in terms of the knowledge, skills, and abilities discussed in this chapter, differentiating the competencies presented here with those not discussed? Support your assessment. 5. How would you design, by combining several theories and models, an influence, power and motivation leadership model for use in health organizations focused on subordinate commitment? Could you modify this model for use with an interdisciplinary health team or group? Explain why this modification was utilized. 6. Evaluate competencies (knowledge, skills, and abilities) found in leadership practice concerning building interpersonal relationships, influence processes, motivation, power, and communication that are necessary to successfully lead health organizations. Support your evaluation. How would you use those capabilities?  1. Define the complexity of the health industry in terms of the workforce and label possible up-to-date and continuous information sources for the health workforce that are affecting the health industry. Use a cost–quality–access model to determine the cumulative impact of several changes on the health industry. 2. In a three-page (or less) paper, distinguish potentially differing motivational factors for each major health workforce group and predict which applications of building interpersonal relationships, influence, and motivation theories or models would work best for each group. 3. In a two- to three-page paper, construct models of communication for a health organization that could be used by a leader for individuals, groups/teams, and the entire organization. As part of your discussion, demonstrate which elements of your models are similar and dissimilar. 4. Select two theories or models of influence, power, and/or motivation. In a two-page paper, identify the constructs and leadership behaviors/actions, and analyze the effectiveness of the theories or models in a health organization setting for achieving commitment, achieving compliance, and achieving resistance. Relate components of quality leader communication to this analysis and illustrate whether they would result in changes to your outcomes. 5. In a two-page paper, explain how goal-setting theory, expectancy theory, and locus of control work together; also, relate how a health leader can utilize the synthesis of these theories to have a productive workforce at the individual subordinate and team or group level. 6. In a two- to three-page paper, evaluate and justify your professional association’s combined health leader’s competencies considering the complexity of the health industry. adership competence essay assignment papers: professional competencies, and personal skills and responsibilities



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