What are the methods a nurse can use to gather cultural information from patients? How does cultural competence relate to better patient care? Discuss the ways in which a nurse demonstrates cultural competency in nursing practice.
The post What are the methods a nurse can use to gather cultural information from patients? appeared first on Infinite Essays.
· What is the global impact of health, wellness, and the delivery of care on emerging populations?
· What nursing theories can be utilized when providing culturally competent care to patients?
· What is the impact of race, culture, and ethnicity on individual and collective identity, and how does this influence beliefs regarding health?
· What are some cultural factors that may affect care for emerging populations?
· How do nurses work with individuals, families, communities, and social-cultural networks to influence health promotion?
Cultural competence in nursing is an absolute necessity. As populations grow and become more diverse, understanding different cultures and their practices and respecting these differences is imperative to providing holistic care to patients in every health care setting. In order to educate patients effectively and empower them to promote their own health, the nurse must fully engage with them and become acclimated to their specific needs. This chapter will provide details on how to become culturally aware and apply cultural sensitivity to nursing care, particularly as a nurse educator. Health promotion education will encompass nutrition education and cultural aspects will be discussed.
·
According to the Center for Disease Control (CDC) (2015a), health disparities are the “preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by disadvantaged populations,” (para. 1). Disadvantaged populations include a wide range of ethnicities. Ethnicity differs from race in that it encompasses ideas and practices of a group that shares commonalities of race, language, history, religion, and/or country or place of origin. Race involves ancestry and shared or common physical characteristics. In an effort to support the growing population of disadvantaged persons worldwide, the World Health Organization (WHO) has formulated the following goals centered on global awareness and improvement of health disparities.
· Promoting development
· Fostering health security
· Strengthening health systems
· Researching disparities, health risks, and effective solutions
· Enhancing partnerships
· Improving performance
Nurses are a crucial component to achieving these goals and must be keenly aware of the challenges such populations face. Emerging populations within the United States include:
· Arab Americans
· Asian Americans and Pacific Islanders
· Black/African Americans
· Latino/Hispanic Americans
· Native Americans/Alaskan Natives
· Homeless
· Lesbian/Gay/Bisexual/Transgender/Questioning (LGBTQ)
· Refugees
The federal government has recognized the challenges emerging populations face and has taken steps to promote and support health within these populations. The National Institute of Health (NIH), National Center on Minority Health and Health Disparities (NCMHD), the Office of Disease Prevention and Health Promotion (ODPHP), and the U.S. Department of Health and Human Services (HHS) have all collaborated to formulate plans to help decrease these disparities. Among the more prominently known and mentioned programs is Healthy People 2020. This initiative created by the ODPHP is composed of many goals all focused on health promotion in the United States, including the country’s emerging and disadvantaged populations.
Mohammed immigrated to America from Saudi Arabia with his wife and two small children in 1995. Though they have lived and worked in America for more than 20 years, they have not yet acclimated to Western culture and do not feel truly at home. Because of the political climate, Mohammed has often felt a great deal of discrimination. Though it is not always blatant, the staring and whispers have been enough to make him feel incriminated. He and his family are devout Muslims, and his wife and daughter have often felt endangered in public wearing their hijabs. They have not sought much medical treatment out of fear of being harassed. Now, Mohammed is hospitalized with chest pain and is being informed he must undergo open heart surgery. He is nervous and feels that the whispers, laughing, and stares he receives from the hospital staff are about him, his family, and his culture. His nurse, Ben, admits to his manager that he does feel a bit uncomfortable caring for Mohammed’s family because he is unfamiliar with their culture, and what he does know about Middle Eastern people comes from what he sees in the news media, most of which is associated with terrorism.
Check for Understanding
How can Ben provide culturally competent care for Mohammed and his family given his apprehensions?
·
·
Health equality is based on the premise that all individuals deserve high quality, easily accessible, and affordable health care regardless of ethnicity or race. Unfortunately, the socioeconomically disadvantaged have poor access to quality health care and ultimately have higher rates of illness and premature death (Egen, Beatty, Blackley, Brown, & Wykoff, 2017). Nurses have a duty to provide and advocate for quality care for persons from all backgrounds, in spite of personal bias. Acknowledgment of this inequality is essential to formulating a plan of action that leads to health equality. Equally imperative for the nurse to understand is the concept of health equity, which is the provision of resources necessary to live well to all individuals regardless of varying social determinants of health (SDOH) (Brennan Ramirez, Baker, & Metzler, 2008).
Nurses are in a unique position to advocate for patients’ needs. Nurses are often the first point of contact for patients and are able to form trusting relationships through which the nurse is able to glean important information regarding patients’ needs. In dealing with health inequity, nurses must utilize the power of assessment to identify patients at risk. Once these inequities have been identified, nurses can work together with the patient and interdisciplinary team to come up with a plan of care that helps the patient attain proper resources to meet his or her goals.
There are many frameworks or models within health care that guide nurses and the health care team in identifying and addressing patients’ cultural needs. The nurse utilizes these models in order to personalize the plan of care and provide individualized care that encompasses cultural needs. One such framework is Campinha-Bacote’s (2011) model of cultural competence (see Figure 3.1).
The Campinha Bacote model involves the nurse’s inner reflection and self-journey in providing culturally competent nursing care; it also guides the nurse to provide culturally sensitive care by teaching nurses cultural skills (Campinha-Bacote, 2011).
Cultural skill is guided by Madeleine Leininger’s culture care theory in which Leininger states that cultural assessment “is the systematic appraisal or examination of individuals, groups, and communities as to their cultural beliefs, values and practices to determine explicit needs and intervention practices within the context of the people being served,” (Campinha-Bacote, 2011, para. 6).
This is done by asking culturally appropriate questions that help the nurse identify needs, such as:
· When do you seek treatment from others when you are ill?
· What do you fear most about your sickness or becoming ill?
· What types of treatments are acceptable to you?
· How do you feel your illness affects you in your daily life?
In addition, nurses must also take into consideration the patient’s SDOH. This includes the assessment of the patient’s social, economic, and physical environments that contribute to the patient’s level of risk. Assessing these determinants is a primary step in achieving cultural competence. These factors, which are directly related to the patient’s culture and belief system, have a significant impact on a patient’s overall health status. In essence, these needs are, at times, the basic necessities of life, such as stable housing and nutrition needs that must be addressed before other health concerns become the focus of care (Theiss & Regenstein, 2017).
Scenario
Sheila is a 41-year-old female patient being treated for hypertension. She goes to the nearby urgent care center for persistent headache, and the intake nurse discovers her blood pressure is 172/90. After thorough discussion and assessing for her SDOH, the nurse finds that Sheila has recently become homeless and cannot afford her medications. The nurse understands that resources need to be provided to meet Sheila’s basic needs in order for her to remain compliant with her medical treatment regimen.
·
Nurses have the unique opportunity to learn about many cultures and grow their cultural competency skills because of their frequent, if not daily, care of patients from different cultures (Rahimaghaee & Mozdbar, 2017). Culture is “a pattern of traditions, beliefs, values, norms, symbols and meanings among a group of people,” (Byrne, 2016, p. 114). There are many different cultures, all with varying values and beliefs.
Values are the beliefs that serve as standards that ultimately influence behavior and thought processes within the cultural group. These beliefs often have heavy influence on perception of health in many ways, including health promotion, health maintenance, when to seek care and treatment, and what types of treatments are acceptable. Value orientation differs in that the collective values of a society shape its overall personality. It is the nurse’s responsibility to understand that some cultural beliefs may incorporate health practices that are considered unsafe or unhealthy to other cultures that do not share the same beliefs.
·
·
A controversial example of this is the practice of female genital mutilation. Female genital mutilation, also known as female genital circumcision, is a practice in which the external female genitalia is partially or totally removed for nonmedical purposes (World Health Organization [WHO], 2018). This practice is seen in countries within the Middle East as well as Africa and parts of Southeast Asia.
The controversy for Western society, as well as other developed countries, lies in the many risks this practice poses to a woman’s health, in addition to the practice being viewed as a violation of human rights (Momoh, Olufade, & Redman-Pinard, 2016). In light of this cultural practice, the nurse must remain sensitive when addressing patients who may have undergone this practice. This includes avoiding the term mutilation, as this might be considered disrespectful to women who have had the procedure and consider it to be a normal part of their culture and not a form of mutilation or cruelty (Momoh et al., 2016).
The nurse must also take child protection issues into account and advocate for patient safety if a minor is at risk for undergoing this procedure. Other controversial practices include refusal of blood or blood products, male circumcision, and beliefs surrounding death and dying. Each culture has different views on different aspects of health that need to be respected, regardless of personal feelings surrounding the practice.
What does it mean to be culturally competent? As nurses, caring for all persons regardless of ethnicity, socioeconomic background, race, or culture, is expected. To provide patients with basic nursing care, nurses must have the ability to suspend personal biases and fully respect patients in spite of differences. Providing culturally competent care is a major element in helping to eliminate outstanding health disparities worldwide. Cultural competency does not mean becoming an expert on every culture encountered, but it does mean that nurses should recognize what they do and do not know in order to provide appropriate care.
Cultural competency means being aware of differences related to culture and adjusting plans of care accordingly as well as remaining sensitive and respectful of choices patients may make based on their culture. Campinha Bacote’s cultural competence model is a nursing theory that aids nurses in this process. Becoming culturally competent is considered a continual process that requires continuous education, self-awareness, and evaluation in order to provide holistic, culturally competent nursing care (Campinha-Bacote, 2011). With the influx of immigrants into the United States and the rise in ethnic minorities, nurses will be faced with the issue of culturally competent care on a daily basis. Cultural competence is just one component of providing integrated health care, which includes treating the patient in a holistic way that addresses all of their psychosocial and physical health care needs.
Within different cultural traditions, there are varying healing systems that are specific to maintaining and restoring health; they are traditional and nontraditional care systems (see Table 3.1). Traditional care systems embody more of the health care modalities seen in Western medicine, such as seeking medical attention from a licensed professional.
Nontraditional systems take a more natural approach, utilizing herbs and traditional practices for healing versus modern medicine modalities of care (Gale, 2014). There is a growing acceptance of the use of complementary alternative medicine (CAM) within the United States, which uses a combination of traditional treatments with alternative therapies such as massage, aromatherapy, or acupuncture (Lavretsky, 2017).
| Criteria | Traditional | Nontraditional |
| Care Philosophy | Curative | “Carative” (not necessarily treatment for a total cure) |
| Approach | Specializations depending on ailment | Holistic and individualized |
| Setting | Professional, including clinics and offices | Homes and community centers |
| Treatments | Pharmaceuticals, advanced technological treatments, and use of “modern medicine” | Herbs, charms, amulets, massage therapy, and meditation |
| Providers | Licensed professional | Healers, shaman, spiritualists, priests, and medicine man |
| Support | Ancillary staff at hospital or professional care setting/facility | Family and friends |
| Payment | Insurance, self-pay | Negotiable |
| Health Philosophy | Influenced by scientific methods, definitions, and research | Continuous search for balance |
Transcultural Nursing
Madeleine Leininger (1991) developed the culture care theory, which recognizes the importance of cultural care in nursing. This is the fundamental basis for transcultural nursing, which is the study of cultural competence and how to apply it to patient care on a daily basis. The theory helps nurses understand elements that influence the patient’s well-being such as religion, culture, and economic factors. This theory also highlights the importance of human caring in all patient interactions and that caring is the true basis of nursing care. The nurse acknowledges and respects cultural differences and formulates a plan of care that is specific to the patient’s individualized cultural needs (de Oliveira Carvalho, Santiago da Rocha, & de Souza Rocha, 2015). The concepts that are central to this theory and guide the nurse’s care are as follows.
· Cultural preservation is the nurse’s ability to retain and respect the patient’s cultural practices and traditions while providing nursing care.
· Cultural accommodation involves the nurse going above and beyond to accommodate a patient’s specific cultural needs.
· Cultural repatterning is the gentle suggestion of modifying certain cultural practices that could cause harm or interrupt the current medical treatments being provided.
The nurse utilizes these skills to provide appropriate, culturally sensitive nursing care to the patient (de Oliveira Carvalho et al, 2015). The sunrise model (see Figure 3.3) illustrates how the elements involved in cultural care affect one another as well as the nurse’s actions and care, all of which contribute to the individual’s health. At the center of the model is the healthy, balanced patient. The patient’s health is directly influenced by a variety of factors, including social, religious, economic, and cultural; collectively these are referred to as the patient’s cultural care worldview. The nurse considers all elements within the patient’s worldview and understands that they each play an important role in affecting the patient’s health. Below the healthy, balanced patient, the model shows the different ways in which the patient may seek restoring health, including folk care, nursing care, and professional systems. Below this are the elements of cultural care that the nurse utilizes in order to provide culturally congruent nursing care to the patient.
·
Safe nursing practice begins with thorough assessment. In order to provide safe care to multicultural patients, proper cultural assessment is a necessity. As previously described, each culture may have their own set of values and beliefs that could affect their plan of care. This also includes family dynamics, such as the decision maker within the family. This is important when discussing course of treatment, as it may be considered rude to discuss these details without a particular family member present. Taking detailed notes on family history is also crucial. Factors such as divorce, involvement of extended family members, power of attorney, end-of-life wishes, paternity, adoption, child custody, and familial violence all play important roles in the patient’s individualized plan of care. The nurse should take all of these elements into consideration and perform an adequate assessment to gather such details, customizing the patient’s plan of care to accommodate his or her needs.
When addressing the needs of emerging populations and immigrants, another topic that should be investigated is access to resources. The patient may be new to the area and/or country and may and may not have an awareness of local custom or approaches to navigate complex systems such as the health care system. In addition, they could simply lack the foundational knowledge, or prior experience necessary to access medical services. Education with interpretive services should be made available to ensure a basic understanding of the information being delivered. Collaboration with interdisciplinary team members ensures effective patient management as well as smooth transition of care.
Vulnerable populations are groups of people who require special attention related to well-being and safety, including pregnant women, human fetuses, neonates, children, cognitively impaired, prisoners, students, employees, uninsured, seniors, immigrants, and the educationally disadvantaged (Samuel-Nakamura, Leads, Cobb, Nguyen Truax, & Schanche Hodge, 2017). Vulnerable populations warrant the protection and care of federal agencies as well as health care institutions in order to ensure safe, effective, appropriate, affordable, and accessible health care. Nurses should be aware of these populations and work together with the interdisciplinary health care team to provide resources to these patients in order to ensure that they receive adequate health care.
·
Nurses have all had experiences in which they go to great lengths to educate a patient regarding a topic only to receive a very confused look or have a patient’s family member tell them the patient did not understand the information just communicated. Of course, this confusion can be caused from a number of communication issues, but the patient’s health literacy may not be a factor the nurse thinks to consider. In the nurse’s effort to expedite care and optimize time in an already stretched thin shift, the nurse might forget the need to slow down or speak in a way that is understandable to those who do not comprehend medical jargon. While medical professionals are capable of deciphering medical terms, even the most educated individual may not understand such terms. Moreover, patients may acknowledge and agree to the presented facts out of embarrassment or anxiety, leaving the nurse unaware that they did not understand. This issue comes with repercussions such as readmission and adverse health outcomes related to poor maintenance or neglected follow-up care (Johnson, 2015).
Nurses must stay abreast of patients’ education needs, especially health literacy and the patients’ ability to fully understand recommendations and education provided. Comprehension is vital to enabling the patient to make informed decisions regarding their health care decisions. Crucial elements include the use of layman’s terms when describing medical procedures or anatomy and the use of the teach back method in which the nurse asks the patient or caregiver/family to repeat what was just explained to them in their own words. In this way, the nurse can determine what they did or did not understand so that clarifications can be made (Tamura-Lis, 2013).
Also important to the education process is limiting “yes or no” questions. These types of questions do not allow for patients to speak freely, and most patients tend to answer simply and without seeking clarification. Instead, the nurse should use open-ended questions, such as, “Can you tell me why it is important to check your blood sugars daily?” This presents an opportunity for further discussion between the nurse and patient. Speaking slowly in concise sentences, sticking to only two or three topics at a time, and supplementing presented material with video media have all been proven to be effective delivery methods for providing patient education (Johnson, 2015).
·
Nutrition is a central component to healthy living. Within much of Western civilization, foods are readily accessible and often highly processed and laden with extra calories, fat, and sugar. These foods can be less expensive than healthier options as well, making healthy choices less accessible for low-income families and individuals. Food is also a key element in daily social life as well, often taking center stage during celebrations, gatherings, and many events.
As a result, the United States, along with other countries around the world, faces a growing crisis of obesity and associated comorbidities. Obesity, diabetes, hypertension, heart disease, cancer, and stroke, along with other diseases, have all become more prominent and have a direct correlation to poor dietary intake (Patience, 2016). Nurses have always been an important proponent in promoting wellness. As nurses’ roles continue to grow and advance, it is important for them to be knowledgeable about patient education needs such as nutrition and activity. This section will explore these elements and details. In order to address the growing concern of obesity and overall health, the ODPHP has developed Healthy People 2020, in which a series of recommendations and implementation programs have been initiated to promote wellness.
As part of a national effort to improve health, ODPHP created initiatives to improve prominent health issues in the United States. Addressing nutrition and obesity is one of the main initiatives because statistics show that nearly 1 in 3 adults is considered obese, and approximately 81.6% of adults do not get the recommended amount of daily activity (Office of Disease Prevention and Health Promotion [ODPHP], n.d.). The ODPHP’s overarching goal is to help persons within the United States live healthy, long lives and provide them the resources to avoid preventable diseases related to poor health. Indicators also point to an alarming number of Americans not consuming anywhere near the recommended amount of fruits and vegetables and a large proportion living sedentary lifestyles, all of which have been proven to increase the development of noncommunicable diseases (ODPHP, n.d.). Moreover, it is evident that American society has shifted from being a country of nutritional deficit-related diseases to one of noncommunicable diseases related to nutritional excess and overconsumption. Such a shift requires the attention of governmental bodies as well as health professionals who work closely within communities to promote and restore health in an ever-growing population with longer life expectancies.
While Healthy People 2020 targets several subjects related to overall health, the program’s focus on nutrition involves helping individuals achieve optimum weight status by teaching them to eat well-balanced meals in order to avoid chronic illness development associated with obesity (ODPHP, n.d.). Central to the issue of nutrition are recommendations such as decreasing fats, sugars, salts, and alcohol as well as learning to incorporate nutrient dense foods. Objectives specific to nutrition include healthier food access, work- and school-related programs, combating obesity, food insecurity, and nutrient deficiencies. Their overarching goals for helping individuals attain wellness include the following.
· Eliminate preventable disease.
· Achieve health equity, and improve health of all groups.
· Create social and physical environments that promote wellness.
· Promote health development and healthy behaviors (ODPHP, n.d.).
The Healthy People website provides links and resources such as choosemyplate.gov, which provides easy to understand recommendations for dietary intake, including the recommended intake of whole grains, fruits, vegetables, carbohydrates, and fats (United States Department of Agriculture [USDA], n.d.). This valuable resource also provides information regarding the nutritional content of the different food groups and why they are essential to health. The website also has tools such as personalized food trackers to visualize typical daily intake and a body mass index (BMI) calculator to determine a baseline health status.
The Healthy People website delivers evidence-based studies, clinical advisories, as well as consumer advice, which is the resource most relevant to the general population. Within the topic of consumer advice, a collection of links is available, providing resources on a plethora of topics, including healthy snack tips for parents, heart health, shopping list tips, and eating healthy during pregnancy. These resources can help nurses to guide their patients in the health promotion and education process (ODPHP, n.d.). Though disease prevention and health promotion are ideal, the issue remains that health-related disparities are increasing in the United States and must be understood in order to create a plan of action for change in the future.
With respect to the goals for Healthy People 2020, the HHS developed specific health-related initiatives for individuals, including those within emerging populations. Each varying initiative is directed at achieving the following overall goals of helping individuals across the United States achieve wellness.
· Increase the proportion of persons with medical insurance.
· Increase the number of population-based data systems used to monitor Healthy People 2020 objectives that collect data on LGBTQ populations.
· Increase the proportion of population-based Healthy People 2020 objectives for which national data are available by race and ethnicity.
· Eliminate very low food security among children.
· Increase the proportion of persons with diabetes who receive formal diabetes education.
·
Nutrition can be a defining factor in attaining optimal or poor health. What is put into the body has a direct impact on its functioning capacity, and poor nutrition can lead to the development of a number of diseases. This chapter focuses briefly on six diseases that are directly linked to nutrition:
· Obesity
· Hypertension
· Diabetes Mellitus (DM)
· Heart Disease
· Cancer
· Stroke
It should be noted that four of these diseases—diabetes, heart disease, stroke and cancer—are some of the leading causes of death in the United States and, therefore, take precedence and require the most amount of attention for health promotion and education, especially from the nurse’s perspective (CDC, 2017a).
Obesity is a prominent and growing concern in the United States, leading to a host of other diseases that result in poor patient outcomes (Lu, Dickin, & Dollahite, 2014). Genetics as well as hormonal imbalances play a causative role in the development of obesity; however, modifiable factors, such as dietary intake and physical activity, remain the driving forces of disease prevention (CDC, 2015c). Bearing all of this in mind, it is crucial to focus on encouraging lifestyle changes that involve proper dietary intake, weight loss and maintenance, increased physical activity, and mental health wellness, as appropriate, to help individuals live their best life.
Hypertension is the elevation in blood pressure greater than 140mmHg systolic and/or a diastolic greater than 90mmHg (American Heart Association, 2017). Multiple risk factors are involved in its development including obesity, DM, genetics, and familial tendency. Again, this disease process is related to the others described within the text, particularly obesity. While this disease can be placed under the umbrella of heart disease, its prominence warrants individual discussion. Fortunately, many of the risk factors associated with hypertension are related to modifiable changes that can be made by the individual. While it is imperative to reinforce lifestyle changes, it is important to emphasize adherence to medical management, such as prescribed medications, in order to manage this disease process and avoid associated complications. This makes health promotion all the more important in helping patients with heart disease achieve a healthy life (American Heart Association, 2017).
Most nurses have an understanding of diabetes disease process and have cared for numerous patients with this diagnosis. This discussion relates specifically to DM type 2, in which insulin is resistant and does not respond appropriately to the influx of glucose received during the digestion process, as well as a decreased amount of insulin production overall (American Diabetes Association, 2015). Prolonged and persistent elevation in glucose levels leads to DM and a wide range of comorbidities associated with it such as obesity. Left untreated or undiagnosed, persistent hyperglycemia can lead to devastating effects such as kidney failure, heart disease, neuropathy, stroke, and death (CDC, 2017b). Empowering patients with the tools to make effective changes is essential to promoting health for these patients.
Heart disease is a broad term used to encompass a number of cardiovascular conditions, including coronary artery disease (CAD), myocardial infarction (MI), congestive heart failure (CHF), hypertension, and high cholesterol (hypocholesteremia) (Mayo Clinic, 2018). With each of these disease processes, the effects and subsequent required management are often lifelong and life altering, requiring medical supervision and care and a great deal of lifestyle modification. Compliance becomes an issue with disease maintenance, as these illnesses often require a combination of pharmacotherapy and lifestyle changes (Mayo Clinic, 2018).
Cancer is the rapid multiplication of abnormal cells that invade surrounding tissues and organs (American Cancer Society, 2015). Causes for cancer are multifactorial and can arise from a combination of genetic, environmental, and lifestyle influences. Nurses should be aware of the emotional and psychosocial impact this disease can take and use their therapeutic communication skills and display true human compassion in working with these patients. Focus should also be placed on screenings in order to detect early stages of cancer so that treatment can begin as soon as possible. Early diagnosis and intervention is associated with a higher rate of survival; therefore, every effort to prevent and treat early should be exhausted in order to intercept tragedy. Once again the primary focus for promoting wellness and preventing disease is centered on dietary modification and lifestyle changes that promote weight loss, weight management, and increased activity (Freedman et al., 2014).
Stroke or cerebrovascular accident (CVA) is the irreversible damage to part of the brain tissue caused by blockage of the vessels or hemorrhagic event. The emphasis of this discussion will be on thrombotic strokes, which are caused by occlusions related to arteriosclerosis. Multiple risk factors contribute to the buildup of plaque within the cerebral vessels leading to partial or total occlusion and the resultant stroke. Paralysis, aphasia, dysphagia, and motor deficits are only a few of the effects this disease can have on patients, leading to an enormous change in quality of life that affects the patient and all those involved in the patient’s care (American Stroke Association, 2012). As previously discussed, these diseases can be prevented, at least in part, with health promotion measures, including nutrition (see Table 3.2).
| Disease Process | Dietary Recommendations |
| Obesity | · Wide variety of fruits and vegetables
· Whole grains · Limit processed foods and foods high in fat and sugar · Lean proteins · Nuts and legumes in moderation · Low-fat or fat-free dairy products · Avoid alcohol · Smaller portions · Medical management as indicated · Increase physical activity slowly |
| Hypertension | · Increase physical activity
· Medical management as indicated · “DASH” (Dietary Approach to Stop Hypertension) diet includes: · Limited sodium – 1,500-2,300 mg per day (low or standard plan based on individual needs) · Emphasis on whole fruits and vegetables · Whole grains · Lean protein sources · Low-fat or fat-free dairy products · Limited high-sugar foods · Avoid alcohol · Limit high-fat foods · Limit caffeine consumption · Nuts and legumes in moderation |
| DM | · Increased activity as recommended by medical professionals managing care
· Medical management for medications if indicated · Low glycemic index foods such as: · Legumes · Dark leafy vegetables · Whole grains · Fish · Fat-free dairy products · Berries · Sweet potatoes · Citrus fruits · Other recommendations consistent with previously mentioned foods such as: · Avoiding alcohol · Limiting foods high in fat and/or sugar content · Avoiding processed foods · Nuts and legumes in moderation |
| Heart Disease | · Whole grains
· Lean protein sources; limit or eliminate red meats · Variety of fruits and vegetables · Fat-free or low-fat dairy products · Limit high-fat and/or high-sugar foods · Limit processed foods · Increased activity based on medical recommendations · Limit sodium if indicated · Nuts and legumes in moderation |
| Cancer | · Whole grains
· Lean protein sources · Variety of fruits and vegetables (the more the better) · Fat-free or low-fat dairy products · Limit high-fat and/or high-sugar foods · Limit processed foods · Nuts and legumes in moderation · Increase water intake · Limit or eliminate alcohol |
| Stroke | · Whole grains
· Lean protein sources; limit or eliminate red meats · Variety of fruits and vegetables · Fat-free or low-fat dairy products · Limit high-fat and/or high-sugar foods · Limit processed foods · Increased activity based on medical recommendations and therapy treatments for post stroke victims · Limit sodium if indicated · Nuts and legumes in moderation |
The importance of eating a well-balanced diet is not a new concept. From childhood, the notion of eating well is instituted into early education and promoted in a wide variety of platforms. The basics, such as the food pyramid and limiting foods that are high in fat and sugar, are elements with which many individuals in American society are at the least, vaguely familiar. The issue of compliance arises due to the abundance of highly-processed, convenient, and inexpensive sources of comfort food.
Regardless of these reasons, reiteration of the proper dietary guidelines in order to promote good health is necessary. The U.S. Department of Agriculture (USDA) develops recommendations regarding proper dietary intake and helps teach these guidelines by way of Internet resources and school, work, and outreach programs throughout the country. Their www.choosemyplate.gov website is a resource that provides a number of tools and advice regarding dietary intake for both adults and children.
The basic recommendations have not changed dramatically over the past 50 years. The basics include the involvement of five primary food groups:
· Fruits
· Vegetables
· Grains
· Protein
· Dairy
Instead of seeing these groups presented in the pyramid that some may remember from the 1990s, the new guidelines are featured on a plate system in which each group is divided based on the daily recommendation. The recommendations for each group are specific depending on age group, sex, and physical activity. In general, the average adult’s daily food consumption should include:
· 2 cups of fruit,
· 2.5 cups of vegetables,
· 6-7 ounces of whole grains,
· 5.5-6 ounces of protein,
· 3 cups of dairy, and
· 5-6 teaspoons of oils/fats (U.S. Department of Health and Human Services [HHS] & USDA, 2015).
There is also advice regarding beverage choices, such as avoiding drinks with added sugars and reducing alcohol consumption. Rather than focusing all attention on adhering to the specific dietary intake recommendations, the website focuses on helping individuals make small changes in their diets, such as switching to low fat or fat-free dairy products and substituting fruit for sugary desserts (Booze, Hardison, & Haven, 2017).
Physical activity is also addressed within this resource, providing tips to increase daily activity, such as taking the stairs instead of the elevator or parking farther away from the entrance of one’s destination. This is vital to promoting wellness because sedentary or low-activity level lifestyles are major contributors to the development of the disease processes discussed in this chapter. The recommendations made are also tailored depending on age, sex, and overall health of the individual. In general, adults are advised to obtain approximately 2.5 hours of moderate physical activity per week at a minimum and include weight-bearing exercise within their regimen for bone strength (HHS & USDA, 2015).
·
The role of educator is necessary in every role nurses may assume throughout their careers. In the nurses’ endeavor to provide holistic care to all patients, health promotion is a key factor in providing patients with the tools to live full, healthy lives. Being knowledgeable regarding prominent noncommunicable diseases and proper dietary recommendations is the first step for nurses to learn to assist their patients in making healthier choices. The next step is learning how to educate their patients.
Nurses have largely leaned on Nola Pender’s health promotion model as a guide to help educate patients on such changes (see Figure 3.6). The model focuses on different factors that can influence a patient’s ability or willingness to absorb information and make a viable change in his or her life. These factors include willingness to change, perceived benefits and barriers, situational influences, and a commitment to change (Khodaveisi, Omidi, Farokhi, & Soltanian, 2017). Nurses should take these aspects into consideration when delivering education regarding dietary intake and lifestyle modifications. If a patient is not ready, willing, or able to institute change, the information provided may not sink in, potentially leading to frustration for both the nurse and the patient and/or family. Not being able to visualize the result of their hard work can be challenging, especially in a profession in which recurrent readmissions for similar diagnoses are often seen in acute care settings. An example of this could be the diabetic patient who has been educated multiple times regarding proper diet, but comes to the emergency room on a monthly basis because of hyperglycemic episodes.
Ultimately the power to change remains in the patient’s hands; whether or not they follow through with the advice of medical professionals is not within the nurse’s control, leaving the nurse with a sense of helplessness. Keep in mind that while many patients may not make changes, there will be some who do and will benefit greatly for it. The work that nurses do is sacred, and while not seeing the fruits of their labor can be deflating at times, nurses can rest assured that they do create positive change for their patients as a whole. A barrier to effective teaching seen throughout health care is health care literacy. An inability to convey important health care information has a direct impact on patient outcomes as well as health care costs; therefore, it is in the nurse’s best interest to become familiar with improved ways to provide health promotion education (Johnson, 2014).
As cultural diversity continues to expand and grow within the United States, it is important to examine the differences in how cultures view nutrition and how these differences affect overall health. This is a key factor in providing culturally competent nursing care. Nutrition is rudimentary to all people regardless of culture; however, different cultures have varying traditions, customs, practices, religions, and routines that impact daily nutritional life. Food culture focuses on how the differences between cultures affect nutritional intake, including dietary preferences, food preparation and storage, food restrictions, and food-safety practices (Garnweidner, Terragni, Pettersen, & Mosdol, 2012).
Nurses must take the concept of food culture and cultural sensitivity into consideration when assessing individuals or families for nutritional health. The assessment process is essential to giving the nurse a clear indicator of the individual’s needs. When evaluating an individual or family regarding cultural aspects, the nurse should include questions related to dietary intake and what that might look like to them. This might include preferences, food preparation methods, prohibited foods, celebratory foods, and customs related to tradition and holidays. When addressing patients who require education regarding one of the diseases discussed in this chapter, simply advising them to eat well may become a challenge.
Scenario
The nurse has a Mexican-American patient who is obese and recently diagnosed with DM and hypertension. The nurse discovers that part of the patient’s culture involves eating large family meals together on a frequent basis. The meals are typically prepared with lard, served in very large portions, and include few or no vegetables, all of which is inconsistent with the proper recommendations for a diabetic patient. The nurse must be sensitive when making suggestions for change within this patient’s life, telling the patient she must stop eating what she is used to will likely not illicit any kind of change. Instead, the nurse may consider suggesting preparing the meal in a different way, such as baking instead of frying, omitting lard from the preparation of the meals, and cutting portions by half. In this way, the patient can make small changes while still remaining consistent with her cultural practices.
Nurses must also take into consideration patient access to resources enabling patient populations to adhere to a healthy life. The government has many programs available to aid communities in obtaining resources such as healthy foods and health care. While the resources discussed previously, such as Healthy People 2020 and ChooseMyPlate, are beneficial, the nurse must consider the patient who has no Internet access to utilize such resources, as well as other socioeconomic concerns that prohibit patients from living well. Each of these government programs provide invaluable resources aiming to provide not only financial assistance to purchase foods, but also education regarding healthy eating and available community resources.
Supplemental Nutrition Assistance Program (SNAP), formerly known as food stamps, is a government program that provides assistance to low-income families and individuals to purchase groceries that they might not otherwise have the resources to obtain. Qualified persons receive an allotment of money, based on income and total family size, on a type of debit card that can be used at qualified stores to purchase groceries. This allows the individual to purchase food items such as grains, fruits, vegetables, proteins, and dairy products (USDA, 2018c).
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a government-sponsored program that gives assistance to pregnant and postpartum mothers, as well as infants and children up to age 5 that are determined to have nutritional-related risks and have low income and/or minimal resources available to them. The program not only offers financial support for nutritional supplementation, but provides valuable resources to its recipients, such as breastfeeding support and substance abuse referral programs (USDA, 2018d).
Child Nutrition Programs (CNP) cover a wide range of assistance programs for children such as Team Nutrition, School Breakfast Program, Child and Adult Care Food Program, National School Lunch Program, Summer Food Service Program, and Special Milk Program. Each of these programs primarily focuses on children coming from low-income families to ensure that they receive adequate nutrition. The programs also focus on health promotion and education from a young age to build healthy habits early on (USDA, 2018b).
There are a number of resources available for senior citizens as well, including Senior Farmer’s Market Nutrition Program, Elderly Nutrition Program, Nutrition Services Incentive Program and Administration for Community Living: Nutrition Services. Each of these provides assistance to low-income seniors with nutritional deficits who would otherwise be unable to purchase healthy foods. In addition to financial resources, these programs also provide education and free health screenings to the elderly who may not otherwise have access these resources (USDA, 2018a).
Hunger and food security resources programs include Commodity Supplemental Food Program, Food Distribution Program on Indian Reservations, and the Emergency Food Assistance Program. These programs offer food services to a wide range of people in low income socioeconomic conditions at no cost depending on qualifications for such assistance. The Food Distribution Program is centered on supplementing these groups with foods grown in the United States to support American agriculture (USDA, 2018a).
The complexities of health promotion are multifaceted and continue to change along with society’s needs. Nurses must stay current on the challenges society faces and the interventions necessary to promote wellness. Weight-related diseases are a prominent concern throughout the United States and require attention in order to prevent further devastation related to its effects. Best practice for dietary and lifestyle changes to help prevent and manage such diseases are at the forefront of patient education for these issues. Nurses should be aware of community resources available to their patients in order to better assist them in promoting healthy living. Nurses must also be aware of patients’ varying education needs with regard to health literacy and cultural sensitivity. Nurses will continue to serve as a catalyst for creating positive changes that will optimize patients’ lives in the future.
In order to provide adequate, culturally competent care, it is essential that major cultures are identified and explored so nurses have a basic understanding of these cultures’ overall health issues and cultural aspects of care that will be observed (see Table 3.3).
Arab Americans originate from countries within the Middle East region, including Lebanon, Syria, Iran, Iraq, Egypt, Yemen, and Jordan. The health afflictions experienced by this ethnic group include diseases such as diabetes and coronary artery disease. This group is also at high risk for mental health issues related to discrimination. There is also a prevalence of tobacco use, which increases the risk for tobacco-associated diseases such as lung cancer and chronic obstructive pulmonary disease (COPD) (Substance Abuse and Mental Health Services Administration [SAMHSA]; 2018; Prevention Research Center, 2013).
Cultural aspects of care for Arab Americans are multifactorial. Family is central to their culture as is religion, which is typically Islam. They uphold values of modesty and have specific dietary rules and prayer rituals. They often prefer same-sex caregivers to preserve their value of modesty. There can be many barriers for the Arab American patient as discrimination is a very real fear that often discourages them from seeking medical attention. Care should be taken to attend to language barrier needs as well.
Asian Americans and Pacific Islanders encompass a very large number of countries of origin, including Japan, China, Vietnam, North and South Korea, Taiwan, Philippines, India, Sri Lanka, Pakistan, Nepal, and others. Such a large number of countries of origin makes their respective cultures extraordinarily diverse. People from this cultural group have a high prevalence of COPD, hepatitis B, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), tuberculosis, and liver disease (SAMHSA, 2018).
Cultural aspects of care that should be considered include understanding that family is a primary focus for this culture group. Older family members are highly respected and have unquestioned authority. Typically speaking, the oldest male in the family is the decision maker. Personal conflict in public is frowned upon, and physician recommendations are highly respected. Their respect for a medical professional’s advice may lead to agreement with every recommendation without thorough consideration or inquiry. The nurse should be aware of this and ensure adequate clarification for the patient and family.
There is also a level of shame associated with seeking treatment for psychological disorders; the nurse should be aware that the patient may not disclose feelings of depression or other psychological distress simply because it is not typical within this culture. This sense of embarrassment carries over to other aspects of health such as sexual wellness. Often sex is considered taboo to talk about, and many Asian Americans may neglect to seek preventative treatment, such as breast examinations or pap smears, because it may be considered embarrassing for them.
Asian folk medicine is a strong part of Asian American culture. These methodologies are heavily influenced by Chinese medicine, for which Taoism is the theoretical foundation. The Tao is based on the concept of balancing opposing forces: yin and yang. Practices related to it can be seen in Western medicine as well, including acupuncture, herbalism, and martial arts. These types of care modalities can be collectively described as CAM.
African American culture encompasses persons of descent from any Black racial group in the continent of Africa. African Americans have been a longstanding marginalized ethnic group in America and continue to face adversity and discrimination in the areas of business, education, politics, and leadership. Unfortunately, the socioeconomic component that afflicts this group most prominently is poverty and lack of health insurance. Diseases that are most prominent for African Americans include diabetes, hypertension, obesity, cancer, heart disease, and HIV/AIDS (SAMHSA, 2018).
Cultural considerations regarding health care for this culture group center on family and religion. The family is by far the most important aspect and is seen as the source of strength and support. An extension of this is seen in their ties to religion and the church. For African Americans, the church is not solely a house of worship, but rather as a community center providing a source of comradery and purpose. In addition, persons within this culture value prayer and believe in praying for healing in times of sickness. They tend to view health as the ability to fulfill expectation of their given role (e.g., mother, father).
Also, of note, some groups in certain areas of the United States such as the South, still rely on folk medicine and health practices to achieve wellness. Remedies such as the use of roots, herbs, rituals, and ceremonies are often utilized. In some instances, a voodoo priest or priestess may be consulted for advice and guidance regarding health.
American Indians and Alaskan Natives (AIAN) encompass persons of North or South American descent who affiliate with a tribe. There are more than 500 federally recognized tribes within the United States, with the Cherokee being the largest. Persons within this culture group continue to experience high rates of poverty, low income, and inaccessibility to health care. Many health issues this culture group faces stem from their socioeconomic misfortune. Persons within the AIAN culture have high incidences of heart disease, cancer, diabetes, stroke, obesity, substance abuse (specifically alcohol), teenage pregnancy, liver disease, hepatitis, sudden infant death syndrome (SIDS), mental health concerns, and high rates of suicide (SAMHSA, 2018).
There are several considerations for nurses to contemplate when addressing health and wellness of patients from this culture. As in other cultures discussed, family is very important to AIAN persons. They also value communal sharing of resources and tend not to focus on planning for the future, but rather the here and now. This may become evident to the nurse when trying to discuss a patient’s long-term outcome following an acute illness or accident. Persons within the AIAN culture also view health as a balance between self and nature. Any violation to nature or the natural order can be seen as direct cause of illness or poor health.
There is also a strong component related to spirituality for AIAN persons. Many use traditional medicinal practices and uphold cultural ceremonies in their everyday lives. They may seek out the care of traditional medicine men or women within their community rather than seek out medical attention from a licensed professional. These faith healers carry out healing ceremonies and may concoct drugs, medicine, and poisons in order to restore balance and wellness.
Latino Americans include a wide range of people from many countries such as Mexico, Cuba, Puerto Rico, and countries within South or Central America. The largest minority group within the United States, they face health issues primarily caused by lack of access to preventative care, lack of insurance, and language barriers. Leading health issues among this culture group are heart disease, cancer, HIV/AIDS, stroke, and diabetes (SAMHSA, 2018; CDC, 2015b).
Cultural considerations of health once again include family and religion. The family is so important to this culture that the needs of family in its entirety often supersede the needs of a specific individual. Elders within the family are consulted prior to any major decisions being made within the family. Latino individuals rely heavily on prayer, particularly during illness or when someone is dying. They believe in the concept of hot and cold when it comes to disease. This theory views illness as an imbalance that requires an opposing force to restore health. For instance, if someone is afflicted with a fever (hot) they should be given something cold to drink. Persons within this culture also have a strong sense of superstition and attribute illness to supernatural causes. They also rely on folk healers and home remedies including rituals, herbs, use of medals and amulets, and prayer.
There is a growing crisis of homelessness in the United States that may be overlooked as a defined culture. Homelessness can be observed when an individual lacks secure living conditions as a result of limited resources and poverty. Homelessness occurs for a variety of reasons, including low income, loss of employment, undiagnosed or untreated mental illness, veteran status, and inability to keep up with incoming expenses. Homelessness also occurs for people with health issues who must choose between being able to pay for the care they need to treat an illness or paying for rent (National Health Care for the Homeless Council, 2011).
Persons who end up homeless are exposed to a number of environmental risks that lead to disease. Lack of proper nutrition, clean water, unsanitary conditions, increased stress levels, and exposure to violence all contribute to the development of complex medical issues. In addition, these persons have a much higher incidence of psychiatric disorders, substance abuse, and HIV/AIDS.
Cultural considerations the nurse must take in to account for persons within the homeless community are numerous. Many patients within this category have no insurance, income, or means to adhere to follow-up care, meaning the treatment they are receiving in the present moment is likely the only treatment they will receive for the foreseeable future. The nurse must take the opportunity allotted to them to provide them with as much education and as many resources as possible. It is also imperative to work with the interdisciplinary health care team members to locate resources for the patient, such as housing and government insurance (Hodge, DiPietro, & Horton-Newell, 2017).
The LGBTQ community is a growing culture that warrants acknowledgment, support, and attention from the medical community. Persons within this culture come from all ethnic, racial, and religious backgrounds. They are a growing minority group in America and have faced a great deal of adversity and discrimination. Their determination and will to stand up for equality has led to many breakthroughs in achieving equal rights under the law, but much work still needs to be done. Persons within this culture group face health issues such as sexually transmitted infections (STIs), HIV/AIDS, substance abuse, tobacco use, mental illness, and suicide (Landry, 2017).
Cultural considerations for the nurse to contemplate when caring for patients within this culture include considering transgender patients’ identity and addressing them as the gender they identify with at all times. Doing so shows respect and helps to gain a provider/patient trust relationship. The nurse must also be aware of their own personal biases and feelings toward LGBTQ individuals and suspend them in order to care for these patients holistically. Choosing to suspend personal beliefs and biases means choosing to advocate and support patients without agreeing with or condoning their personal choices. Mental health assessment must be taken into account as many of these patients, particularly adolescents, may be victims of bullying and become depressed and have thoughts of suicide (Bratsis, 2014). The nurse must always be an advocate for the patient and help to formulate a plan of care that is individualized. Sensitivity should be taken when discussing partner relationships and the need for HIV/AIDS testing, resources, and/or treatment.
Over the past few decades, there has been an influx of refugees and immigrants to different areas of the world. The WHO states “globally, there are an estimated 250 million international immigrants and an estimated 65 million people forcibly displaced from their homes,” (WHO, n.d., para. 1). Refugees are defined as people who seek asylum in a country other than their country of origin because of fear of discrimination for racial, ethnic, religious, or political reasons. Immigrants are people who leave their countries of origin to seek permanent residence within another one.
Immigration occurs for a variety of reasons, including job opportunities, poor living conditions, medical attention, and the desire for equal rights. Refugees face a host of health problems, such as hypertension, arthritis, diabetes, chronic respiratory diseases, cardiovascular diseases, and mental illness such as depression and post-traumatic stress disorder (PTSD) (Hunter, 2016). Immigrants typically have a range of health issues that relate to their ethnic backgrounds but have higher incidences of mental illness related to stress. Persons within these emerging populations can be from any ethnicity or racial background. An example are the Syrian refugees who have fled in large numbers to varying countries around the world.
Cultural considerations for this population are complex. The nurse must consider the patients’ ethnicity association as well as their refugee or immigrant status, which can have its own set of health repercussions. Mental health assessment must be taken into careful consideration, as many refugee patients have endured tragic conditions that can lead to crippling mental illness. Lack of finances, insurance, language barriers, loss of family support, inaccessibility to health care, fear of being ostracized, and fear of deportation can all impact these patients’ ability to attain necessary health care. Nurses should be aware of these issues and advocate for the patients’ needs as well as help them to access necessary resources. The WHO works with federal agencies from countries worldwide to help the refugee population attain the health care they need.
| Emerging Population | Common Health Issues | Important Cultural Components | Health Care Considerations |
| Arab Americans | · DM
· CAD · COPD · Lung Cancer · Mental Health |
· Religion
· Family · Modesty |
· Same-Sex Caregivers
· Language Barriers · Familial Decision Making |
| Asian Americans/Pacific Islanders | · COPD
· Hepatitis B · HIV/AIDS · Tuberculosis · Liver Disease |
· Family
· Elder Importance · Privacy · Use of CAM |
· Avoidance of Care
· Familial Decision Making · Language Barriers · Same-Sex Caregivers |
| African Americans/Blacks | · DM
· Heart Disease · COPD · Cancer · HIV/AIDS · Obesity |
· Religion
· Family · High Rates of Poverty |
· Chaplain Services
· Familial Decision Making · Socioeconomic Needs |
| American Indians/Alaskan Natives | · Heart Disease
· Cancer · DM · Stroke · Obesity · Substance Abuse (specifically alcohol) · Teenage Pregnancy · Liver Disease · Hepatitis · Sudden Infant Death Syndrome (SIDS) · Mental Health · Suicide |
· High Rates of Poverty
· Access to Resources · Spirituality · Family · Folk Healers |
· Socioeconomic Needs
· Familial Decision Making · Language Barriers |
| Latino/Hispanic Americans | · Heart Disease
· HIV/AIDS · Stroke · DM |
· Family
· Religion · Elder Respect · Folk Healers |
· Chaplain Services
· Familial Decision Making · Language Barriers |
| Rural Population/Homeless | · Mental Health
· Substance Abuse · HIV/AIDS · Hepatitis · Range of Other Medical Diseases |
· Uninsured
· No Access to Resources · No Follow-Up Care · Poverty · Instability |
· Resource Management
· Collaboration of Care · Crisis Intervention |
| Lesbian/Gay/Bisexual/Transgender/Queer/Questioning (LGBTQ) | · Mental Health
· Substance Abuse · Suicide · HIV/AIDS |
· Fear of Discrimination
· Sense of Community |
· Crisis Intervention
· Resource Management · Caregiver Sensitivity · Partner Involvement |
| Immigrant and Refugee Population | · Hypertension
· Arthritis · DM · COPD · Cardiovascular Diseases · Mental Illness (particularly PTSD) |
· Poverty
· Access to Resources · Fear of Deportation · Uninsured · Instability |
· Resource Management
· Crisis Intervention · Collaboration of Care · Language Barriers |
Throughout the discussion of the many emerging populations, there is a common element of spirituality and/or religion. This commonality warrants nurses to assess for specific values, beliefs, practices, and spiritual care that may influence their plan of care. While there are a variety of questionnaires available to assist with collecting such information, the nurse may find that open conversation is one of the optimal ways to discover the patient’s spiritual needs as well as help solidify a trusting patient/provider relationship. The nurse should offer appropriate spiritual resources as available to the patient and family throughout the length of stay, regardless of patient prognosis. The Joint Commission has made it evident that spiritual care is of great importance and has outlined recommendations specific to the provision of spiritual care that help to guide the health care provider in caring for patients’ spiritual needs. Their recommendations highlight the importance of assessing a patient’s religion and associated customs/practices and emphasizes the importance of addressing these needs in order to provide fully competent nursing care. While no specific tool is recommended over others, the HOPE tool and the Spiritual Health are examples of widely utilized spiritual assessment tools (The Joint Commission, n.d.).
·
Above all, the nurse’s best tool is the assessment; beginning the nursing process with the assessment is best practice. Thorough assessment gives the nurse the picture of the patient that is necessary to provide individualized care. The nurse may use Campinha-Bacote’s cultural competency model to help guide the process as an asset to performing a thorough assessment. The nurse utilizes the power of data collection to gather pieces of info crucial to completing a complete assessment. The Heritage Assessment Tool (HAT) is an effective tool nurses often use to gather cultural information on their patients (see Figure 3.8).
| Heritage Assessment Tool | ||||
| Where was your mother born? | ||||
| Where was your father born? | ||||
| Where were your grandparents born? | ||||
| Your mother’s mother? | ||||
| Your mother’s father? | ||||
| Your father’s mother? | ||||
| Your father’s father? | ||||
| How many brothers and sisters do you have? | ||||
| In what setting did you grow up? | Urban | |||
| Rural | ||||
| Suburban | ||||
| In what country did your parents grow up? | Mother | |||
| Father | ||||
| How old were you when you came to the United States? | ||||
| How old were your parents when they came to the United States? | Mother | |||
| Father | ||||
| Who lived with you when you were growing up? | ||||
| Have you maintained contact with | Aunts | |||
| Uncles | ||||
| Cousins | ||||
| Brothers and sisters | ||||
| Are you and your spouse from the same ethnic background? | ||||
| What kind of school did you attend? | Public | |||
| Private | ||||
| Parochial | ||||
| Do you currently live in a neighborhood in which the neighbors are the same religion and ethnic background as yourself? | ||||
| Do you belong to a religious institution? | ||||
| Would you describe yourself as an active member? | ||||
| How often do you attend your religious institution? | More than once a week | |||
| Weekly | ||||
| Monthly | ||||
| Special holidays only | ||||
| Never | ||||
| Do you practice your religion at home? | If yes, please specify: | |||
| Praying | ||||
| Bible reading | ||||
| Diet | ||||
| Celebrating religious holidays | ||||
| Do you prepare foods of your ethnic background? | ||||
| Do you participate in ethnic activities? |
The HAT is a succinct survey that assists the nurse in obtaining basic but crucial information regarding the patient’s culture, beliefs, needs, and practices that may affect his or her care and treatment. Such data is helpful not only to structure the plan of care, but also to educate nurses adequately regarding new cultures that will expand their cultural competence. There are a number of similar tools to assist in gathering data related to culture. Regardless of the tool being used, the importance lies in the way in which the data is used to care for the patient.
·
Nurses have a fundamental obligation to address the changing needs of patients. As emerging populations grow, it is imperative that nurses advocate and support changes that are needed to help these populations live well. The American Nurses Association’s (ANA) Code of Ethics (ANA, 2015) incorporates several provision statements based upon advocating for patients’ rights and the importance of treating patients with dignity and respect. In Table 3.4, statements that can be directly correlated with cultural competence appear in blue text.
| Provision 1 | The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person. |
| Provision 2 | The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population. |
| Provision 3 | The nurse promotes, advocates for, and protects the rights, health, and safety of the patient. |
| Provision 4 | The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care. |
| Provision 5 | The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth. |
| Provision 6 | The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care. |
| Provision 7 | The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy. |
| Provision 8 | The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities. |
| Provision 9 | The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy. |
The ANA recognizes cultural competence as an imperative part of nursing and describes its importance in their Diversity Awareness Mission Statement. The statement encourages nurses to continue developing their awareness of cultural and diversity issues as well as acknowledge their personal attitudes and perceptions that could impact care for such patients (ANA, n.d.). In addition to the emerging populations discussed within this chapter, the ANA recognizes that the following groups warrant attention from nursing.
· Bariatric patients
· Geriatric patients
· Uninsured
· Mental health community
As these patient populations continue to grow, so too does the demand for nurses to be culturally sensitive and aware of their varying needs.
·
While the discussion of cultural diversity has largely been focused on the emerging patient populations, the topic of cultural diversity of health care workers/nurses has been acknowledged as well. The ANA has recognized the lack of diversity in the nursing workforce. Evidence suggests patients from varying ethnic backgrounds with mental health diagnoses have increased positive outcomes when their caregivers are from diverse ethnic backgrounds. The ANA and the Substance Abuse and Mental Health Services Administration (SAMHSA) have developed the Minority Fellowship Program (MFP), which grants funds to assist nurses from minority populations in attaining doctorate degrees with an emphasis in mental health. Their overarching goal is to
increase the number of rigorously educated nurses from under-represented ethnic minority groups in order to conduct research about mental health issues…assume leadership roles…expand mental health literature about minority populations…and function as members of interdisciplinary research and treatment teams with the intent of improving the mental health status of ethnic/minority populations. (ANA, n.d., para. 1)
The program has existed for three decades now, working with the mental health community to help empower nurses by enabling them to achieve higher education in order to help ease this growing disparity.
·
A component familiar to nurses is evidence-based practice (EBP). EBP is the catalyst for driving change within nursing practice. Cultural competency will continue to be essential to nursing, therefore, research and EBP are necessary to its continued development. There are several journals that produce scholarly works based on culturally competent care, such as the Journal of Cultural Diversity and the Journal of Multicultural Nursing and Health.
The need for more thorough culturally competent care has warranted the assistance and attention of many federal agencies. With the changes following the Patient Protection and Affordable Care Act (ACA), many hospital expansion initiatives have been instituted to better address health promotion and cultural needs of the growing population of insured individuals. In fact, one of the primary focuses of the ACA is prevention and community health overall (Heiman & Artiga, 2015). The National Institutes of Health (NIH) support many programs that aim to improve health for identified emerging populations, such as the Clear Communication Program, which helps to provide resources to overcome language and health literacy barriers in health care. The NIH also supports the Office of Minority Health (OMH), which advocates for National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (CLAS) (see Table 3.5). According to the OMH (2016) website, the goal of the CLAS standards is “to advance health equity, improve quality, and help eliminate health care disparities by establishing a blueprint for individuals as well as health and health care organizations to implement culturally and linguistically appropriate services,” (para. 1). Such guidelines are utilized and implemented in many different health care settings in order to better achieve culturally competent care.
| National Enhanced Culturally and Linguistically Appropriate Service Standards |
| Principal Standard |
| Standard 1: Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs. |
| Governance, Leadership and Workforce |
| Standard 2: Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy, practices, and allocated resources.
Standard 3: Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and workforce that are responsive to the population in the service area.
Standard 4: Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis. |
| Communication and Language Assistance |
| Standard 5: Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services.
Standard 6: Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing.
Standard 7: Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided.
Standard 8: Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area. |
| Engagement, Continuous Improvement and Accountability |
| Standard 9: Establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them throughout the organization’s planning and operations.
Standard 10: Conduct ongoing assessments of the organization’s CLAS-related activities and integrate CLAS-related measures into assessment measurement and continuous quality improvement activities.
Standard 11: Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery.
Standard 12: Conduct regular assessments of community health assets and needs, and use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area.
Standard 13: Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural and linguistic appropriateness.
Standard 14: Create conflict- and grievance-resolution processes that are culturally and linguistically appropriate to identify, prevent, and resolve conflicts or complaints.
Standard 15: Communicate the organization’s progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public. |
In correlation with the OMH, the National Partnership for Action (NPA) developed the National Stakeholder Strategy for Achieving Health Equity. This document is a collection of advice from leaders throughout the country who acknowledge the need for cultural care and their ideas for developing solutions for decreasing health disparities among emerging populations and developing a culturally competent workforce. The National Institute on Minority Health and Health Disparities (NIMHD) focuses on research and implemented EBP to improve health for ethnic minority groups and decrease health disparities among these groups.
Collaboration among government, the private sector, and health care professionals is necessary to see changes occur in cultural competent care. Through the implementation of interventions such as CLAS guidelines, and the continued education of health care workers regarding cultural competence, a health care workforce can be built that will help decrease health disparities among minority groups.
Culturally competent care is a foundation for providing holistic nursing care. Nurses have a duty to provide culturally sensitive care and to be aware of the ever-changing emerging populations within the United States. Nurses provide resources, advocate for patients, and promote health and wellness by providing education regarding best nutrition practices. Proper initial assessment for cultural needs is important in individualizing care for each patient. Federal agencies recognize the need for culturally competent care and work together to formulate plans to help decrease health disparities among disadvantaged groups. Moving forward, it is evident that cooperation among many agencies and health care workers is required in order to help reduce and eliminate the health disparities that affect persons from emerging population groups nationwide.
Complementary Alternative Medicine (CAM): Term for therapies that have not been accepted as part of conventional Western medicine such as yoga, acupuncture, and meditation.
Cultural Competence: To be respectful and responsive to the health beliefs and practices as well as cultural and linguistic needs of diverse population groups.
Culture: Traditional beliefs and values shared among a group of people.
Emerging Populations: Populations or ethnic groups that have not achieved institutional power or recognition.
Ethnic Group: People within a community who share the same ethnicity.
Ethnicity: A group of people who share a common culture, religion, and/or language.
Health Disparities: Variables that contribute to inequities or an unequal distribution of resources for various populations; preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by disadvantaged populations; specifically relatable to social, economic, and/or environmental disadvantages.
Health Equity: Provision of resources necessary to live well to all individuals regardless of varying social determinants of health (SDOH).
Health Promotion: Educating people about healthy lifestyles, reduction of risk, developmental needs, activities of daily living and preventive self-care that enables them to improve their health by making positive decisions.
Homelessness: Individual who lacks permanent residence.
Immigrant: Those who leave their native country to take up permanent residence in foreign country.
Minority Group: People who lack social power within society, often ethnically diverse groups.
Nontraditional Care System: Health care based on traditional methods or remedies such as herbal medicine.
Race: Group of people with a common ancestry defined by similar physical traits.
Refugee: An individual or group of people seeking asylum in a country other than their country of origin because of fear of discrimination for racial, ethnic, religious, or political reasons.
Taoism: Principles of religion rooted in ancient Chinese culture.
Traditional Care System: Health care based on traditional Western medicine’s modality of care and treatments.
Transcultural Nursing: The study of providing culturally competent nursing care.
Values: The beliefs that serve as standards that ultimately influence behavior and thought processes within the cultural group.
Vulnerable Populations: People who require special attention related to well being and safety, including persons who cannot advocate for their own needs such as children, prisoners, and cognitively impaired.
American Cancer Society. (2015). Cancer basics: What is cancer? Retrieved from https://www.cancer.org/cancer/cancer-basics/what-is-cancer.html
American Diabetes Association. (2015). Facts about type 2. Retrieved from http://www.diabetes.org/diabetes-basics/type-2/facts-about-type-2.html
American Heart Association. (2017). The facts about high blood pressure. Retrieved from http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/GettheFactsAboutHighBloodPressure/The-Facts-About-High-Blood-Pressure_UCM_002050_Article.jsp#.Wo2rMoPwZpg
American Nurses Association. (2015). Code of ethics with interpretive statements. Retrieved from http://nursingworld.org/DocumentVault/Ethics-1/Code-of-Ethics-for-Nurses.html
American Nurses Association. (n.d.). Diversity awareness mission statement. Retrieved from http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/Improving-Your-Practice/Diversity-Awareness/Mission-Statement.html
American Stroke Association. (2012). Effects of stroke. Retrieved from http://www.strokeassociation.org/STROKEORG/AboutStroke/EffectsofStroke/Effects-of-Stroke_UCM_308534_SubHomePage.jsp
Booze, K., Hardison, B., & Haven, J. (2017). A year of MyPlate, MyWins: Small changes add up to big wins; Help put your best fork forward. Journal of the Academy of Nutrition and Dietetics, 117(3), 363-366. doi: 10.1016/j.jand.2017.01.002
Bratsis, M. (2014). Preventing teen suicide. Science Teacher, 81(6), 14.
Brennan Ramirez, L. K., Baker, E. A., Metzler, M. (2008). Promoting health equity: A resource to help communities address social determinants of health. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/nccdphp/dch/programs/healthycommunitiesprogram/tools/pdf/sdoh-workbook.pdf
Byrne, D. (2016). Cultural competency in baccalaureate nursing education: A conceptual analysis. International Journal for Human Caring, 20(2), 114-119.
Campinha-Bacote, J., (2011) Delivering patient-centered care in the midst of a cultural conflict: The role of cultural competence. OJIN: The Online Journal of Issues in Nursing, 16(2). doi: 10.3912/OJIN.Vol16No02Man05
Centers for Disease Control and Prevention. (2015a). Health disparities. Retrieved from https://www.cdc.gov/healthyyouth/disparities/index.htm
Centers for Disease Control and Prevention. (2015b). Hispanic health. Retrieved from https://www.cdc.gov/vitalsigns/hispanic-health/index.html
Centers for Disease Control and Prevention. (2015c). Strategies to prevent obesity. Retrieved from https://www.cdc.gov/obesity/strategies/index.html
Centers for Disease Control and Prevention. (2017a). Leading causes of death. Retrieved from https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm
Centers for Disease Control and Prevention. (2017b). Diabetes quick facts. Retrieved from https://www.cdc.gov/diabetes/basics/quick-facts.html
de Oliveira Carvalho, A., Santiago da Rocha, S., & de Souza Rocha, K. N. (2015). Nursing practice in healthy youth from the perspective of the transcultural theory of Leininger. Ciencia, Cuidado e Saude, 14(4), 1546-1554. doi:10.4025/cienccuidsaude.v14i4.27836
Egen, O., Beatty, K., Blackley, D. J., Brown, K., & Wykoff, R. W. (2017). Health and social conditions of the poorest versus wealthiest counties in the United States. American Journal of Public Health, 107(1), 130-135.
Freedman, D. A., Peña-Purcell, N., Friedman, D. B., Ory, M., Flocke, S., Barni, M. T., & Hébert, J. R. (2014). Extending cancer prevention to improve fruit and vegetable consumption. Journal of Cancer Education, 29(4), 790-795. doi:10.1007/s13187-014-0656-4
Gale, N. (2014). The sociology of traditional, complementary and alternative medicine. Sociology Compass, 8(6), 805-822. doi:10.1111/soc4.12182
Garnweidner, L., Terragni, L., Pettersen, K., & Mosdol, A. (2012). Perceptions of the host country’s food culture among female immigrants from Africa and Asia: Aspects relevant for cultural sensitivity in nutrition communication. Journal of Nutrition Education and Behavior, 44(4), 335-342.
Heiman, H., & Artiga, S. (2015). Beyond health care: The role of social determinants in promoting health and health equity. Retrieved from https://www.issuelab.org/resources/22899/22899.pdf
Hodge, J. G., DiPietro, B., & Horton-Newell, A. E. (2017). Homelessness and the public’s health: Legal responses. Journal of Law, Medicine & Ethics, 45(1), 28-32. doi:10.1177/1073110517703314
Hunter, P. (2016). The refugee crisis challenges national health care systems. EMBO Reports, 17(4), 492-495. doi: 10.15252/embr.201642171
Johnson, A. (2014). Health literacy, does it make a difference? Australian Journal of Advanced Nursing, 31(3), 39-45.
Johnson, A. (2015). Health literacy: how nurses can make a difference. Australian Journal of Advanced Nursing, 33(2), 20-27.
Khodaveisi, M., Omidi, A., Farokhi, S., & Soltanian, A. R. (2017). The effect of Pender’s health promotion model in improving the nutritional behavior of overweight and obese women. International Journal of Community Based Nursing and Midwifery, 5(2), 165-174.
Landry, J. (2017). Delivering culturally sensitive care to LGBTQI patients. The Journal for Nurse Practitioners, 13(5), 342-347. doi: 10.1016/j.nurpra.2016.12.015
Lavretsky, H. (2017). Complementary, alternative, and integrative medicine use is rising among aging baby boomers. The American Journal of Geriatric Psychiatry, 25(12), 1402-1403. doi:10.1016/j.jagp.2017.08.004
Leininger, M. (1991). Culture care diversity and universality: A theory of nursing. New York, NY: National League for Nursing Press.
Lu, A., Dickin, K., & Dollahite, J. (2014). Development and application of a framework to assess community nutritionists’ use of environmental strategies to prevent obesity. Journal of Nutrition Education and Behavior, 46(6), 475-483.
Mayo Clinic. (2018). Heart disease. Retrieved from https://www.mayoclinic.org/diseases-conditions/heart-disease/symptoms-causes/syc-20353118
Momoh, C., Olufade, O., & Redman-Pinard, P. (2016). What nurses need to know about female genital mutilation. British Journal of Nursing, 25(9), S30-S34.
National Health Care for the Homeless Council. (2011). Homelessness and health: What’s the connection? Retrieved from http://www.nhchc.org/wp-content/uploads/2011/09/Hln_health_factsheet_Jan10.pdf
Office of Disease Prevention and Health Promotion. (n.d.). Nutrition, physical activity, and obesity. Retrieved from https://www.healthypeople.gov/2020/leading-health-indicators/2020-lhi-topics/Nutrition-Physical-Activity-and-Obesity/data
Office of Minority Health (OMH). (2016). The national CLAS standards. Retrieved from https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlid=53
Patience, S. (2016). Advising patients on nutrition and healthy eating. British Journal of Nursing, 25(21), 1182.
Prevention Research Center. (2013). Addressing the unique needs of the Arab American population. Retrieved from http://prc.sph.umich.edu/2013/04/addressing-unique-arab-american-population/
Rahimaghaee, F., & Mozdbar, R. (2017). Cultural intelligence and its relation with professional competency in nurses. Nursing Practice Today, 4(3), 115-124.
Samuel-Nakamura, C., Leads, P., Cobb, S., Nguyen Truax, F., & Schanche Hodge, F. (2017). Environmental contexts of vulnerable populations: Implications for nursing practice, research, and education. Californian Journal of Health Promotion, 15(2), 75-78.
Substance Abuse and Mental Health Services Administration. (2018). Racial and ethnic minorities. Retrieved from https://www.samhsa.gov/specific-populations/racial-ethnic-minority
Tamura-Lis, W. (2013). Teach-back for quality education and patient safety. Urologic Nursing, 33(6), 267-298. doi:10.7257/1053-816X.2013.33.6.267
The Joint Commission. (n.d.). Standards FAQ details: Provision of care, treatment, and services. Retrieved from https://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFAQId=1492&StandardsFAQChapterId=118&ProgramId=0&ChapterId=0&IsFeatured=False&IsNew=False&Keyword=
Theiss, J., & Regenstein, M. (2017). Facing the need: Screening practices for the social determinants of health. Journal of Law, Medicine & Ethics, 45(3), 431-441. doi:10.1177/1073110517737543
U.S. Department of Agriculture. (2018a). Programs and services. Retrieved from https://www.fns.usda.gov/programs-and-services
U.S. Department of Agriculture. (2018b). School meals. Retrieved from https://www.fns.usda.gov/school-meals/child-nutrition-programs
U.S. Department of Agriculture. (2018c). Supplemental nutrition assistance program (SNAP). Retrieved from https://www.fns.usda.gov/snap/supplemental-nutrition-assistance-program-snap
U.S. Department of Agriculture. (2018d). Women, infants, and children (WIC). Retrieved from https://www.fns.usda.gov/wic/women-infants-and-children-wic
U.S. Department of Agriculture. (n.d.). Dietary guidelines. Retrieved from https://www.cnpp.usda.gov/dietary-guidelines
U.S. Department of Health and Human Services and U.S. Department of Agriculture. (2015). Dietary guidelines for Americans 2015-2020 (8th ed.). Washington, DC: Author.
World Health Organization. (2018). Female genital mutilation. Retrieved from http://www.who.int/mediacentre/factsheets/fs241/en/
World Health Organization. (n.d.).Refugee and migrant health. Retrieved from http://www.who.int/migrants/en/
· CDC – Racial and Ethnic Approaches to Community Health (REACH) |
Explore the resources available on the Racial and Ethnic Approaches to Community Health (REACH) page of the Centers for Disease Control and Prevention (CDC) website. These materials will be useful in completing the assignment for this topic.
URL:
http://www.cdc.gov/chronicdisease/resources/publications/aag/reach.htm
· US Department of Health and Human Services |
Explore the resources available on the Minority Health page of the U.S. Department of Health and Human Services website. These materials will be useful in completing the assignment for this topic.
URL:
https://minorityhealth.hhs.gov/
· CDC – Minority Health |
Explore the resources available on the Minority Health page of the Centers for Disease Control and Prevention (CDC) website. These materials will be useful in completing the assignment for this topic.
URL:
http://www.cdc.gov/minorityhealth/index.html
· CDC – Minority Health – Resources |
Explore the resources available at the Minority Health – Resources page of the Centers for Disease Control and Prevention (CDC) website. These materials will be useful in completing the assignment for this topic.
URL:
https://www.cdc.gov/minorityhealth/
· SAMHSA – Racial and Ethnic Minority Populations |
Explore the resources available on the Racial and Ethnic Minority Populations page of the Substance Abuse and Mental Health Services Administration (SAMHSA) website. These materials will be useful in completing the assignment for this topic.
URL:
http://www.samhsa.gov/specific-populations/racial-ethnic-minority
· Healthy People 2020 |
Explore the Healthy People 2020 website.
URL:
http://www.healthypeople.gov/
The post Cultural Awareness appeared first on Infinite Essays.
THIRD EDITION
Introduction to Health Care Management
Edited by
Sharon B. Buchbinder, RN, PhD Professor and Program Coordinator
MS in Healthcare Management Program School of Graduate and Professional Studies
Stevenson University Owings Mills, Maryland
Nancy H. Shanks, PhD Professor Emeritus
Department of Health Professions Health Care Management Program
Metropolitan State University of Denver Denver, Colorado
World Headquarters Jones & Bartlett Learning 5 Wall Street Burlington, MA 01803 978-443-5000 info@jblearning.com www.jblearning.com
Jones & Bartlett Learning books and products are available through most bookstores and online booksellers. To contact Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jblearning.com.
Substantial discounts on bulk quantities of Jones & Bartlett Learning publications are available to corporations, professional associations, and other qualified organizations. For details and specific discount information, contact the special sales department at Jones & Bartlett Learning via the above contact information or send an email to specialsales@jblearning.com.
Copyright © 2017 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission from the copyright owner.
The content, statements, views, and opinions herein are the sole expression of the respective authors and not that of Jones & Bartlett Learning, LLC. Reference herein to any specific commercial product, process, or service by trade name, trademark, manufacturer, or otherwise does not constitute or imply its endorsement or recommendation by Jones & Bartlett Learning, LLC and such reference shall not be used for advertising or product endorsement purposes. All trademarks displayed are the trademarks of the parties noted herein. Introduction to Health Care Management, Third Edition is an independent publication and has not been authorized, sponsored, or otherwise approved by the owners of the trademarks or service marks referenced in this product.
There may be images in this book that feature models; these models do not necessarily endorse, represent, or participate in the activities represented in the images. Any screenshots in this product are for educational and instructive purposes only. Any individuals and scenarios featured in the case studies throughout this product may be real or fictitious, but are used for instructional purposes only.
This publication is designed to provide accurate and authoritative information in regard to the Subject Matter covered. It is sold with the understanding that the publisher is not engaged in rendering legal, accounting, or other professional service. If legal advice or other expert assistance is required, the service of a competent professional person should be sought.
Production Credits VP, Executive Publisher: David D. Cella Publisher: Michael Brown Associate Editor: Lindsey Mawhiney Sousa Associate Editor: Nicholas Alakel Associate Production Editor: Rebekah Linga Senior Marketing Manager: Sophie Fleck Teague
Manufacturing and Inventory Control Supervisor: Amy Bacus Composition: Integra Software Services Pvt. Ltd. Cover Design: Kristin E. Parker Rights & Media Specialist: Merideth Tumasz Media Development Editor: Shannon Sheehan Cover and Title Page Image: © Yegor Korzh/ShutterStock, Inc. Printing and Binding: Edwards Brothers Malloy Cover Printing: Edwards Brothers Malloy
10950-4
Library of Congress Cataloging-in-Publication Data Names: Buchbinder, Sharon Bell, editor. | Shanks, Nancy H., editor. Title: Introduction to health care management / [edited by] Sharon B.
Buchbinder and Nancy H. Shanks. Description: Third edition. | Burlington, Massachusetts : Jones & Bartlett
Learning, [2015] | Includes bibliographical references and index. Identifiers: LCCN 2015040132 | ISBN 9781284081015 (paper) Subjects: | MESH: Health Services Administration. | Efficiency, Organizational. | Health Care
Costs. | Leadership. Classification: LCC RA971 | NLM W 84.1 | DDC 362.1–dc23 LC record available at
http://lccn.loc.gov/2015040132
6048
Printed in the United States of America 20 19 18 17 16 10 9 8 7 6 5 4 3 2 1
We dedicate this book to our loving husbands, Dale Buchbinder and Rick Shanks—
Who coached, collaborated, and coerced us to “FINISH THE THIRD EDITION!”
Contents
FOREWORD PREFACE ACKNOWLEDGMENTS ABOUT THE EDITORS CONTRIBUTORS
CHAPTER 1 An Overview of Health Care Management Jon M. Thompson, Sharon B. Buchbinder, and Nancy H. Shanks Introduction The Need for Managers and Their Perspectives Management: Definition, Functions, and
Competencies Management Positions: The Control in the
Organizational Heirarchy Focus of Management: Self, Unit/Team, and
Organization Role of the Manager in Establishing and Maintaining
Organizational Culture Role of the Manager in Talent Management Role of the Manager in Ensuring High Performance Role of the Manager in Leadership Development and
Succession Planning Role of the Manager in Innovation and Change
Management Role of the Manager in Health Care Policy Research in Health Care Management Chapter Summary
CHAPTER 2 Leadership Louis Rubino Leadership vs. Management History of Leadership in the U.S. Contemporary Models Leadership Styles Leadership Competencies Leadership Protocols Governance Barriers and Challenges Ethical Responsibility Important New Initiatives Leaders Looking to the Future Special Research Issues Conclusion
CHAPTER 3 Management and Motivation Nancy H. Shanks and Amy Dore Introduction Motivation—The Concept History of Motivation Theories of Motivation A Bit More About Incentives and Rewards Why Motivation Matters Motivated vs. Engaged—Are the Terms the Same? Measuring Engagement Misconceptions About Motivation and Employee
Satisfaction Motivational and Engagement Strategies Motivating Across Generations Managing Across Generations Research Opportunities in Management and
Motivation Conclusion
CHAPTER 4 Organizational Behavior and Management Thinking Sheila K. McGinnis Introduction The Field of Organizational Behavior Organizational Behavior’s Contribution to
Management Key Topics in Organizational Behavior Organizational Behavior Issues in Health
Organizations Thinking: The “Inner Game” of Organizational
Behavior The Four Key Features of Thinking Mental Representation: The Infrastucture of Thinking Processing Information: Fundamental Thinking
Habits Decision Making, Problem Solving, and Biased
Thinking Habits Social Cognition and Socio-Emotional Intelligence Research Opportunities in Organizational Behavior
and Management Thinking Conclusion
CHAPTER 5 Strategic Planning Susan Casciani Introduction Purpose and Importance of Strategic Planning The Planning Process SWOT Analysis Strategy Identification and Selection Rollout and Implementation
Outcomes Monitoring and Control Strategy Execution Strategic Planning and Execution: The Role of the
Health Care Manager Opportunities for Research in Strategic Planning Conclusion
CHAPTER 6 Healthcare Marketing Nancy K. Sayre Introduction What Is Marketing? A Brief History of Marketing in Health Care The Strategic Marketing Process Understanding Marketing Management Health Care Buyer Behavior Marketing Mix Marketing Plan Ethics and Social Responsibility Opportunities for Research in Health Care Marketing Conclusion
CHAPTER 7 Quality Improvement Basics Eric S. Williams, Grant T. Savage, and Patricia A. Patrician Introduction Defining Quality in Health Care Why Is Quality Important? The Relevance of Health Information Technology in
Quality Improvement Quality Improvement Comes (Back) to America Leaders of the Quality Movement Baldrige Award Criteria: A Strategic Framework for
Quality Improvement
Common Elements of Quality Improvement Three Approaches to Quality Improvement Quality Improvement Tools Opportunities for Research in Health Care Quality Conclusion
CHAPTER 8 Information Technology Nancy H. Shanks and Sharon B. Buchbinder Introduction Information Systems Used by Managers The Electronic Medical Record (EMR) The Challenges to Clinical System Adoption The Future of Health Care Information Technology The Impact of Information Technology on the Health
Care Manager Opportunities for Research on Health Care
Professionals Conclusion
CHAPTER 9 Financing Health Care and Health Insurance Nancy H. Shanks Introduction Introduction to Health Insurance Brief History of Health Insurance Characteristics of Health Insurance Private Health Insurance Coverage The Evolution of Social Insurance Major “Players” in the Social Insurance Arena Statistics on Health Insurance Coverage and Costs Those Not Covered—The Uninsured Opportunities for Research on Emerging Issues Conclusion
CHAPTER 10 Managing Costs and Revenues Kevin D. Zeiler Introduction What Is Financial Management and Why Is It
Important? Tax Status of Health Care Organizations Financial Governance and Responsibility Structure Managing Reimbursements from Third-Party Payers Coding in Health Care Controlling Costs and Cost Accounting Setting Charges Managing Working Capital Managing Accounts Receivable Managing Materials and Inventory Managing Budgets Opportunities for Research on Managing Costs and
Revenues Conclusion
CHAPTER 11 Managing Health Care Professionals Sharon B. Buchbinder and Dale Buchbinder Introduction Physicians Registered Nurses Licensed Practical Nurses/Licensed Vocational Nurses Nursing Assistants and Orderlies Home Health Aides Midlevel Practitioners Allied Health Professionals Opportunities for Research on Health Care
Professionals Conclusion
CHAPTER 12 The Strategic Management of Human Resources Jon M. Thompson Introduction Environmental Forces Affecting Human Resources
Management Understanding Employees as Drivers of
Organizational Performance Key Functions of Human Resources Management Workforce Planning/Recruitment Employee Retention Research in Human Resources Management Conclusion
CHAPTER 13 Teamwork Sharon B. Buchbinder and Jon M. Thompson Introduction What Is a Team? The Challenge of Teamwork in Health Care
Organizations The Benefits of Effective Health Care Teams The Costs of Teamwork Electronic Tools and Remote and Virtual Teams Face to Face Versus Virtual Teams Real-World Problems and Teamwork Who’s on the Team? Emotions and Teamwork Team Communication Methods of Managing Teams of Health Care
Professionals Opportunities for Research on Emerging Issues Conclusion
CHAPTER 14 Addressing Health Disparities: Cultural Proficiency Nancy K. Sayre Introduction Changing U.S. Demographics and Patient Populations Addressing Health Disparities by Fostering Cultural
Competence in Health Care Organizations Best Practices Addressing Health Disparities by Enhancing Public
Policy Opportunities for Research on Health Disparities and
Cultural Proficiency Conclusion
CHAPTER 15 Ethics and Law Kevin D. Zeiler Introduction Legal Concepts Tort Law Malpractice Contract Law Ethical Concepts Patient and Provider Rights and Responsibilities Legal/Ethical Concerns in Managed Care Biomedical Concerns Beginning- and End-of-Life Care Opportunities for Research in Health Care Ethics and
Law Conclusion
CHAPTER 16 Fraud and Abuse Kevin D. Zeiler Introduction
What Is Fraud and Abuse? History The Social Security Act and the Criminal-Disclosure
Provision The Emergency Medical Treatment and Active Labor
Act Antitrust Issues Physician Self-Referral/Anti-Kickback/Safe Harbor
Laws Management Responsibility for Compliance and
Internal Controls Corporate Compliance Programs Opportunities for Research in Fraud and Abuse Conclusion
CHAPTER 17 Special Topics and Emerging Issues in Health Care Management Sharon B. Buchbinder and Nancy H. Shanks Introduction Re-Emerging Outbreaks, Vaccine Preventable
Diseases, and Deaths Bioterrorism in Health Care Settings Human Trafficking Violence in Health Care Settings Medical Tourism Consumer-Directed Health Care Opportunities for Research on Emerging Issues
CHAPTER 18 Health Care Management Case Studies and Guidelines Sharon B. Buchbinder, Donna M. Cox, and Susan Casciani Introduction Case Study Analysis
Case Study Write-Up Team Structure and Process for Completion
CASE STUDIES* Metro Renal—Case for Chapters 12 and 2 United Physician Group—Case for Chapters 5, 9, 11,
and 15 Piecework—Case for Chapters 9 and 10 Building a Better MIS-Trap—Case for Chapter 8 Death by Measles—Case for Chapters 17, 11, and 15 Full Moon or Bad Planning?—Case for Chapters 17,
11, and 15 How Do We Handle a Girl Like Maria?—Case for
Chapters 17 and 4 The Condescending Dental Hygienist—Case for
Chapters 7, 12, 15, and 4 The “Easy” Software Upgrade at Delmar Ortho—Case
for Chapters 8 and 13 The Brawler—Case for Chapters 11, 12, and 17 I Love You…Forever—Case for Chapters 17, 12, and
11 Managing Health Care Professionals—Mini-Case
Studies for Chapter 11 Problems with the Pre-Admission Call Center—Case
for Chapters 13 and 10 Such a Nice Young Man—Case for Chapters 17, 11,
and 12 Sundowner or Victim?—Case for Chapters 15 and 17 Last Chance Hospital—Case for Chapters 5 and 6 The Magic Is Gone—Case for Chapters 3, 12, and 13 Set Up for Failure?—Case for Chapter 3 Sustaining an Academic Food Science and Nutrition
Center Through Management Improvement—Case
for Chapters 2 and 12 Giving Feedback—Empathy or Attributions?—Case for
Chapter 4 Socio-Emotional Intelligence Exercise: Understanding
and Anticipating Major Change—Case for Chapter 4
Madison Community Hospital Addresses Infection Prevention—Case for Chapters 7 and 13
Trouble with the Pharmacy—Case for Chapter 7 Emotional Intelligence in Labor and Delivery—Case
for Chapters 2, 12, and 13 Communication of Patient Information During
Transitions in Care—Case for Chapters 7 and 12 Multidrug-Resistant Organism (MDRO) in a
Transitional Care Unit—Case for Chapters 7 and 12 Are We Culturally Aware or Not?—Case for Chapters
14 and 5 Patients “Like” Social Media—Case for Chapters 6
and 5 Where Do You Live? Health Disparities Across the
United States—Case for Chapter 14 My Parents Are Turning 65 and Need Help Signing
Up for Medicare—Case for Chapter 9 Newby Health Systems Needs Health Insurance—
Case for Chapter 9 To Partner or Not to Partner with a Retail Company—
Case for Chapters 17, 5, and 6 Wellness Tourism: An Option for Your Organization?
—Case for Chapters 17 and 5 Conflict in the Capital Budgeting Process at University
Medical Center: Let’s All Just Get Along—Case for Chapter 10
The New Toy at City Medical Center—Case for Chapters 11 and 13
Recruitment Challenge for the Middle Manager—Case for Chapters 2 and 12
I Want to Be a Medical Coder—Case for Chapter 10 Managing Costs and Revenues at Feel Better
Pharmacy—Case for Chapter 10 Who You Gonna Call?—Case for Chapter 16 You Will Do What You Are Told—Case for Chapter
15
GLOSSARY INDEX
Foreword
In the U.S., health care is the largest industry and the second-largest employer, with more than 11 million jobs. This continuous growth trend is a result of many consequences, including: the large, aging Baby Boomer population, whose members are remaining active later in life, contributing to an increase in the demand for medical services; the rapidly changing financial structure and increasingly complex regulatory environment of health care; the integration of health care delivery systems, restructuring of work, and an increased focus on preventive care; and the ubiquitous technological innovations, requiring unceasing educational training and monitoring.
Given this tremendous growth and the aforementioned causes of it, it is not surprising that among the fastest-growing disciplines, according to federal statistics, is health care management, which is projected to grow 23% in the next decade. Supporting this growth are the increasing numbers of undergraduate programs in health care management, health services administration, and health planning and policy—with over 300 programs in operation nationwide today.
The health care manager’s job description is constantly evolving to adapt to this hyper-turbulent environment. Health care managers will be called on to improve efficiency in health care facilities and the quality of the care provided; to manage, direct, and coordinate health services in a variety of settings, from long-term care facilities and hospitals to medical group practices; and to minimize costs and maximize efficiencies, while also ensuring that the services provided are the best possible.
As the person in charge of a health care facility, a health care administrator’s duties can be varied and complex. Handling such responsibilities requires a mix of business administration skills and knowledge of health services, as well as the federal and state laws and regulations that govern the industry.
Written by leading scholars in the field, this compendium provides future and current health care managers with the foundational knowledge needed to succeed. Drs. Buchbinder and Shanks, with their many years of clinical,
practitioner, administration, and academic experience, have assembled experts in all aspects of health care management to share their knowledge and experiences. These unique viewpoints, shared in both the content and case studies accompanying each chapter, provide valuable insight into the health care industry and delve into the core competencies required of today’s health care managers: leadership, critical thinking, strategic planning, finance and accounting, managing human resources and professionals, ethical and legal concerns, and information and technology management. Contributing authors include clinicians, administrators, professors, and students, allowing for a variety of perspectives.
Faculty will also benefit from the depth and breadth of content coverage spanning all classes in an undergraduate health care management curriculum. Its most appropriate utility may be found in introductory management courses; however, the vast array of cases would bring value to courses in health care ethics, managerial finance, quality management, and organizational behavior.
This text will serve as a cornerstone document for students in health management educational programs and provide them with the insight necessary to be effective health care managers. Students will find this textbook an indispensable resource to utilize both during their academic programs, as well as when they enter the field of health care management. It is already on its way to becoming one of the “classics” in the field!
Dawn Oetjen, PhD Associate Dean, Administration and Faculty Affairs
College of Health and Public Affairs University of Central Florida
Orlando, FL
Preface
The third edition of Introduction to Health Care Management is driven by our continuing desire to have an excellent textbook that meets the needs of the health care management field, health care management educators, and students enrolled in health care management programs around the world. The inspiration for the first edition of this book came over a good cup of coffee and a deep-seated unhappiness with the texts available in 2004. This edition builds on the strengths of the first two editions and is based on an ongoing conversation with end users—instructors and students—from all types of higher education institutions and all types of delivery modalities. Whether your institution is a traditional “bricks and mortar” school or a fully online one, this book and its ancillary materials are formatted for your ease of use and adoption.
For this edition, many of the same master teachers and researchers with expertise in each topic revised and updated their chapters. Several new contributors stepped forward and wrote completely new cases for this text because we listened to you, our readers and users. With a track record of more than eight years in the field, we learned exactly what did or did not work in the classrooms and online, so we further enhanced and refined our student- and professor-friendly textbook. We are grateful to all our authors for their insightful, well-written chapters and our abundant, realistic case studies.
As before, this textbook will be useful to a wide variety of students and programs. Undergraduate students in health care management, nursing, public health, nutrition, athletic training, and allied health programs will find the writing to be engaging. In addition, students in graduate programs in discipline-specific areas, such as business administration, nursing, pharmacy, occupational therapy, public administration, and public health, will find the materials both theory-based and readily applicable to real-world settings. With four decades of experience in higher education, we know first and foremost that teaching and learning are not solo sports, but a team effort —a contact sport. There must be a give-and-take between the students and the instructors for deep learning to take place. This text uses active learning
methods to achieve this goal. Along with lively writing and content critical for a foundation in health care management, this third edition continues to provide realistic information that can be applied immediately to the real world of health care management. In addition to revised and updated chapters from the second edition, there are learning objectives, discussion questions, and case studies included for each chapter, with additional instructors’ resources online and Instructor’s Guides for all of the case studies. PowerPoint slides, Test Bank items, and research sources are also included for each chapter, as well as a glossary. A sample syllabus is also provided. Specifically, the third edition contains:
Significantly revised chapters on organizational behavior and management thinking, quality improvement, and information technology.
Revisions and updates to all chapters, including current data and recent additions to the literature.
A new emphasis on research that is ongoing in each of the areas of health care.
A new chapter on a diverse group of emerging issues in health care management including: re-emerging outbreaks, vaccine-preventable diseases, and deaths; bioterrorism in health care settings; human trafficking; violence in health care settings; medical tourism; and consumer-directed health care.
Forty cases in the last chapter, 26 of which are new or totally revised for this edition. They cover a wide variety of settings and an assortment of health care management topics. At the end of each chapter, at least one specific case study is identified and linked to the content of that chapter. Many chapters have multiple cases.
Guides for all 40 cases provided with online materials. These will be beneficial to instructors as they evaluate student performance and will enable professors at every level of experience to hit the ground running on that first day of classes.
Totally revised test banks for each chapter, providing larger pools of questions and addressing our concerns that answers to the previous test banks could be purchased online.
Never underestimate the power of a good cup of joe. We hope you enjoy this book as much as we enjoyed revising it. May your classroom and online discussions be filled with active learning experiences, may your teaching be filled with good humor and fun, and may your coffee cup always be full.
Sharon B. Buchbinder, RN, PhD Stevenson University
Nancy H. Shanks, PhD Metropolitan State University of Denver
Acknowledgments
This third edition is the result of what has now been a 10-year process involving many of the leaders in excellence in undergraduate health care management education. We continue to be deeply grateful to the Association of University Programs in Health Administration (AUPHA) faculty, members, and staff for all the support, both in time and expertise, in developing the proposal for this textbook and for providing us with excellent feedback for each edition.
More than 20 authors have made this contributed text a one-of-a-kind book. Not only are our authors expert teachers and practitioners in their disciplines and research niches, they are also practiced teachers and mentors. As we read each chapter and case study, we could hear the voices of each author. It has been a privilege and honor to work with each and every one of them: Mohamad Ali, Dale Buchbinder, Susan Casciani, Donna Cox, Amy Dore, Brenda Freshman, Callie Heyne, Ritamarie Little, Sheila McGinnis, Mike Moran, Patricia Patrician, Lou Rubino, Sharon Saracino, Grant Savage, Nancy Sayre, Windsor Sherrill, Jon Thompson, Eric Williams, and Kevin Zeiler.
And, finally, and never too often, we thank our husbands, Dale Buchbinder and Rick Shanks, who listened to long telephone conversations about the book’s revisions, trailed us to meetings and dinners, and served us wine with our whines. We love you and could not have done this without you.
About the Editors
Sharon B. Buchbinder, RN, PhD, is currently Professor and Program Coordinator of the MS in Healthcare Management Program at Stevenson University in Owings Mills, Maryland. Prior to this, she was Professor and Chair of the Department of Health Science at Towson University and President of the American Hospital Management Group Corporation, MASA Healthcare Co., a health care management education and health care delivery organization based in Owings Mills, Maryland. For more than four decades, Dr. Buchbinder has worked in many aspects of health care as a clinician, researcher, association executive, and academic. With a PhD in public health from the University of Illinois School of Public Health, she brings this blend of real-world experience and theoretical constructs to undergraduate and graduate face-to-face and online classrooms, where she is constantly reminded of how important good teaching really is. She is past chair of the Board of the Association of University Programs in Health Administration (AUPHA) and coauthor of the Bugbee Falk Award–winning Career Opportunities in Health Care Management: Perspectives from the Field. Dr. Buchbinder also coauthors Cases in Health Care Management with Nancy Shanks and Dale Buchbinder.
Nancy H. Shanks, PhD, has extensive experience in the health care field. For 12 years, she worked as a health services researcher and health policy analyst and later served as the executive director of a grant-making, fund- raising foundation that was associated with a large multihospital system in Denver. During the last 20 years, Dr. Shanks has been a health care administration educator at Metropolitan State University of Denver, where she has taught a variety of undergraduate courses in health services management, organization, research, human resources management, strategic management, and law. She is currently an Emeritus Professor of Health Care Management and an affiliate faculty member, after having served as Chair of the Department of Health Professions for seven years. Dr. Shanks’s research interests have focused on health policy issues, such as providing access to health care for the uninsured.
Contributors
Mohamad A. Ali, MBA, MHA, CBM Healthcare Strategy Consultant MASA Healthcare, LLC Washington, DC
Dale Buchbinder, MD, FACS Chairman, Department of Surgery and Clinical Professor of Surgery The University of Maryland Medical School Good Samaritan Hospital Baltimore, MD
Susan Casciani, MSHA, MBA, FACHE Adjunct Professor Stevenson University Owings Mills, MD
Donna M. Cox, PhD Professor and Director Alcohol, Tobacco, and Other Drugs Prevention Center Department of Health Science Towson University Towson, MD
Amy Dore, DHA Associate Professor, Health Care Management Program Department of Health Professions Metropolitan State University of Denver Denver, CO
Brenda Freshman, PhD
Associate Professor Health Administration Program California State University, Long Beach Long Beach, CA
Callie E. Heyne, BS Research Associate Clemson University Clemson, SC
Ritamarie Little, MS, RD Associate Director Marilyn Magaram Center for Food Science, Nutrition, & Dietetics California State University, Northridge Northridge, CA
Sheila K. McGinnis, PhD Healthcare Transformation Director City College Montana State University, Billings Billings, MT
Michael Moran, DHA Adjunct Faculty School of Business University of Colorado, Denver Denver, CO
Patricia A. Patrician, PhD, RN, FAAN Colonel, U.S. Army (Retired) Donna Brown Banton Endowed Professor School of Nursing University of Alabama, Birmingham Birmingham, AL
Louis Rubino, PhD, FACHE Professor & Program Director Health Administration Program Health Sciences Department California State University, Northridge Northridge, CA
Sharon Saracino, RN, CRRN Patient Safety Officer Nursing Department Allied Services Integrated Health Care System–Heinz Rehab Wilkes-Barre, PA
Grant T. Savage, PhD Professor of Management Management, Information Systems, & Quantitative Methods Department University of Alabama, Birmingham Birmingham, AL
Nancy K. Sayre, DHEd, PA, MHS Department Chair Department of Health Professions Coordinator, Health Care Management Program Assistant Professor, Health Care Management Program Metropolitan State University of Denver Denver, CO
Windsor Westbrook Sherrill, PhD Professor of Public Health Sciences Associate Vice President for Health Research Clemson University Clemson, SC
Jon M. Thompson, PhD Professor, Health Services Administration
Director, Health Services Administration Program James Madison University Harrisonburg, VA
Eric S. Williams, PhD Associate Dean of Assessment and Continuous Improvement Professor of Health Care Management Minnie Miles Research Professor Culverhouse College of Commerce University of Alabama Tuscaloosa, AL
Kevin D. Zeiler, JD, MBA, EMT-P Associate Professor, Health Care Management Program Department of Health Professions Metropolitan State University of Denver Denver, CO
CHAPTER 1
An Overview of Health Care Management
Jon M. Thompson, Sharon B. Buchbinder, and Nancy H. Shanks
LEARNING OBJECTIVES By the end of this chapter, the student will be able to:
Define healthcare management and the role of the health care manager; Differentiate among the functions, roles, and responsibilities of health care managers;
Compare and contrast the key competencies of health care managers; and
Identify current areas of research in health care management.
INTRODUCTION Any introductory text in health care management must clearly define the profession of health care management and discuss the major functions, roles, responsibilities, and competencies for health care managers. These topics are the focus of this chapter. Health care management is a growing profession with increasing opportunities in both direct care and non–direct care settings. As defined by Buchbinder and Thompson (2010, pp. 33–34), direct care settings are “those organizations that provide care directly to a patient, resident or client who seeks services from the organization.” Non-direct
care settings are not directly involved in providing care to persons needing health services, but rather support the care of individuals through products and services made available to direct care settings. The Bureau of Labor Statistics (BLS, 2014) indicates health care management is one of the fastest- growing occupations, due to the expansion and diversification of the health care industry. The BLS projects that employment of medical and health services managers is expected to grow 23% from 2012 to 2022, faster than the average for all occupations (see Figure 1-1).
These managers are expected to be needed in both inpatient and outpatient care facilities, with the greatest growth in managerial positions occurring in outpatient centers, clinics, and physician practices. Hospitals, too, will experience a large number of managerial jobs because of the hospital sector’s large size. Moreover, these estimates do not reflect the significant growth in managerial positions in non–direct care settings, such as consulting firms, pharmaceutical companies, associations, and medical equipment companies. These non–direct care settings provide significant assistance to direct care organizations, and since the number of direct care managerial positions is expected to increase significantly, it is expected that growth will also occur in managerial positions in non–direct care settings.
Health care management is the profession that provides leadership and direction to organizations that deliver personal health services and to divisions, departments, units, or services within those organizations. Health care management provides significant rewards and personal satisfaction for those who want to make a difference in the lives of others. This chapter gives a comprehensive overview of health care management as a profession. Understanding the roles, responsibilities, and functions carried out by health care managers is important for those individuals considering the field to make informed decisions about the “fit.” This chapter provides a discussion of key management roles, responsibilities, and functions, as well as management positions at different levels within health care organizations. In addition, descriptions of supervisory level, mid-level, and senior management positions within different organizations are provided.
FIGURE 1-1 Occupations with the Most New Jobs in Hospitals, Projected 2012–2022. Employment and Median Annual Wages, May 2013
Source: U.S. Bureau of Labor Statistics, Employment Projections program (projected new jobs, 2012– 2022) and Occupational Employment Statistics Survey (employment and median annual wages, May 2013).
THE NEED FOR MANAGERS AND THEIR PERSPECTIVES Health care organizations are complex and dynamic. The nature of organizations requires that managers provide leadership, as well as the supervision and coordination of employees. Organizations were created to achieve goals beyond the capacity of any single individual. In health care organizations, the scope and complexity of tasks carried out in provision of services are so great that individual staff operating on their own could not get the job done. Moreover, the necessary tasks in producing services in health care organizations require the coordination of many highly
specialized disciplines that must work together seamlessly. Managers are needed to ensure organizational tasks are carried out in the best way possible to achieve organizational goals and that appropriate resources, including financial and human resources, are adequate to support the organization.
Health care managers are appointed to positions of authority, where they shape the organization by making important decisions. Such decisions relate, for example, to recruitment and development of staff, acquisition of technology, service additions and reductions, and allocation and spending of financial resources. Decisions made by health care managers not only focus on ensuring that the patient receives the most appropriate, timely, and effective services possible, but also address achievement of performance targets that are desired by the manager. Ultimately, decisions made by an individual manager impact the organization’s overall performance.
Managers must consider two domains as they carry out various tasks and make decisions (Thompson, 2007). These domains are termed external and internal domains (see Table 1-1). The external domain refers to the influences, resources, and activities that exist outside the boundary of the organization but that significantly affect the organization. These factors include community needs, population characteristics, and reimbursement from commercial insurers, as well as government plans, such as the Children’s Health Insurance Plans (CHIP), Medicare, and Medicaid. The internal domain refers to those areas of focus that managers need to address on a daily basis, such as ensuring the appropriate number and types of staff, financial performance, and quality of care. These internal areas reflect the operation of the organization where the manager has the most control. Keeping the dual perspective requires significant balance and effort on the part of management in order to make good decisions.
MANAGEMENT: DEFINITION, FUNCTIONS, AND COMPETENCIES As discussed earlier, management is needed to support and coordinate the services provided within health care organizations. Management has been defined as the process, comprised of social and technical functions and activities, occurring within organizations for the purpose of accomplishing predetermined objectives through human and other resources (Longest, Rakich, & Darr, 2000). Implicit in the definition is that managers work through and with other people, carrying out technical and interpersonal activities to achieve the desired objectives of the organization. Others have stated that a manager is anyone in the organization who supports and is responsible for the work performance of one or more other persons (Lombardi & Schermerhorn, 2007).
While most beginning students of health care management tend to focus on the role of the senior manager or lead administrator of an organization, it should be realized that management occurs through many others who may not have “manager” in their position title. Examples of some of these managerial positions in health care organizations include supervisor, coordinator, and director, among others (see Table 1-2). These levels of managerial control are discussed in more detail in the next section.
Managers implement six management functions as they carry out the process of management (Longest et al., 2000):
Planning: This function requires the manager to set a direction and determine what needs to be accomplished. It means setting priorities and determining performance targets.
Organizing: This management function refers to the overall design of the organization or the specific division, unit, or service for which the manager is responsible. Furthermore, it means designating reporting relationships and intentional patterns of interaction. Determining positions, teamwork assignments, and distribution of authority and responsibility are critical components of this function.
Staffing: This function refers to acquiring and retaining human resources. It also refers to developing and maintaining the workforce through various strategies and tactics.
Controlling: This function refers to monitoring staff activities and performance and taking the appropriate actions for corrective action to increase performance.
Directing: The focus in this function is on initiating action in the organization through effective leadership and motivation of, and communication with, subordinates.
Decision making: This function is critical to all of the aforementioned management functions and means making effective decisions based on consideration of benefits and the drawbacks of alternatives.
In order to effectively carry out these functions, the manager needs to possess several key competencies. Katz (1974) identified key competencies of the effective manager, including conceptual, technical, and interpersonal skills. The term competency refers to a state in which an individual has the requisite or adequate ability or qualities to perform certain functions (Ross, Wenzel, & Mitlyng, 2002). These are defined as follows:
Conceptual skills are those skills that involve the ability to critically analyze and solve complex problems. Examples: a manager conducts an analysis of the best way to provide a service or determines a strategy to reduce patient complaints regarding food service.
Technical skills are those skills that reflect expertise or ability to perform a specific work task. Examples: a manager develops and implements a new incentive compensation program for staff or designs and implements modifications to a computer-based staffing model.
Interpersonal skills are those skills that enable a manager to communicate with and work well with other individuals, regardless of whether they are peers, supervisors, or subordinates. Examples: a manager counsels an employee whose performance is below expectation or communicates to subordinates the desired performance level for a service for the next fiscal year.
MANAGEMENT POSITIONS: THE CONTROL IN THE ORGANIZATIONAL HEIRARCHY Management positions within health care organizations are not confined to the top level; because of the size and complexity of many health care organizations, management positions are found throughout the organization. Management positions exist at the lower, middle, and upper levels; the upper level is referred to as senior management. The hierarchy of management means that authority, or power, is delegated downward in the
organization, and lower-level managers have less authority than higher-level managers, whose scope of responsibility is much greater. For example, a vice president of Patient Care Services in a hospital may be in charge of several different functional areas, such as nursing, diagnostic imaging services, and laboratory services; in contrast, a director of Medical Records—a lower-level position—has responsibility only for the function of patient medical records. Furthermore, a supervisor within the Environmental Services department may have responsibility for only a small housekeeping staff, whose work is critical, but confined to a defined area of the organization. Some managerial positions, such as those discussed previously, are line manager positions because the manager supervises other employees; other managerial positions are staff manager positions because they carry out work and advise their bosses, but they do not routinely supervise others. Managerial positions also vary in terms of required expertise or experience. Some positions require extensive knowledge of many substantive areas and significant working experience, and other positions are more appropriate for entry-level managers who have limited or no experience.
The most common organizational structure for health care organizations is a functional organizational structure, whose key characteristic is a pyramid-shaped hierarchy that defines the functions carried out and the key management positions assigned to those functions (see Figure 1-2). The size and complexity of the specific health services organization will dictate the particular structure. For example, larger organizations—such as large community hospitals, hospital systems, and academic medical centers—will likely have deep vertical structures reflecting varying levels of administrative control for the organization. This structure is necessary due to the large scope of services provided and the corresponding vast array of administrative and support services that are needed to enable the delivery of clinical services. Other characteristics associated with this functional structure include a strict chain of command and line of reporting, which ensure communication and assignment and evaluation of tasks are carried out in a linear command and control environment. This structure offers key advantages, such as specific divisions of labor and clear lines of reporting and accountability.
Other administrative structures have been adopted by health care organizations, usually in combination with a functional structure. These include matrix, or team-based, models and service line management models.
The matrix model recognizes that a strict functional structure may limit the organization’s flexibility to carry out the work, and that the expertise of other disciplines is needed on a continuous basis. An example of the matrix method is when functional staff, such as nursing and rehabilitation personnel, are assigned to a specific program, such as geriatrics, and they report for programmatic purposes to the program director of the geriatrics department. Another example is when clinical and administrative staff are assigned to a team investigating new services that is headed by a marketing or business development manager. In both of these examples, management would lead staff who traditionally are not under their direct administrative control. Advantages of this structure include improved lateral communication and coordination of services, as well as pooled knowledge.
In service line management, a manager is appointed to head a specific clinical service line and has responsibility and accountability for staffing, resource acquisition, budget, and financial control associated with the array of services provided under that service line. Typical examples of service lines include cardiology, oncology (cancer), women’s services, physical rehabilitation, and behavioral health (mental health). Service lines can be established within a single organization or may cut across affiliated organizations, such as within a hospital system where services are provided at several different affiliated facilities (Boblitz & Thompson, 2005). Some facilities have found that the service line management model for selected clinical services has resulted in many benefits, such as lower costs, higher quality of care, and greater patient satisfaction, compared to other management models (Duffy & Lemieux, 1995). The service line management model is usually implemented within an organization in conjunction with a functional structure, as the organization may choose to give special emphasis and additional resources to one or a few services lines.
FIGURE 1-2 Functional Organizational Structure
FOCUS OF MANAGEMENT: SELF, UNIT/TEAM, AND ORGANIZATION Effective health care management involves exercising professional judgment and skills and carrying out the aforementioned managerial functions at three levels: self, unit/team, and organization wide. First and foremost, the individual manager must be able to effectively manage himself or herself. This means managing time, information, space, and materials; being responsive and following through with peers, supervisors, and clients; maintaining a positive attitude and high motivation; and keeping a current understanding of management techniques and substantive issues of health care management. Drucker (2005) suggests that managing yourself also involves knowing your strengths, how you perform, your values, where you belong, and what you can contribute, as well as taking responsibility for your relationships. Managing yourself also means developing and applying appropriate technical, interpersonal, and conceptual skills and competencies and being comfortable with them, in order to be able to effectively move to the next level—that of supervising others.
The second focus of management is the unit/team level. The expertise of the manager at this level involves managing others in terms of effectively completing the work. Regardless of whether you are a senior manager, mid- level manager, or supervisor, you will be “supervising” others as expected in your assigned role. This responsibility includes assigning work tasks, review and modification of assignments, monitoring and review of individual performance, and carrying out the management functions described earlier to ensure excellent delivery of services. This focal area is where the actual work gets done. Performance reflects the interaction of the manager and the employee, and it is incumbent on the manager to do what is needed to shape the performance of individual employees. The focus of management at this echelon recognizes the task interdependencies among staff and the close coordination that is needed to ensure that work gets completed efficiently and effectively.
The third management focus is at the organizational level. This focal area reflects the fact that managers must work together as part of the larger organization to ensure organization-wide performance and organizational viability. In other words, the success of the organization depends upon the success of its individual parts, and effective collaboration is needed to ensure that this occurs. The range of clinical and nonclinical activities that occur within a health care organization requires that managers who head individual units work closely with other unit managers to provide services. Sharing of information, collaboration, and communication are essential for success. The hierarchy looks to the contribution of each supervised unit as it pertains to the whole. Individual managers’ contributions to the overall performance of the organization—in terms of various performance measures such as cost, quality, satisfaction, and access—are important and measured.
ROLE OF THE MANAGER IN ESTABLISHING AND MAINTAINING ORGANIZATIONAL CULTURE Every organization has a distinct culture, known as the beliefs, attitudes, and behavior that are shared among organizational members. Organizational
culture is commonly defined as the character, personality, and experience of organizational life i.e., what the organization really “is” (Scott, Mannion, Davies, & Marshall, 2003). Culture prescribes the way things are done, and is defined, shaped, and reinforced by the management team. All managers play a role in establishing the culture of a health care organization, and in taking the necessary leadership action to sustain, and in some cases change, the culture. Culture is shaped by the values, mission, and vision for the organization. Values are principles the organization believes in and shape the organization’s purpose, goals, and day-to-day behaviors. Adopted values provide the foundation for the organization’s activities and include such principles as respect, quality service, and innovation. The mission of the organization is its fundamental purpose, or what the organization seeks to achieve. The vision of the organization specifies the desired future state for the organization and reflects what the organization wants to be known and recognized for in the future. Statements of values, mission, and vision result from the organizational strategic planning process. These statements are communicated widely throughout the organization and to the community and shape organizational strategic and operational actions. Increasingly, organizations are establishing codes of conduct or standards of behavior that all employees must follow (Studer, 2003). These standards of behavior align with the values, mission, and vision. The role of managers in the oversight of standards of behavior is critical in several respects: for setting expectations for staff behavior, modelling the behavior, measuring staff performance, and improving staff performance. Mid-level and lower-level managers are instrumental to organization-wide adoption and embracing of the culture as they communicate desired behaviors and reinforce culture through modelling expectations through their own behaviors. For example, a value of customer service or patient focus requires that managers ensure proper levels of service by their employees via clarifying expectations and providing internal customer service to their own staff and other managers. Furthermore, managers can measure and evaluate employee compliance with organizational values and standards of behavior by reviewing employee performance and working with staff to improve performance. Performance evaluation will be explored in a later chapter in this text.
ROLE OF THE MANAGER IN TALENT
MANAGEMENT In order to effectively master the focal areas of management and carry out the required management functions, management must have the requisite number and types of highly motivated employees. From a strategic perspective, health care organizations compete for labor, and it is commonly accepted today that high-performing health care organizations are dependent upon individual human performance, as discussed further in Chapter 12. Many observers have advocated for health care organizations to view their employees as strategic assets who can create a competitive advantage (Becker, Huselid, & Ulrich, 2001). Therefore, human resources management has been replaced in many health care organizations with talent management. The focus has shifted to securing and retaining the talent needed to do the job in the best way, rather than simply filling a role (Huselid, Beatty, & Becker, 2005). As a result, managers are now focusing on effectively managing talent and workforce issues because of the link to organizational performance (Griffith, 2009).
Beyond recruitment, managers are concerned about developing and retaining those staff who are excellent performers. Many health care organizations are creating high-involvement organizations that identify and meet employee needs through their jobs and the larger organizational work setting (Becker et al., 2001). One of the critical responsibilities of managers in talent management is promoting employee engagement, which describes the motivation and commitment of staff to contribute to the organization. There are several strategies used by managers to develop and sustain employee engagement, as well as to develop and maintain excellent performers. These include formal methods such as offering training programs; providing leadership development programs; identifying employee needs and measuring employee satisfaction through engagement surveys; providing continuing education, especially for clinical and technical fields; and enabling job enrichment. In addition, managers use informal methods such as conducting periodic employee reviews, soliciting employee feedback, conducting rounds and employee huddles, offering employee suggestion programs, and other methods of managing employee relations and engagement. These topics are explored in more detail in a later chapter in this book.
ROLE OF THE MANAGER IN ENSURING HIGH PERFORMANCE At the end of the day, the role of the manager is to ensure that the unit, service, division, or organization he or she leads achieves high performance. What exactly is meant by high performance? To understand performance, one has to appreciate the value of setting and meeting goals and objectives for the unit/service and organization as a whole, in terms of the work that is being carried out. Goals and objectives are desired end points for activity and reflect strategic and operational directions for the organization. They are specific, measurable, meaningful, and time oriented. Goals and objectives for individual units should reflect the overarching needs and expectations of the organization as a whole because, as the reader will recall, all entities are working together to achieve high levels of overall organizational performance. Studer (2003) views the organization as needing to be results oriented, with identified pillars of excellence as a framework for the specific goals of the organization. These pillars are people (employees, patients, and physicians), service, quality, finance, and growth. Griffith (2000) refers to high-performing organizations as being championship organizations—that is, they expect to perform well on different yet meaningful measures of performance. Griffith further defines the “championship processes” and the need to develop performance measures in each of the following: governance and strategic management; clinical quality, including customer satisfaction; clinical organization (caregivers); financial planning; planning and marketing; information services; human resources; and plant and supplies. For each championship process, the organization should establish measures of desired performance that will guide the organization. Examples of measures include medication errors, surgical complications, patient satisfaction, staff turnover rates, employee satisfaction, market share, profit margin, and revenue growth, among others. In turn, respective divisions, units, and services will set targets and carry out activities to address key performance processes. The manager’s job, ultimately, is to ensure these targets are met by carrying out the previously discussed management functions. A control process for managers has been advanced by Ginter, Swayne, and Duncan (2002) that describes five key steps in the performance
management process: set objectives, measure performance, compare performance with objectives, determine reasons for deviation, and take corrective action. Management’s job is to ensure that performance is maintained or, if below expectations, improved.
Stakeholders, including insurers, state and federal governments, and consumer advocacy groups, are expecting, and in many cases demanding, acceptable levels of performance in health care organizations. These groups want to make sure that services are provided in a safe, convenient, low-cost, and high-quality environment. For example, The Joint Commission (formerly JCAHO) has set minimum standards for health care facilities operations that ensure quality, the National Committee for Quality Assurance (NCQA) has set standards for measuring performance of health plans, and the Centers for Medicare and Medicaid Services (CMS) has established a website that compares hospital performance along a number of critical dimensions. In addition, CMS has provided incentives to health care organizations by paying for performance on measures of clinical care and not paying for care resulting from never events i.e., shocking health outcomes that should never occur in a health care setting such as wrong site surgery (e.g., the wrong leg) or hospital-acquired infections (Agency for Healthcare Research and Quality, n.d.). Health insurers also have implemented pay-for- performance programs for health care organizations based on various quality and customer service measures.
In addition to meeting the reporting requirements of the aforementioned organizations, many health care organizations today use varying methods of measuring and reporting the performance measurement process. Common methods include developing and using dashboards or balanced scorecards that allow for a quick interpretation of organizational performance across a number of key measures (Curtright, Stolp-Smith, & Edell, 2000; Pieper, 2005). Senior administration uses these methods to measure and communicate performance on the total organization to the governing board and other critical constituents. Other managers use these methods at the division, unit, or service level to profile its performance. In turn, these measures are also used to evaluate managers’ performance and are considered in decisions by the manager’s boss regarding compensation adjustments, promotions, increased or reduced responsibility, training and development, and, if necessary, termination or reassignment.
ROLE OF THE MANAGER IN LEADERSHIP DEVELOPMENT AND SUCCESSION PLANNING Because health care organizations are complex and experience challenges from internal and external environments, the need for leadership skills of managers at all levels of the organization has become paramount. Successful organizations that demonstrate high operational performance depend on strong leaders (Squazzo, 2009). Senior executives have a primary role in ensuring managers throughout the organization have the knowledge and skills to provide effective leadership to achieve desired levels of organizational performance. Senior management also plays a key role in succession planning to ensure vacancies at mid- and upper levels of the organization due to retirements, departures, and promotions are filled with capable leaders. Therefore, key responsibilities of managers are to develop future leaders through leadership development initiatives and to engage in succession planning.
Leadership development programs are broadly comprised of several specific organizational services that are offered to enhance leadership competencies and skills of managerial staff in health care organizations. Leadership development is defined as educational interventions and skill- building activities designed to improve the leadership capabilities of individuals (Kim & Thompson, 2012; McAlearney, 2005). Such initiatives not only serve to increase leadership skills and behaviors, but also ensure stability within organizational talent and culture through career advancement and succession planning (Burt, 2005). In order to embrace leadership development, managers provide technical and psychological support to the staff through a range of leadership development activities:
Leadership development program: Training and leadership development on a variety of required topics, through a formally designated program, using structured learning and competency-based assessment using various formats, media, and locations (Kim & Thompson, 2012)
Courses on leadership and management: Didactic training through specific courses offered face-to-face, online, or in hybrid form (Garman, 2010; Kim & Thompson, 2012)
Mentoring: Formal methods used by the organization for matching aspiring leaders with mid-level and senior executives to assist in their learning and personal growth (Garman, 2010; Landry & Bewley, 2010)
Personal development coaching: Usually reserved for upper-level executives; these formal organizational efforts assist in improving performance by shaping attitudes and behavior and focusing on personal skills development (Garman, 2010; Scott, 2009)
Job enlargement: The offering of expanded responsibilities, developmental assignments, and special projects to individuals to cultivate leadership skills for advancement advance within the organization (Fernandez-Aaroz, 2014; Garman, 2010; Landry & Bewley, 2010)
360-degree performance feedback: Expensive, labor-intensive, and usually reserved for upper-level executives; a multisource feedback approach where an individual staff member or manager receives an assessment of performance from several key individuals (e.g., peers, superiors, other managers, and subordinates) regarding performance and opportunities for improvement (Garman, 2010; Landry & Bewley, 2010)
Leadership development programs have shown positive results. For example, health systems report benefits such as improvement of skills and quality of the workforce, enhancing organizational efficiency in educational activities, and reducing staff turnover and related expenses when leadership training is tied to organization-wide strategic priorities (McAlearney, 2005). In addition, hospitals with leadership development programs have been found to have higher volumes of patients, higher occupancy, higher net patient revenue, and higher total profit margin when compared to hospitals without these programs (Thompson & Kim, 2013). Studies have also shown that leadership development programs in health systems are related to greater focus on employee growth and development, improved employee retention, and greater focus on organizational strategic priorities (McAlearney, 2010). Finally, within a single health system, a leadership
development program led to greater market share, reduced employee turnover, and improved core quality measures (Ogden, 2007). However, one of the key drawbacks to leadership development programs is the cost of developing and operating the programs (Squazzo, 2009).
Due to the competitive nature of health care organizations and the need for highly motivated and skilled employees, managers are faced with the challenge of succession planning for their organizations. Succession planning refers to the concept of taking actions to ensure staff can move up in management roles within the organization to replace those managers who retire or move to other opportunities in other organizations. Succession planning has most recently been emphasized at the senior level of organizations, in part due to the large number of retirements that are anticipated from Baby Boomer chief executive officers (CEOs) (Burt, 2005). To continue the emphasis on high performance within health care organizations, CEOs and other senior managers are interested in finding and nurturing leadership talent within their organizations who can assume the responsibility and carry forward the important work of these organizations.
Health care organizations are currently engaged in several practices to address leadership succession needs. First, mentoring programs for junior management that includes the participation of senior management have been advocated as a good way to prepare future health care leaders (Rollins, 2003). Mentoring studies show that mentors view their efforts as helpful to the organization (Finley, Ivanitskaya, & Kennedy, 2007). Some observers suggest having many mentors is essential to capturing the necessary scope of expertise, experience, interest, and contacts to maximize professional growth (Broscio & Scherer, 2003). Mentoring middle-level managers for success as they transition to their current positions is also helpful in preparing those managers for future executive leadership roles (Kubica, 2008).
A second method of succession planning is through formal leadership development programs. These programs are intended to identify management potential throughout an organization by targeting specific skill sets of individuals and assessing their match to specific jobs, such as vice president or chief operating officer (COO). One way to implement this is through talent reviews, which, when done annually, help create a pool of existing staff who may be excellent candidates for further leadership development and skill strengthening through the establishment of development plans. Formal programs that are being established by many
health care organizations focus on high-potential people (Burt, 2005). Thompson and Kim (2013) found that 48% of community hospitals offered a leadership development program, and McAlearney (2010) reported that about 50% of hospital systems nationwide had an executive-level leadership development program. However, many health care organizations have developed programs that address leadership development at all levels of the organization, not just the executive level, and require all managers to participate in these programs to strengthen their managerial and leadership skills and to contribute to organizational performance.
ROLE OF THE MANAGER IN INNOVATION AND CHANGE MANAGEMENT Due to the pace of change in the health services industry and the complexity of health services organizations, the manager plays a significant role in leading innovation and spearheading change management. Health services organizations cannot remain static. The environmental forces discussed earlier in this chapter strongly point to the need for organizations to respond and adapt to these external influences. In addition, achieving and maintaining high performance outcomes or results is dependent on making improvements to the organizational structure and processes. Moreover, managers are encouraged to embrace innovation to identify creative ways to improve service and provide care effectively and efficiently.
Innovation and change management are intricately related, but different, competencies. Hamel (2007) describes management innovation and operational innovation. Management innovation addresses the organization’s management processes as the practices and routines that determine how the work of management gets conducted on a daily basis. These include such practices as internal communications, employment assessment, project management, and training and development. In contrast, operational innovation addresses the organization’s business processes. In the health care setting, these include processes such as customer service, procurement of supplies and supply chain changes, care coordination across staff, and development and use of clinical procedures and practices. Some operational innovation is structural in nature and involves acquisition of
information and clinical products, such as electronic medical/health records, or a new device or procedure, such as robotic surgery or new medications (Staren, Braun, & Denny, 2010). There are specific skills needed by managers to be innovators in management. These skills include thinking creatively about ways to proactively change management and operational practices to improve the organization. It also involves a willingness to test these innovative practices and assess their impact. Also, a manager must facilitate recruitment and development of employees who embrace creativity and innovation. Having innovative clinical and administrative staff is critical to implementing operational innovation. A culture of innovation depends upon staff who are generating ideas for operational innovation, and the manager is a linchpin in establishing a culture of innovation that supports idea generation. Recent studies of innovative and creative companies found that leaders should rely on all staff collaborating by helping one another and engaging in a dynamic process of seeking and giving feedback, ideas, and assistance (Amabile, Fisher, & Pillemer, 2014). Several barriers to innovation have been identified. These barriers include lack of an innovation culture that supports idea generation, lack of leadership in innovation efforts, and high costs of making innovative changes (Harrington & Voehl, 2010). In addition, formal rules and regulations, professional standards, and administrative policies may all work against innovation (Dhar, Griffin, Hollin, & Kachnowski, 2012). Finally, daily priorities and inertia reflecting the status quo that cause managers to focus on routines and day-to-day tasks limit staff ability to be creative, engage in discovery, and generate ideas (Dhar et al., 2012).
Organizational change, or change management, is related to but different from innovation. Organizational change is a structured management approach to improving the organization and its performance. Knowledge of performance gaps is a necessary prerequisite to change management, and managers must routinely assess their operational activities and performance and make adjustments in the work structure and processes to improve performance (Thompson, 2010). Managing organizational change has become a significant responsibility of managers and a key competency for health care managers (Buchbinder & Thompson, 2010). Managing the change process within health care organizations is critical because appropriately and systematically managing change can result in improved organizational performance. However, change is difficult and the
change process creates both staff resistance and support for a change. A process model of change management has been suggested by Longest
et al. (2000). This rational, problem-based model identifies four key steps in systematically understanding and managing the change process: (1) identification of the need for change, (2) planning for implementing the change, (3) implementing the change, and (4) evaluating the change.
There are several key management competencies that health care managers need to possess to effectively manage change within their organizations. Thompson (2010) suggests that managers:
–Embrace change and be a change agent; –Employ a change management process; –Effectively address support and resistance to change; –Use change management to make the organization innovative and
successful in the future; and, –Recruit staff and succession plan with change management in mind.
ROLE OF THE MANAGER IN HEALTH CARE POLICY As noted earlier in this chapter, managers must consider both their external and internal domains as they carry out management functions and tasks. One of the critical areas for managing the external world is to be knowledgeable about health policy matters under consideration at the state and federal levels that affect health services organizations and health care delivery. This is particularly true for senior-level managers. This awareness is necessary to influence policy in positive ways that will help the organization and limit any adverse impacts. Staying current with health care policy discussions, participating in deliberations of health policy, and providing input where possible will allow health care management voices to be heard. Because health care is such a popular yet controversial topic in the U.S. today, continuing changes in health care delivery are likely to emanate from the legislative and policy processes at the state and federal levels. For example, the Patient Protection and Affordable Care Act, signed into law in 2010 as a
major health care reform initiative, has had significant implications for health care organizations in terms of patient volumes, reimbursement for previously uninsured patients, and the movement to improve population health and develop value-based purchasing. Other recent federal policy changes include cuts in Medicare reimbursement and increases in reporting requirements. State legislative changes across the country affect reimbursement under Medicaid and the Children’s Health Insurance Program, licensure of facilities and staff, certificate of need rules for capital expenditures and facility and service expansions, and state requirements on mandated health benefits and modified reimbursements for insured individuals that affect services offered by health care organizations.
In order to understand and influence health policy, managers must strive to keep their knowledge current. This can be accomplished through targeted personal learning, networking with colleagues within and outside of their organizations, and participating in professional associations, such as the American College of Healthcare Executives and the Medical Group Management Association. These organizations, and many others, monitor health policy discussions and advocate for their associations’ interests at the state and federal levels. Knowledge gained through these efforts can be helpful in shaping health policy in accordance with the desires of health care managers.
RESEARCH IN HEALTH CARE MANAGEMENT Current research in management focuses on best practices. For example, the best practices of managers and leaders in ensuring organizational performance has been the focus of work by McAlearney, Robbins, Garman, and Song (2013) and Garman, McAlearney, Harrison, Song, and McHugh (2011). The best practices identified by these researchers include staff engagement, staff acquisition and development, staff frontline empowerment, and leadership alignment and development. Understanding what leaders do to develop their staff and prepare lower-level managers for leadership roles has been a common research focus as well. Leadership development programs have been examined in terms of their structure and
impact. McAlearney (2008) surveyed health care organizations and key informants to determine the availability of leadership development programs and their role in improving quality and efficiency, and found these programs enhanced the skills and quality of the workforce, improved efficiency in educational development, and reduced staff turnover. A study of high- performing health organizations found various practices are used to develop leaders internally, including talent reviews to identify candidates for upward movement, career development planning, job rotations, and developmental assignments (McHugh, Garman, McAlearney, Song, & Harrison, 2010). In addition, a 2010 study examined leadership development in health and non- health care organizations and found best practices included 360-degree performance evaluation, mentoring, coaching, and experiential learning (National Center for Healthcare Leadership, 2010). A study of U.S. health systems found about half of health systems offered a leadership development program and also found that leadership development initiatives helped the systems focus on employee growth and development and improved employee retention (McAlearney, 2010). As noted earlier in this chapter, some recent studies have examined the characteristics of leadership development programs in hospitals, finding correlations of programs with size, urban location, and not-for-profit ownership status (Kim and Thompson, 2012; Thompson and Kim, 2013). A new area of management research is the participation of early careerists in leadership development programs, and recent evidence shows that some leadership development activities are of more interest to staff than others (Thompson and Temple, 2015). A number of important areas of management research exist today, and include looking at the effect of leadership development training on specific decision-making by managers, career progression due to participation in leadership development, and the impact of collaboration among staff on firm innovation and performance (Amabile, Fisher, & Pillemer, 2014).
CHAPTER SUMMARY The profession of health care management is challenging yet rewarding, and requires persons in managerial positions at all levels of the organization to possess sound conceptual, technical, and interpersonal skills to carry out the necessary managerial functions of planning, organizing, staffing, directing,
controlling, and decision making. In addition, managers must maintain a dual perspective where they understand the external and internal domains of their organization and the need for development at the self, unit/team, and organization levels. Opportunities exist for managerial talent at all levels of a health care organization, including supervisory, middle-management, and senior-management levels. The role of manager is critical to ensuring a high level of organizational performance, and managers are also instrumental in establishing and maintaining organizational culture, talent recruitment and retention, leadership development and succession planning, innovation and change management, and shaping health care policy.
Note: Portions of this chapter were originally published as “Understanding Health Care Management” in Career Opportunities in Healthcare Management: Perspectives from the Field, by Sharon B. Buchbinder and Jon M. Thompson, and an adapted version of this chapter is reprinted here with permission of the publisher.
DISCUSSION QUESTIONS
1. Define health care management and health care managers.
2. Delineate the functions carried out by health care managers and give an example of a task in each function.
3. Explain why interpersonal skills are important in health care management.
4. Compare and contrast three models of organizational design.
5. Why is the health care manager’s role in ensuring high performance so critical? Explain.
6. Characterize the health care manager’s role in change management and assess the extent to which this has an impact on the success of the change process.
REFERENCES Agency for Healthcare Research and Quality (AHRQ). (n.d.). Never events.
Retrieved from http://www.psnet.ahrq.gov/primer.aspx?primerID=3 Amabile, T., Fisher, C. M., & Pillemer, J. (2014). IDEO’s culture of helping.
Harvard Business Review, 92, 54–61. Becker, B. E., Huselid, M. A., & Ulrich, D. (2001). The HR scorecard: Linking
people, strategy, and performance. Boston, MA: Harvard Business School Press.
Boblitz, M., & Thompson, J. M. (2005). Assessing the feasibility of developing centers of excellence: Six initial steps. Healthcare Financial Management, 59, 72–84.
Broscio, M., & Scherer, J. (2003). Building job security: Strategies for becoming a highly valued contributor. Journal of Healthcare Management, 48, 147–151.
Buchbinder, S. B., & Thompson, J. M. (2010). Career opportunities in health care management: Perspectives from the field. Sudbury, MA: Jones and Bartlett.
Bureau of Labor Statistics (BLS). (2014). Occupational outlook handbook 2014 edition. Retrieved from www.bls.gov/oco/ocos014.htm
Burt, T. (2005). Leadership development as a corporate strategy: Using talent reviews to improve senior management. Healthcare Executive, 20, 14–18.
Curtright, J. W., Stolp-Smith, S. C., & Edell, E. S. (2000). Strategic management: Development of a performance measurement system at the Mayo Clinic. Journal of Healthcare Management, 45, 58–68.
Dhar, M., Griffin, M., Hollin, I., & Kachnowski, S. (2012). Innovation spaces: Six strategies to inform health care. The Health Care Manager, 31, 166–177.
Drucker, P. F. (2005). Managing oneself. Harvard Business Review, 83(1), 100–109.
Duffy, J. R., & Lemieux, K. G. (1995, Fall). A cardiac service line approach to patient-centered care. Nursing Administration Quarterly, 20, 12–23.
Fernandez-Araoz, C. (2014). 21st century talent spotting. Harvard Business Review, 92(6), 46–56.
Finley, F. R., Ivanitskaya, L. V., & Kennedy, M. H. (2007). Mentoring junior healthcare administrators: A description of mentoring practices in 127 U.S. hospitals. Journal of Healthcare Management, 52, 260–270.
Garman, A. N. (2010). Leadership development in the interdisciplinary context. In B. Freshman, L. Rubino, and Y. R. Chassiakos, (Eds.), Collaboration across the disciplines in health care (pp. 43–63). Sudbury, MA: Jones and Bartlett.
Garman, A. N., McAlearney, A. S., Harrison, M. I., Song, P. H., & McHugh, M. (2011). High-performance work systems in health care management, Part 1: Development of an evidence-informed model. Health Care Management Review, 36(3), 201–213.
Ginter, P. M., Swayne, L. E., & Duncan, W. J. (2002). Strategic management of healthcare organizations (4th ed.). Malden, MA: Blackwell.
Griffith, J. R. (2000). Championship management for healthcare organizations. Journal of Healthcare Management, 45, 17–31.
Griffith, J. R. (2009). Finding the frontier of hospital management. Journal of Healthcare Management, 54(1), 57–73.
Hamel, G. (2007). The future of management. Boston, MA: Harvard Business School Press.
Harrington, H. J., & Voehl, F. (2010). Innovation in health care. International Journal of Innovation Science, 2, 13–27.
Huselid, M. A., Beatty, R. W., & Becker, B. E. (2005, December). “A players” or “A” positions? The strategic logic of workforce management. Harvard Business Review, 83, 100–117.
Katz, R. L. (1974). Skills of an effective administrator. Harvard Business Review, 52, 90–102.
Kim, T. H., & Thompson, J. M. (2012). Organizational and market factors associated with leadership development programs in hospitals: A national study. Journal of Healthcare Management, 57(2), 113–132.
Kubica, A. J. (2008). Transitioning middle managers. Healthcare Executive, 23, 58–60.
Landry, A. Y., & Bewley, L. W. (2010). Leadership development, succession planning and mentoring. In S. R. Hernandez & S. J. O’Connor (Eds.), Strategic management of human resources in health services organizations (3rd ed., pp. 133–146). Clifton Park, NY: Delmar.
Lombardi, D. M., & Schermerhorn, J. R. (2007). Healthcare management. Hoboken, NJ: John Wiley.
Longest, B. B., Rakich, J. S., & Darr, K. (2000). Managing health services organizations and systems. Baltimore, MD: Health Professions Press.
McAlearney, A. S. (2005). Exploring mentoring and leadership development in health care organizations: Experience and opportunities. Career Development International, 10(6/7), 493–511.
McAlearney, A. S. (2008). Using leadership development programs to improve quality and efficiency in healthcare. Journal of Healthcare Management, 53(5), 319–332.
McAlearney, A. S. (2010). Executive leadership development in U.S. health systems. Journal of Healthcare Management, 55(3), 206–224.
McAlearney, A. S., Robbins, J., Garman, A. N., & Song, P. H. (2013). Implementing high performance work practices in healthcare organizations: Qualitative and conceptual evidence. Journal of Healthcare Management, 58(6), 446–462.
McHugh, M., Garman, A., McAlearney, A., Song, P., & Harrison, M. (2010). Using workforce practices to drive quality improvement: A guide for hospitals. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from www.hret.org/workforce/resources/workforce-guide.pdf
National Center for Healthcare Leadership (NCHL). (2010). Best practices in healthcare leadership academies. Chicago, IL: Author. Retrieved from http://www.nchl.org/Documents/Ctrl_Hyperlink/doccopy5381_uid6102014456192.pdf
Ogden, G. (2010). Talent management in a time of cost management. Healthcare Financial Management, 64(3), 80–82, 84.
Pieper, S. K. (2005). Reading the right signals: How to strategically manage with scorecards. Healthcare Executive, 20, 9–14.
Rollins, G. (2003). Succession planning: Laying the foundation for smooth transitions and effective leaders. Healthcare Executive, 18, 14–18.
Ross, A., Wenzel, F. J., & Mitlyng, J. W. (2002). Leadership for the future: Core competencies in health care. Chicago, IL: Health Administration Press/AUPHA Press.
Scott, G. (2009). The leader as coach. Healthcare Executive, 24(4), 40–43. Scott, T., Mannion, R., Davies, H. T. O., & Marshall, M. M. (2003).
Implementing culture change in health care: Theory and practice.
International Journal for Quality in Health Care. Retrieved from http://intqhc.oxfordjournals.org/content/15/2/111
Squazzo, J. D. (2009, November/December). Cultivating tomorrow’s leaders: Comprehensive development strategies ensure continued success. Healthcare Executive, 24(6), 8–20.
Staren, E. D., Braun, D. P., & Denny, D. (2010). Optimizing innovation in health care organizations. Physician Executive Journal, March/April, 54– 62.
Studer, Q. (2003). Hardwiring excellence. Gulf Breeze, FL: Fire Starter. Thompson, J. M. (2007). Health services administration. In S. Chisolm
(Ed.), The health professions: Trends and opportunities in U.S. health care (pp. 357–372). Sudbury, MA: Jones and Bartlett.
Thompson, J. M. (2010). Understanding and managing organizational change: Implications for public health management. Journal of Public Health Management & Practice, 16(20), 167–173.
Thompson, J. M., & Kim, T. H. (2013). A profile of hospitals with leadership development programs. The Health Care Manager, 32(2), 179–188.
Thompson, J. M., & Temple, A. (2015). Early careerist interest and participation in leadership development programs. The Health Care Manager, 34(4), 350–358.
CHAPTER 2
Leadership Louis Rubino
LEARNING OBJECTIVES By the end of this chapter, the student will be able to:
Distinguish between leadership and management; Summarize the history of leadership in the U.S. from the 1920s to current times;
Compare and contrast leadership styles, competencies, and protocols; Summarize old and new governance trends; Analyze key barriers and challenges to successful leadership; Provide a rationale for why health care leaders have a greater need for ethical behavior;
Explore important new initiatives requiring health care leaders’ engagement; and
Discuss special research issues related to leadership.
LEADERSHIP VS. MANAGEMENT In any business setting, there must be leaders as well as managers. But are these the same people? Not necessarily. There are leaders who are good managers and there are managers who are good leaders, but usually neither case is the norm. In health care, this is especially important to recognize because of the need for both. Health care is unique in that it is a service industry that depends on a large number of highly trained personnel as well
as trade workers. Whatever the setting, be it a hospital, a long-term care facility, an ambulatory care center, a medical device company, an insurance company, an accountable care organization, or some other health care entity, leaders as well as managers are needed to keep the organization moving in a forward direction and, at the same time, maintain current operations. This is done by leading and managing its people and assuring good business practices.
Leaders usually take a focus that is more external, whereas the focus of managers is more internal. Even though they need to be sure their health care facility is operating properly, leaders tend to spend the majority of their time communicating and aligning with outside groups that can benefit their organizations (partners, community, vendors) or influence them (government, public agencies, media). See Figure 2-1. There is crossover between leaders and managers across the various areas, though a distinction remains for certain duties and responsibilities.
Usually the top person in the organization (e.g., Chief Executive Officer, Administrator, Director) has full and ultimate accountability. This type of leader may be dictated by the current conditions faced by the organization. A more strategic leader, who defines purpose and vision and aligns people, processes, and values, may be needed. Or, a network leader, who could connect people across disciplines, organizational departments, and regions, may be essential. Whichever type surfaces, there will be several managers reporting to this person, all of whom have various functional responsibilities for different areas of the organization (e.g., Chief Nursing Officer, Physician Director, Chief Information Officer). These managers can certainly be leaders in their own areas, but their focus will be more internal within the organization’s operations. They are the operational leaders of the organization. Together, these three types of leaders/followers produce an interdependent leadership system, a team which will prove more high performing in the current health care field (Maccoby, Norman, Norman, & Margolies, 2013).
FIGURE 2-1 Leadership and Management Focus
Leaders have a particular set of competencies that require more forward thinking than those of managers. Leaders need to set a vision or direction for the organization. They need to be able to motivate their employees, as well as other stakeholders, so the business continues to exist and, hopefully, thrive in periods of change. No industry is as dynamic as health care, with rapid change occurring due to the complexity of the system and government regulations. Leaders are needed to keep the entity on course and to maneuver around obstacles, like a captain commanding his ship at sea. Managers must tend to the business at hand and make sure the staff is following proper procedures and meeting established targets and goals. They need a different set of competencies. See Table 2-1.
HISTORY OF LEADERSHIP IN THE U.S. Leaders have been around since the beginning of man. We think of the strongest male becoming the leader of a caveman clan. In Plato’s time, the Greeks began to talk about the concept of leadership and acknowledged the political system as critical for leaders to emerge in a society. In Germany during the late 19th century, Sigmund Freud described leadership as unconscious exhibited behavior; later, Max Weber identified how leadership is present in a bureaucracy through assigned roles. Formal leadership studies in the U.S., though, have only been around for the last 100 years (Sibbet, 1997).
We can look at the decades spanning the 20th century to see how leadership theories evolved, placing their center of attention on certain key components at different times (Northouse, 2016). These emphases often matched or were adapted from the changes occurring in society.
With the industrialization of the U.S. in the 1920s, productivity was of paramount importance. Scientific management was introduced, and researchers tried to determine which characteristics were identified with the most effective leaders based on their units having high productivity. The Great Man Theory was developed out of the idea that certain traits determined good leadership. The traits that were recognized as necessary for effective leaders were ones that were already inherent in the person, such as being male, being tall, being strong, and even being Caucasian. Even the idea that “you either got it or you don’t” was supported by this theory, the notion being that a good leader had charisma. Behaviors were not
considered important in determining what made a good leader. This theory discouraged anyone who did not have the specified traits from aspiring to a leadership position.
Fortunately, after two decades, businesses realized leadership could be enhanced through certain conscious acts, and researchers began to study which behaviors would produce better results. Resources were in short supply due to World War II, and leaders were needed who could truly produce good results. This was the beginning of the Style Approach to Leadership. Rather than looking at only the characteristics of the leader, researchers started to recognize the importance of two types of behaviors in successful leadership: completing tasks and creating good relationships. This theory states leaders have differing degrees of concern over each of these behaviors, and the best leaders would be fully attentive to both.
In the 1960s, American society had a renewed emphasis on helping all of its people and began a series of social programs that still remain today. The two that impact health care directly, by providing essential services, are Medicare for the elderly (age 65 and over) and the disabled and Medicaid for the indigent population. The Situational Approach to Leadership then came into prominence and supported this national concern. This set of theories focused on the leader changing his or her behavior in certain situations in order to meet the needs of subordinates. This would imply a very fluid leadership process whereby one can adapt one’s actions to an employee’s needs at any given time.
Not much later, researchers believed perhaps leaders should not have to change how they behaved in a work setting, but instead the appropriate leaders should be selected from the very beginning. This is the Contingency Theory of Leadership and was very popular in the 1970s. Under this theory, the focus was on both the leader’s style as well as the situation in which the leader worked, thus building upon the two earlier theories. This approach was further developed by what is known as the Path–Goal Theory of Leadership. This theory still placed its attention on the leader’s style and the work situation (subordinate characteristics and work task structure) but also recognized the importance of setting goals for employees. The leader was expected to remove any obstacles in order to provide the support necessary for them to achieve those goals.
In the later 1970s, the U.S. was coming out of the Vietnam War, in which
many of its citizens did not think the country should have been involved. More concern was expressed over relationships as the society became more psychologically attuned to how people felt. The Leader–Member Exchange Theory evolved over the concern that leadership was being defined by the leader, the follower, and the context. This new way of looking at leadership focused on the interactions that occur between the leaders and the followers. This theory claimed leaders could be more effective if they developed better relationships with their subordinates through high-quality exchanges.
After Vietnam and a series of weak political leaders, Americans were looking for people to take charge who could really make a difference. Charismatic leaders came back into vogue, as demonstrated by the support shown to President Ronald Reagan, an actor turned politician. Unlike the Great Man Theory earlier in the century, this time the leader had to have certain skills to transform the organization through inspirational motivational efforts. Leadership was not centered upon transactional processes that tied rewards or corrective actions to performance. Rather, the transformational leader could significantly change an organization through its people by raising their consciousness, empowering them, and then providing the nurturing needed as they produced the results desired.
In the late 1980s, the U.S. started to look more globally for ways to have better production. Total Quality Management became a popular concept and arose from researchers studying Japanese principles of managing production lines. In the health care setting, this was embraced through a process still used today called Continuous Quality Improvement or Performance Improvement. In the decade to follow, leaders assigned subordinates to a series of work groups in order to focus on a particular area of production. Attention was placed on developing the team for higher level functioning and on how a leader could create a work environment that could improve the performance of the team. Individual team members were expendable, and the team entity was all important.
We have entered the 21st century with some of the greatest leadership challenges ever in the health care field. Critical personnel shortages, limited resources, and increased governmental regulations provide an environment that yearns for leaders who are attentive to the organization and its people, yet can still address the big picture. Several of today’s leadership models relate well to the dynamism of the health care field and are presented here.
Looking at these models, there seems to be a consistent pattern of self-aware leaders who are concerned for their employees and understand the importance of meaningful work. As we entered the 2000s, leaders needed to use Adaptive Leadership to create flexible organizations able to meet the relentless succession of challenges faced in health care and elsewhere (Heifetz, Grashow, & Linsky, 2009). Plus, today’s astute health care leaders recognize the importance of considering the global environment, as health care wrestles with international issues that impact us locally, such as outsourcing services, medical tourism, and over-the-border drug purchases, giving rise to the global leader. See Table 2-2.
CONTEMPORARY MODELS Today’s health care industry does not prescribe any one type of leadership model. Many leaders are successful drawing from a variety of traditional and contemporary models. It is wise for the leadership student, as well as the practitioner, to become familiar with the various contemporary models so they can be utilized when appropriate. See Table 2-3.
Emotional Intelligence (EI) Emotional Intelligence (EI) is a concept made famous by Daniel Goleman in the late 1990s. It suggests that there are certain skills (intrapersonal and interpersonal) that a person needs to be well adjusted in today’s world. These skills include self-awareness (having a deep understanding of one’s emotions, strengths, weaknesses, needs, and drives), self-regulation (a propensity for reflection, an ability to adapt to changes, the power to say no to impulsive urges), motivation (being driven to achieve, being passionate about one’s profession, enjoying challenges), empathy (thoughtfully considering others’ feelings when interacting), and social skills (moving people in the direction you desire by your ability to interact effectively) (Freshman & Rubino, 2002).
Since September 11, 2001, leaders have needed to be more understanding of their subordinates’ world outside of the work environment. EI, when applied to leadership, suggests a more caring, confident, enthusiastic boss who can establish good relations with workers. Researchers have shown that EI can distinguish outstanding leaders and strong organizational performance (Goleman, 1998). For health care as an industry and for health care managers, this seems like a good fit, especially during this time of change (Delmatoff & Lazarus, 2014). See Table 2-4.
Authentic Leadership The central focus of authentic leadership is that people will want to naturally associate with someone who is following their internal compass of true purpose (George & Sims, 2007). Leaders who follow this model are
ones who know their authentic selves, define their values and leadership principles, understand what motivates them, build a strong support team, and stay grounded by integrating all aspects of their lives. Authentic leaders have attributes such as confidence, hope, optimism, resilience, high levels of integrity, and positive values (Brown & Gardner, 2007). Assessments given to leaders in a variety of international locations have provided the evidence- based knowledge that there is a correlation between authentic leadership and positive outcomes based on supervisor-rated performance (Walumbwa, Avolio, Gardner, Wernsing, & Peterson, 2008).
Diversity Leadership Our new global society forces health care leaders to address matters of diversity, whether with their patient base or with their employees. This commitment to diversity is necessary for today’s leader to be successful. The environment must be assessed so goals can be set that embrace the concept of diversity in matters such as employee hiring and promotional practices, patient communication, and governing board composition, to name a few. Strategies have to be developed to make diversity work for the organization. The leader who recognizes the importance of diversity and designs its acceptance into the organizational culture will be most successful (Warden, 1999). Health care leaders are called to be role models for cultural competency (see Chapter 14 for more on this important topic) and to be able to attract, mentor, and coach those of different, as well as similar, backgrounds (Dolan, 2009).
Servant Leadership Many people view health care as a very special type of work. Individuals usually work in this setting because they want to help people. Servant leadership applies this concept to top administration’s ability to lead, acknowledging that a health care leader is largely motivated by a desire to serve others. This leadership model breaks down the typical organizational hierarchy and professes the belief of building a community within an organization in which everyone contributes to the greater whole. A servant leader is highly collaborative and gives credit to others generously. This leader is sensitive to what motivates others and empowers all to win with shared goals and vision. Servant leaders use personal trust and respect to build bridges and use persuasion rather than positional authority to foster cooperation. This model works especially well in a not-for-profit setting, since it continues the mission of fulfilling the community’s needs rather than the organization’s (Swearingen & Liberman, 2004).
Spirituality Leadership The U.S. has experienced some very serious misrepresentations and misreporting by major health care companies, as reported by U.S. governmental agencies (e.g., Columbia/HCA, GlaxoSmithKline, HealthSouth). Trying to claim a renewed sense of confidence in the system, a model of leadership has emerged that focuses on spirituality. This spiritual focus does not imply a certain set of religious beliefs but emphasizes ethics, values, relationship skills, and the promotion of balance between work and self (Wolf, 2004). The goal under this model is to define our own uniqueness as human beings and to appreciate our spiritual depth. In this way, leaders can deepen their understanding and at the same time be more productive. These leaders have a positive impact on their workers and create a working environment that supports all individuals in finding meaning in what they do. They practice five common behaviors of effective leaders as described by Kouzes and Posner (1995): (1) Challenge the process, (2) Inspire a shared vision, (3) Enable others to act, (4) Model the way, and (5) Encourage the heart, thus taking leadership to a new level.
Resilient Leadership
Being a health care leader is an exciting yet challenging job. Much stress is placed on the executive and its takes a strong, resilient leader to overcome these pressures, bounce back, and keep the organization moving forward. Certain resilience-building practices can be used by the leader to build inner strength and perseverance (Wicks & Buck, 2013). A self-care protocol that includes self-awareness, alone time, mindfulness, and keeping a healthy perspective can be essential to not only the individual leader but also to coach his/her team members to avoid burnout and foster high staff morale.
The Emerging Health Care Leader Students of health administration do not become successful leaders overnight. It usually takes years of study and experience to become comfortable and proficient in the role. A basic foundation is necessary before a leader can emerge and certain strategies can be applied to help an individual build and grow their career (Baedke & Lamberton, 2015). Some of these include paying attention to one’s character, examining self- discipline, cultivating your personal brand, and to constantly network. The best leaders are ones who are continually learning and using this new knowledge to further their development as a leader in today’s changing health care world.
LEADERSHIP STYLES Models give us a broad understanding of someone’s leadership philosophy. Styles demonstrate a particular type of leadership behavior that is consistently used. Various authors have attempted to explain different leadership styles (Northouse, 2015; Studer, 2008). Some styles are more appropriate to use with certain health care workers, depending on their education, training, competence, motivation, experience, and personal needs. The environment must also be considered when deciding which style is the best fit.
In a coercive leadership style power is used inappropriately to get a desired response from a follower. This very directive format should probably not be used unless the leader is dealing with a very problematic subordinate or is in an emergency situation and needs immediate action. In health care
settings over longer periods of time, three other leadership styles could be used more effectively: participative, pacesetting, and coaching.
Many health care workers are highly trained, specialized individuals who know much more about their area of expertise than their supervisor. Take the generally trained chief operating officer of a hospital who has several department managers (e.g., Imaging, Health Information Systems, Engineering) reporting to him or her. These managers will respond better and be more productive if the leader is participative in his or her style. Asking these managers for their input and giving them a voice in making decisions will let them know they are respected and valued.
In a pacesetting style, a leader sets high performance standards for his or her followers. This is very effective when the employees are self-motivated and highly competent—e.g., research scientists or intensive care nurses. A coaching style is recommended for the very top personnel in an organization. With this style, the leader focuses on the personal development of his or her followers rather than the work tasks. This should be reserved for followers the leader can trust and those who have proven their competence. See Table 2-5.
LEADERSHIP COMPETENCIES A leader needs certain skills, knowledge, and abilities to be successful. These are called competencies. The pressures of the health care industry have initiated the examination of a set of core competencies for a leader who works in a health care setting (Dye & Garman, 2015). Criticism has been directed at educational institutions for not producing administrators who can begin managing effectively right out of school. Educational programs in health administration are working with the national coalition groups (e.g., Health Leadership Council, National Center for Healthcare Leadership, and American College of Healthcare Executives) and health care administrative practitioners to come up with agreed upon competencies. Once identified, the programs can attempt to have their students learn how to develop these traits and behaviors.
Some of the competencies are technical—for example, having analytical skills, having a full understanding of the law, and being able to market and write. Some of the competencies are behavioral—for example, decisiveness, being entrepreneurial, and an ability to achieve a good work/life balance. As people move up in organizations, their behavioral competencies are a greater determinant of their success as leaders than their technical competencies (Hutton & Moulton, 2004). Another way to examine leadership competencies is under four main groupings or domains. The Functional and Technical Domain is necessary but not sufficient for a competent leader. Three other domains provide competencies that are behavioral and relate both to the individual (Self-Development and Self-Understanding) and to other people (Interpersonal). A fourth set of competencies falls under the heading Organizational and has a broader perspective. See Table 2-6 for a full listing of the leadership competencies under the four domains.
LEADERSHIP PROTOCOLS Health care administrators are expected to act a certain way. Leaders are role models for their organizations’ employees, and they need to be aware that their actions are being watched at all times. Sometimes people at the top of an organization get caught up in what they are doing and do not realize the message they are sending throughout the workplace by their inappropriate behavior. Specific ways of serving in the role of a health care leader can be demonstrated and can provide the exemplary model needed to send the correct message to employees. These appropriate ways in which a leader acts are called protocols.
There is no shortage of information on what protocols should be followed by today’s health care leader. Each year, researchers, teachers of health administration, practicing administrators, and consultants write books filled
with their suggestions on how to be a great leader (for some recent examples, see Dye, 2010; Ledlow & Coppola, 2011; and Rath and Conchie, 2008). There are some key ways a person serving in a leadership role should act. These are described here and summarized in Table 2-7.
Professionalism is essential to good leadership. This can be manifested not only in the way people act but also in their mannerisms and their dress. A leader who comes to work in sloppy attire or exhibits discourteous or obnoxious behavior will not gain respect from followers. Trust and respect are very important for a leader to acquire. Trust and respect must be a two- way exchange if a leader is to get followers to respond. Employees who do not trust their leader will consistently question certain aspects of their job. If they do not have respect for the leader, they will not care about doing a good job. This could lead to low productivity and bad service.
Even a leader’s mood can affect workers. A boss who is confident, optimistic, and passionate about his or her work can instill the same qualities in the workers. Such enthusiasm is almost always infectious and is passed on to others within the organization. The same can be said of a leader who is weak, negative, and obviously unenthusiastic about his or her work—these poor qualities can be acquired by others.
Leaders must be very visible throughout the organization. Having a presence can assure workers that the top people are “at the helm” and give a sense of stability and confidence in the business. Quint Studer (2009), founder and CEO of Studer Group, states how rounding can help leaders
meet certain standard goals: making sure staff know they are cared about, know what is going on (what is working well, who should be recognized, which systems need to work better, which tools and equipment need attention), and know that proper follow-up actions are taking place. Leaders must be open communicators. Holding back information that could have been shared with followers will cause ill feelings and a concern that other important matters are not being disclosed. Leaders also need to take calculated risks. They should be cautious, but not overly so, or they might lose an opportunity for the organization. And finally, leaders in today’s world need to recognize that they are not perfect. Sometimes there will be errors in what is said or done. These must be acknowledged so they can be put aside and the leader can move on to more pressing current issues.
The post MS in Healthcare Management Program School of Graduate and Professional Studies appeared first on Infinite Essays.
Module 6 Case Study: The Condescending Dental Hygienist
Read the attached case study with a focus on the key management issues.
Using the resources provided at the end of this case study, answer the plan development and response questions as indicated in APA format.
Use a minimum of 3 scholarly references, listed in APA format. Do not use personal opinion to complete this assignment, it is based on legal and ethical issues, use scholarly sources to find your answer.
The post The Condescending Dental Hygienist appeared first on Infinite Essays.
