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THIRD EDITION
Organizational Behavior in
HEALTH CARE
Nancy Borkowski, DBA, CPA, FACHE, FHFMA
Professor, Department of Health Services Administration
School of Health Professions
University of Alabama at Birmingham
Birmingham, AL
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Library of Congress Cataloging-in-Publication Data
Borkowski, Nancy, author.
Organizational behavior in health care / Nancy Borkowski. — Third.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-284-05104-9 (paper)
I. Title.
[DNLM: 1. Health Services Administration. 2. Group Processes. 3. Health Personnel—psychology.
4. Organizational Culture. 5. Personnel Management. W 84.1]
RA971.35
362.11068’3—dc23
2015003497
6048
Printed in the United States of America
19 18 17 16 15 10 9 8 7 6 5 4 3 2 1
To my husband
Contents
Preface
Contributors
About the Author
PART I—INTRODUCTION
Chapter 1
Overview and History of Organizational Behavior
Chapter 2
Diversity and Cultural Competency in Health Care
Chapter 3
Attitudes and Perceptions
Chapter 4
Workplace Communication
PART II—UNDERSTANDING INDIVIDUAL BEHAVIORS
Chapter 5
Content Theories of Motivation
Chapter 6
Process Theories of Motivation
Chapter 7
Attribution Theory and Motivation
PART III—LEADERSHIP
Chapter 8
Power, Politics, and Influence
Chapter 9
Trait and Behavioral Theories of Leadership
Chapter 10 Contingency Theories and Situational Models of
Leadership
Chapter 11 Contemporary Leadership Theories
PART IV—INTRAPERSONAL AND INTERPERSONAL ISSUES
Chapter 12 Stress in the Workplace and Stress Management
Chapter 13 Decison Making
Chapter 14 Conflict Management and Negotiation Skills
PART V—GROUPS AND TEAMS
Chapter 15 Overview of Group Dynamics
Chapter 16 Groups
Chapter 17 Work Teams and Team Building
PART VI—MANAGING ORGANIZATIONAL CHANGE
Chapter 18 Organization Development
Chapter 19 Managing Resistance to Change
Index
Preface
In 2005 with the first edition of this book, I wrote, “the U.S. health care
industry has grown and changed dramatically over the past twenty-five
years.” That was an understatement! Since the passing of the Patient
Protection and Affordable Care Act of 2010, the industry has experienced
some of the most dynamic changes health care managers have seen. In the
coming years, more system-wide changes will occur as we continue our push
forward to achieve value-based health care. Health care managers are
quickly learning that what worked in the past may not work in the future.
As such, I was compelled to write an organizational behavior book
specifically for health care managers who are on the front lines every day,
motivating and leading others in a constantly changing, complex
environment. This is not an easy task, as I know firsthand!
The purpose of this book is to provide health care managers and other
professionals with an in-depth analysis of the theories and concepts of
organizational behavior while embracing the uniqueness and complexity of
the industry. Although health care is similar to other industries, it is also
very different. As the nation’s largest industry, it employs more than 15
million people in numerous interrelated and interdependent segments.
Using an applied focus, this book provides a clear and concise overview of
the essential topics in organizational behavior from the health care
manager’s perspective. It is my goal that this book will give you a greater
understanding of why and how people and groups behave the way they do in
the workplace. With this knowledge, you will be able to predict and thus
effectively influence the behavior of those you lead. Please let me know if I
accomplish my goal! You can reach me at nborkows@uab.edu.
In addition, I tried to ensure that I referenced all the individuals whose
work contributed to the development of this book. However, if by chance I
failed to give credit to someone along the way, please contact me so I may
make the necessary correction.
At this time I wish to acknowledge individuals without whose efforts and
support I would not have been able to complete this book. First, I wish to
thank my colleagues and third edition contributors, Jean Gordon, Paul
Harvey, Mark Martinko, and Jeff Ritter. Second, I thank my wonderful
family for their patience, understanding, and support over the years.
Finally, I wish to thank the many wonderful and caring people employed
throughout the health care industry that I have had and will have the
opportunity to work with. My life continues to be blessed by these dedicated
individuals!
Thank you for purchasing (and reading) my book. I welcome your
comments and suggestions.
With personal regards,
Nancy M. Borkowski, DBA, CPA, FACHE, FHFMA
Contributors
Jean Gordon, RN, MBA, MSN, DBA
Visiting Professor
Florida International University
Miami, Florida
Paul Harvey, PhD
Associate Professor of Management
Peter T. Paul College of Business and Economics
University of New Hampshire
Durham, New Hampshire
Mark Martinko, PhD
UQ Business School
University of Queensland
Brisbane, Australia
Jeffrey Ritter, DBA
Assistant Professor
Barry University
Health Management Programs
College of Nursing and Health Sciences
Miami Shores, Florida
About the Author
Nancy M. Borkowski, DBA, CPA, FACHE, FHFMA, is Professor in the
Department of Health Services Administration at the University of
Alabama at Birmingham. She received her DBA with specializations in
health services administration and accounting from Nova Southeastern
University. Dr. Borkowski has over 20 years’ experience in the health care
industry and is a two-time past recipient of the American College of
Healthcare Executives’ (ACHE) Southern Florida Senior Career Healthcare
Executive Award, which recognizes individuals who have made significant
contributions to the advancement of health management excellence.
A nationally recognized author, Dr. Borkowski is also a certified public
accountant, board certified in health management, and a Fellow of both the
American College of Healthcare Executives and the Healthcare Financial
Management Association. The first edition of her book Organizational
Behavior in Health Care, referred to as “one of the most significant
advances in the field of health services administration,” was honored with
the American Journal of Nursing’s 2005 Book of the Year Award for nursing
leadership and management. Dr. Borkowski is the author of three textbooks
that are widely used in graduate and undergraduate health administration
and nursing programs both nationally and internationally.
Dr. Borkowski’s work has been published in the Journal of Ambulatory Care
Management, Leadership in Health Services, Group & Organization
Management, Organizational Behavior and Human Decision Processes,
Health Care Management Review, Journal of Health Administration
Education, Journal of Health and Human Services Administration,
International Journal of Public Administration, and various other journals.
Her teaching interests are leadership, organizational behavior, and strategic
management. Dr. Borkowski is a past recipient of the ACHE’s Excellence in
Teaching Award, which is given to faculty who engage in furthering
academic excellence and
management students.
the
professional
development
of
health
Over the past decade, Dr. Borkowski has served in various leadership roles
for the Academy of Management’s Health Care Management Division, the
American College of Healthcare Executives’ Southern Florida Regent’s
Advisory Council, the South Florida Healthcare Executive Forum, and
various other health-related organizations. In 2013, Dr. Borkowski received
the Jessie Trice Hero Award for her leadership and commitment to
improving the lives of underserved and minority populations. She has also
been honored with the Exemplary Service Award from the American College
of Healthcare Executives (2012) and the Reeves Silver Merit Award from
the Healthcare Financial Management Association (2014).
PART I
Introduction
Part I includes four different but related topics. In Chapter 1, the history
of organizational behavior and its importance to today’s health care
managers are discussed. Chapter 2 describes the changing environment in
which health care managers find themselves. The chapter examines the
numerous issues that have emerged within the health care industry because
of the nation’s changing demographics. Chapter 3 deals with attitudes and
perceptions, which are the “backbone” to understanding organizational
behavior. You will find the terms “attitude” and “perception” frequently
referred to within the various organizational behavior theories. Finally,
Chapter 4 discusses the importance of communications. Recent surveys
revealed that 70 percent of small to mid-size businesses claim that
ineffective communication is their primary problem. Sentinel event data
from The Joint Commission estimates that communication failure was the
root cause of patient harm 70 percent of the time in 2,400 reported negative
outcomes studied. No wonder the ability to communicate effectively is
considered an essential job skill for today’s health care managers and
leaders.
CHAPTER 1
Overview and History of
Organizational Behavior
LEARNING OUTCOMES
After completing this chapter, the student should understand:
The definition of organizational behavior.
The major challenges facing today’s and tomorrow’s health care
organizations and health care managers.
The importance of the Hawthorne Studies to the study of
organizational behavior.
The importance of McGregor’s Theory X and Theory Y to the study of
organizational behavior.
The difference between organizational behavior, organization theory,
organizational development, and human resources management.
OVERVIEW
Organizational behavior (OB) is an applied behavioral science that
emerged from the disciplines of psychology, sociology, anthropology, political
science, and economics. OB is the study of individual and group dynamics
within an organization setting. Whenever people work together, numerous
and complex factors interact. The discipline of OB attempts to understand
these interactions so that managers can predict behavioral responses and,
as a result, manage the resulting outcomes.
According to Ott (1996, p. 1), OB asks the following questions:
1.
Why do people behave the way they do when they are in
organizations?
2. Under what circumstances will people’s behavior in organizations
change?
3. What impacts do organizations have on the behavior of individuals,
formal groups (such as departments), and informal groups (such as
people from several departments who meet regularly in the company’s
lunchroom)?
4. Why do different groups in the same organization develop different
behavior norms?
From Ott. Classic Readings in Organizational Behavior, 2E. © 1996 South-Western, a part of Cengage Learning, Inc.
Reproduced by permission.
There are three goals of OB. First, OB attempts to explain why individuals
and groups behave the way they do within the organizational setting.
Second, OB tries to predict how individuals and groups will behave on the
basis of internal and external factors. Third, OB provides managers with
tools to assist in the management of individuals’ and groups’ behaviors so
they willingly put forth their best effort to accomplish organizational goals.
In the health care industry, OB has become more important because people
with diverse backgrounds and cultural values have to work together
effectively and efficiently.
WHY STUDY ORGANIZATIONAL BEHAVIOR IN HEALTH
CARE?
The largest U.S. industry is health care, which currently employs over 18
million individuals. The industry will account for almost a third of the
nation’s projected job growth through 2022, adding almost 5 million jobs.
The projected 2.6 percent-per-year growth rate is the fastest among all
major service producing sectors (Bureau of Labor Statistics, 2013).
Each segment of the health care industry (e.g., hospitals, home health,
rehabilitation facilities) employs a different mix of health-related
occupations, ranging from highly skilled licensed professionals, such as
physicians and nurses, to those with on-the-job training. Furthermore, each
segment of the industry has various economic structures (e.g., for-profit,
not-for-profit, governmental). As such, today’s health care managers need to
possess the skills to communicate effectively with, motivate, and lead
diverse groups of people within a large, dynamic, and complex industry.
Communication, motivation, and leadership are all concepts within the
discipline of OB. Furthermore, managers need to understand the causes of
workplace problems, such as low performance, turnover, conflict, and stress,
so that they may be proactive and minimize these unnecessary negative
outcomes. With a greater understanding of OB, managers are better able to
predict and, thus, influence the behavior of employees to achieve
organizational goals.
Given the service-related intensity of the industry, the understanding of
individuals’ behavior and group dynamics within health service
organizations is critical to a health care manager’s success. Research
indicates that the primary reasons managers fail stem from difficulty in
handling change, not being able to work well in teams, and poor
interpersonal relations. There is a saying that employees don’t leave
organizations, they leave managers!
THE HEALTH CARE INDUSTRY
Changes within the health care industry over the past 30 years have been
powerful, far-reaching, and continuous. Since readers are probably familiar
with most of these changes from either their own experiences or from a
previous health care delivery system course, the discussion will address
some of the trends or future concerns that will impact tomorrow’s health
care industry.
Past changes and future trends are interrelating forces that have or will
shape tomorrow’s health care organizations, whether they occur at the
system level or the organizational level. Declining reimbursement and
changes in payment schemes for services has had, and will continue to have,
two of the deepest impacts on the industry. Technology has also caused
significant changes within the industry. Biomedical and genetic research,
along with advances in information technology and use of “big data,” are
producing rapid changes in clinical treatments. In addition, the industry has
experienced more government mandates, such as the Health Insurance
Portability and Accountability Act of 1996; the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003; the American Recovery and
Reinvestment Act of 2009; and most recently, the Patient Protection and
Affordable Care Act of 2010 (ACA). With an increased focus on chronic
disease management, patients are living longer and are requiring more
long-term and home health care services now and in the future. Patients’
and health care workers’ characteristics are also changing. Both populations
are becoming older and more diverse. Patients are better informed and, as
such, have increasingly higher expectations of health care professionals.
This trend has changed the way health care services are delivered, with a
focus on patient satisfaction and safety, as well as on quality of services.
Physician–patient relationships have changed because patients are
beginning to understand that much of the responsibility for wellness lies
with them. The economics of health care is in a state of flux. For example,
reimbursements are moving toward value-based payments; therefore, we
see an increase in the use of evidence-based medicine. There are continuing
shortages of staff, especially in the areas of primary care physicians, nurses,
imaging technicians, and pharmacists, leading to competition for wellqualified people. There are changes taking place in the disease environment.
Many factors of modern life are contributing to the emergence of new
diseases, reemergence of old ones, and evolution of pathogens immune to
many of today’s medications. In addition, because of potential terrorism
attacks, health care providers are concerned with biodisaster preparedness.
Finally, even with some states’ Medicaid expansion programs and the ACA,
there continues to be the issue of caring for the uninsured that contributes
to the overuse and misuse of hospital emergency departments.
To deal with these changes, we have seen a number of health care
organizations restructure themselves into integrated delivery networks,
which may be part of a local, regional, or national system. We have seen
increased vertical, horizontal, and virtual integration. Vertical integration
focuses on the development of a continuum of care services to meet the
patient’s full range of health care needs. This integration model, in which a
single entity owns and operates all the segments providing care, may
include preventive services, specialized and primary ambulatory care, acute
care, subacute care, long-term care, and home health care, as well as a
health plan. Recently, we have seen the creation of accountable care
organizations (ACOs), in which groups of doctors, hospitals, and other
health care providers have joined together to provide coordinated care to
predetermined patient populations. Horizontal integration usually occurs
through mergers, acquisitions, and/or consolidation within one segment of
the industry. For example, during the 1990s there were numerous hospital
acquisitions by the large, for-profit, publicly held hospital chains of Hospital
Corporation of America (HCA), Tenet Healthcare, and Health Management
Associates (now part of Community Health Systems)—and these
acquisitions continue today. In addition, not-for-profit hospitals have
merged with for-profit health systems as a result of competition and the
need to reduce cost by economies of scale. Virtual integration, which
emphasizes coordination of health care services through patientmanagement agreements, provider incentives, and/or information systems,
has increased. This virtual integration has evolved to meet the need for
better technology and information infrastructures that allow for information
sharing, patient care management, and cost control.
Because of the dramatic changes and the future trends in the health care
industry, most managers have been required to change the way they and
other employees carry out their job responsibilities. These changes have
been forced upon the industry by the need to increase productivity due to
decreasing reimbursement and increasing competition. At the same time,
health care providers must deliver patient-centered, value-based care. These
are not easy tasks. As a result, many health care providers are breaking
down their traditional hierarchical structures and moving toward
multidisciplinary team-managed environments. Employees are finding
themselves in new roles with new responsibilities. All of these changes
cause disruptions in the workplace. The study of OB will assist health care
managers to minimize the negative effects (such as stress and conflict)
related to this “new” environment and maximize their ability to motivate
staff and lead their organizations effectively.
HISTORY OF ORGANIZATIONAL BEHAVIOR
The beginnings of OB can be found within the human relations/behavioral
management movement, which emerged during the 1920s as a response to
the traditional or classic management approach. Beginning in the late
1700s, the Industrial Revolution was the driving force for the development
of large factories employing many workers. Managers at that time were
concerned “about how to design and manage work in order to increase
productivity and help organizations attain maximum efficiency” (Daft, 2004,
p. 24). This traditional approach included Frederick Taylor’s (1911) wellknown framework of scientific management, or “Taylorism,” as it is now
labeled. Taylor believed that efficiency was achieved by creating jobs that
economized time, human energy, and other productive resources. Through
his time-and-motion studies, Taylor scientifically divided manufacturing
processes into small, efficient units of work. Through Taylor’s work,
productivity greatly increased. For example, Henry Ford developed his
assembly line according to the principles of Taylorism and was able to churn
out Model Ts at a remarkable and economical pace (Benjamin, 2003).
Although the classic approach to management focused on efficiency within
organizations, Taylor did attempt to address a human relations aspect in
the workplace. In his book The Principles of Scientific Management, Taylor
stated that:
in order to have any hope of obtaining the initiative (i.e., best
endeavors, hard work, skills and knowledge, ingenuity, and good-will)
of his workmen the manager must give some special incentive to his
men beyond that which is given to the average of the trade. This
incentive can be given in several different ways, as, for example, the
hope of rapid promotion or advancement; higher wages, either in the
form of generous piecework prices or of a premium or bonus of some
kind for good and rapid work; shorter hours of labor; better
surroundings and working conditions than are ordinarily given, etc.,
and, above all, this special incentive should be accompanied by that
personal consideration for, and friendly contact with, his workmen
which comes only from a genuine and kindly interest in the welfare of
those under him. It is only by giving a special inducement or
incentive of this kind that the employer can hope even approximately
to get the initiative of his workmen.
Although Taylor discussed a concern for workers within the scientific
management approach, the human relations or behavioral movement of
management did not begin until after the landmark Hawthorne Studies.
THE HAWTHORNE STUDIES
Elton Mayo, Frederick Roethlisberger, and their colleagues from Harvard
Business School conducted a number of experiments from 1924 to 1933 at
the Hawthorne Plant of the Western Electric Company in Cicero, Illinois.
The Hawthorne Studies were significant to the development of OB because
the researchers demonstrated the important influence of human factors on
worker productivity. It was through these experiments that the Hawthorne
Effect was identified. The Hawthorne Effect is the bias that occurs when
people know that they are being studied. Roethlisberger and Dickson (1939)
in their book Management and the Worker and Homans (1950) in his book
The Human Group provided a comprehensive account of the Hawthorne
Studies. There were four phases to the Hawthorne Studies: the illumination
experiments, the relay-assembly group experiments, the interviewing
program, and the bank-wiring observation-room group studies. The intent of
these studies was to determine the effect of working conditions on
productivity.
The illumination experiments were conducted to determine whether
increasing or decreasing lighting would lead to changes in productivity. The
researchers were surprised to learn that productivity increased by both the
control group (no change in lighting) and the experimental group (lighting
alternated upward and downward). The researchers determined that it was
not the lighting that caused the increased productivity; rather, it resulted
from the attention received by the group.
In the relay-assembly group experiments, productivity of a segregated
group of workers was studied as they were subjected to different working
conditions. The researchers and management observed the group closely for
five years. During the first part of the experiment, the working conditions
of employees were improved by extending their rest periods, decreasing the
length of their workday, and providing them a “free” day and lunches. In
addition, the workers were consulted before any changes were made,
because their agreement had to be obtained before the change would be
implemented. The workers of the group were given the freedom to interact
with one another during the workday. Furthermore, one researcher also
served as their supervisor who, during the experiment, expressed concern
about their physical health and well-being. The researchers eagerly sought
the employees’ opinions, hopes, and fears during the experiment. During the
improved-conditions period, the workers’ productivity increased. In part two
of the experiment, the original working conditions were restored.
Surprisingly, the researchers found that the employees’ productivity
remained at the previous high level (when they had the improved working
conditions). This result was attributed to group dynamics because the group
was allowed to develop socially with a common purpose.
The bank-wiring observation-room experiment was similar to the relayassembly experiment. A group of workers were segregated so their
productivity and group dynamics could be studied. The workers were paid
with a piecework rate that reflected both group and individual efforts. The
researchers found that the wage incentive did not work. The group had
developed its own standard as to what constituted a “proper day’s work.” As
such, the group’s level of productivity remained constant because they did
not want management to know that they could produce at a higher level. If
a member of the group produced more than the agreed-upon level, the other
members influenced the “rate buster” to return his productivity level to the
group’s norm. In addition, if a member of the group failed to produce the
required level of output, the other members traded jobs to ensure that the
group’s output level remained constant. The results of the bank-wiring
experiment mirrored the relay-assembly experiment results. The
researchers concluded that there was no cause-and-effect relationship
between working conditions and productivity and that any increase or
decrease in productivity was attributed to group dynamics.
As a result of the bank-wiring experiment, researchers became very
interested in exploring informal employee groups and the social functions
that occur within the group and that influence the behavior of the individual
group members. As part of the Hawthorne Studies, the researchers
conducted extensive interviews with the employees. Over 21,000 interviews
were conducted to determine the employees’ attitudes toward the company
and their jobs. A major outcome of these interviews was that the
researchers discovered that workers were not isolated, unrelated
individuals; they were social beings and their attitudes toward change in the
workplace were based upon (1) the personal social conditioning (values,
hopes, fears, expectations, etc.) they brought to the workplace, formed from
their previous family or group associations, and (2) the human satisfaction
the employees derived from their social participation with coworkers and
supervisors. What the researchers learned was that an employee’s
expression of dissatisfaction may be a symptom of an underlying problem in
the workplace, at home, or in the person’s past.
THEORIES X AND Y
Another significant impact in the development of OB came from Douglas
McGregor (1957, 1960) when he proposed two theories by which managers
view their employees: Theory X (negative/pessimistic) and Theory Y
(positive/optimistic). Theories X and Y reflect polar positions and are ways
of seeing and thinking about people, which, in turn, affect their behavior.
Theory X states that employees are unintelligent and lazy. They dislike
work, avoiding it whenever possible. In addition, employees should be
closely controlled because they have little desire for responsibility, have
little aptitude for creativity in solving organizational problems, and will
resist change. In contrast, Theory Y states that employees are creative and
competent; they want meaningful work; they want to contribute; and they
want to participate in decision-making and leadership functions.
Borrowing from Maslow’s Hierarchy of Needs, McGregor stated that the
autocratic or Theory X managers were no longer effective in the workplace
because they relied on an employee’s lower needs for motivation
(physiological concerns and safety), but in modern society those needs were
mostly satisfied and thus no longer acted as a motivator for the employee.
For example, managers would ask, “Why aren’t people more productive? We
pay good wages, provide good working conditions, have excellent fringe
benefits, and provide steady employment. Yet people do not seem to be
willing to put forth more than minimum efforts.” The answers to these
questions were embedded in Theory X’s managerial assumptions of people.
If managers believed that their employees had an inherent dislike for work
and must be coerced, controlled, and directed to achieve organizational
goals, the resulting behavior was nothing more than self-fulfilling
prophesies. The manager’s assumptions caused the staff’s “unmotivated”
behavior.
However, at the opposite end of the spectrum from Theory X, McGregor
proposed Theory Y, where managers created opportunities, removed
obstacles, and encouraged growth and learning for their employees.
McGregor stated that participative or Theory Y managers supported
decentralization and delegation of decision making, job enlargement, and
participative management because they allowed employees degrees of
freedom to direct their own activities and to assume responsibility, thereby
satisfying their higher-level needs (see Figure 1–1).
Figure 1–1 McGregor X-Y Theory Diagram
SUMMARY
Since 1960, a wealth of information has emerged within the study of OB,
which will be addressed in this textbook. In Part I, the issues of diversity,
perceptions, attitudes, and communication are discussed. Part II add
