Essay Examples - MBA Thesis Healthcare

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1: INTRODUCTION AND BACKGROUND

The United States has long been recognized as a nation with exorbitant healthcare costs, comparative to other countries. The National Institutes of Health recorded increased healthcare costs from $10.9 to $15.6 billion dollars between 1993 and 1999. Also, pharmaceutical research and development doubled to $24 billion dollars (National Academy Press 2001, pg. 2). Although very costly the quality of care is often not analogous to associated costs. This reality is further understood when observing the number of preventable hospital deaths per year. Due to the number of avoidable deaths, many individuals view the hospital as one of the most dangerous places to receive healthcare.

Alexander Pope asserted that making mistakes is a natural or human tendency. However, when human error results in the loss of thousands of lives and billions of dollars in healthcare costs, something must be done. That is why there has been a major push to implement quality and safety metrics within the American healthcare system. Scientific and technological advances are essential to improved quality and safety metrics. However increased access is equally important, if the healthcare system is to adequately service the population. The U.S. Census Bureau projected the number of uninsured Americans to be as high as forty million. As a disclaimer the number of uninsured Americans could be significantly less since the recent implementation of Obama Care (National Academy Press 2001, pg. 2).

Increased healthcare costs are attributed to the skyrocketing pharmaceutical costs, advanced technologies, and the evolving healthcare needs of patients. Additionally, medical errors are occurring with greater frequency due to fragmentation in the healthcare delivery model. Duplication of services, inexcusable time delays for care, and other ineffective processes also add significantly to costs (National Academy Press 2001, pg. 2).

In regards to safety measures hospitals need to reduce infections obtained while receiving treatment. As hospitals reduce infections obtained during patient visits, there would theoretically be less frequency of visits. Under a fee-for-service compensation structure this could adversely impact overall revenue. One compensation structure that could work concurrently with a strategy to reduce infection is the capitation or risk-sharing approach. This would require fewer resources to service patients while simultaneously reducing patient infections (National Academy Press 2001, pg. 193).

The bottom line is that healthcare organizations are responsible for reducing costs and are subsequently held to a higher level of accountability. Organizations like the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) are enforcing hospital compliance. When hospitals are found out of compliance as evident by incidents of increased infection, safety problems, or procedural mistakes, there are fiscal repercussions.

Often they end up absorbing significant healthcare expenses related to patient hospitalization. In addition JCAHO can further penalize hospitals by regulating reimbursement rates from Medicaid and Medicare. There are five specific areas relative to hospital care that JCAHO evaluates. This includes chronic myocardial infarction, congestive heart failure, pneumonia, surgical techniques, and circumstances related to pregnancy (National Academy Press 2001, pg. 102-103).

The National Committee for Quality Assurance assesses how effective health plans are in managing chronic ailments relative to cardiovascular, cancer, and influenza. Additionally, the National Quality Forum is another organization pursuing comprehensive quality metrics and related goals (National Academy Press 2001, pgs. 102-103).

According to the Institute of Medicine (IOM) quality healthcare is safe, patient-centric, timely, and equitable. The IOM committees determined that two processes, guideline development and technology assessment are equally important. Recommended criteria in both processes include pervasiveness, practice variability, rate, and seriousness of illness. Cost mitigation and improved outcomes are also factors in establishing quality of care metrics (National Academy Press 2001, pg. 103).

Further, when addressing safety concerns companies are encouraged to establish a culture where reporting identified errors and potential hazards is normative practice. Frontline employees are an organizations greatest asset to improving relevant processes and guidelines. In order for systematic issues to permeate a work environment, acquisition, dissemination, and incorporation of best practices must become intentional. Even if ideas did not originate within the organization the integration of best healthcare practices should be the overriding goal (National Academy Press 2001, pg. 122).

Previous research has determined that improved communication could mitigate errors, incidents of readmission, and other medical complications. When operative communication occurs between physicians and allied professionals then outcomes should be positive. Effective communication is not solely limited to the healthcare field. Communication is at the heart of every successful relationships, whether it be business or personal. In healthcare many quality issues, errors, and discrepancies occur due to miscommunication of daily tasks. With the advent of Electronic medical records (EMR) patient information is more easily accessible. However, the availability of EMR systems does not eliminate the necessity of authentic face-to-face dialogue.

Antoine de Saint- Exupery compared successful leadership with ship building. He believed that successful leaders know how to ignite the fire and passion within others. Transformative leadership causes others to collect wood for ship building or do whatever work is necessary for goal attainment (Bartiromo, 2010 pg. 242). To translate that principle into an effective healthcare strategy the focus must be on development of people. Companies should focus on becoming aware of the challenges that frontline employees face. They should consequently develop strategic plans for workflow improvement and improved employee satisfaction. Preoccupation with current trends and innovation are important, yet suffer significantly without comparative human development.

Chapter 1.1 RESEARCH PROBLEMS

This thesis will explore the necessity of influential communication within a healthcare environment. Two factors quality care and patient safety are identified as variables dependent on authentic and efficient communication. Further, medical errors, complications, and readmission rates are usually attributed to lack of communication. This paper will explore causative factors hindering the nurse and physician relationship. Further examination will include identification of the variables hindering communication. Once discovered research will explore the associated impact on safety and quality care.

In hospitals throughout the country, a nurse will often hesitate to contact a doctor who has historically displayed incensed behavior. Nurses worry about informing doctors of their patients’ conditions or seeking their medical opinion regarding treatment. This reluctance is often attributed to fear of ridicule or embarrassment especially around colleagues and patients. The obvious downside is that lack of communication inadvertently places patients at greater risk. The absence of communication in a healthcare setting has existed for decades. In fact a 1990’s study found that poor communication has led to somewhere between 44,000 and 98,000 annual deaths.

Pitiable communication has also been identified as a leading factor of preventable deaths.

This has resulted in studies designed to improve communication due to its adverse impact on healthcare facilities and the general public. Although improving dialogue between physicians and other healthcare staff is important, there are equally important relationships. Future research should also consider physician and patient interaction, physician with physician relationships, and hospitals communicating with other hospitals (Taran 2011, pg. 86).

Enriched communication is not solely the responsibility of healthcare facilities. Medical and vocational schools need to address strategies for effective communication in a healthcare setting. Nurses often chafe at the expectation that they will be acquiescent when working with physicians. In contrast, physicians are typically viewed as imposing care providers with the majority of the power.

Nursing is also a predominantly female held occupation, while doctors are traditionally males. Although these statistics are rapidly changing, the success rate of nurse and physician communication is sorely lacking. Hospitals cannot completely revolutionize the way that nurses and physicians communicate overnight, however they can make positive changes. In-service training is a viable and cost-effective way to address this issue without directly blaming a specific stakeholder.

Assertiveness training should be taught in nursing schools and during hospital employee orientation. Primary benefits include improved patient safety and increased awareness concerning how lack of communication can negatively impact patient safety. Along with assertiveness training, team building workshops should also be integrated in orientations for doctors, nurses, and other healthcare personnel.

Hospitals should also hold meetings and social functions for all disciplines. Meetings should not only include nurse managers but also, staff nurses. If patient safety is the number one concern, then directly focusing on those involved in patient care should be the focus. Both physician and nurse leaders need to invest in the simplest, yet easily disregarded aspect of patient care which is communication.

A team based approach, where all healthcare professionals are free to express their input is the desired model. Hospitals should also engage in daily rounding in critical disciplines to ascertain workflow problems and get feedback from frontline employees. In departments such as intensive care and ER, feedback should come from respiratory therapists, pharmacists, social workers, nurses and physicians.

The value of group sharing, include improved collaboration among team members and better team morale. Within each department there should be established rules of engagement that ensure each team member feels comfortable voicing their concerns. Disruptive behavior should not be tolerated, while professional accountability ensures a positive and productive work environment. These are critical initial steps in the process of improving patient safety.

1.1 RESEARCH PURPOSE AND OBJECTIVES

The purpose of this research project is to analyze factors associated with rising healthcare costs and associated safety concerns. Consequently the research will inexorably conclude that inadequate communication is a prominent factor that must be allayed. Additionally, nurses, physicians, and other healthcare practitioners must be viewed as equal partners.

This requires a heightened awareness of how important each role and function is within the healthcare continuum. Doctors cannot properly diagnose patients without supportive frontline staff to identify and communicate symptoms associated with patient conditions. Likewise nurses and other healthcare providers need Doctors to provide insight and recommendations concerning appropriate treatment.

Additionally, research will reveal the need for hospitals to incorporate assertiveness and team building training. Ideally this training would take place during new employee orientation and subsequently during ongoing in-service training. This approach could improve participant engagement with other departments in a manner that also encourages safe practices. Assertiveness training provides an opportunity for respectful yet directive dialogue between doctors and nurses. The value of such training is that it creates a new paradigm where all stakeholders within the continuum of care are equally valued.

1.2 RESEARCH APPROACH AND METHOD

Research methodology is an examination of the lens through which a particular subject is understood. For example in the analysis of healthcare and healthcare delivery there are specific methodologies for analyzing the process for servicing patients. From the point of entry into the healthcare facility to the diagnosis of related issues, and recommendations, healthcare is complex. When looking at communication within a healthcare setting the interrelationship between various stakeholders becomes a central focus.

Specifically understanding the message-oriented process is critical to identifying causative factors of subsequent actions. If for example stakeholders feel valued in the process of the message oriented process then the workflow is generally viewed as more productive. Consequently if stakeholders feel hesitant or have minimal trust for the communication process then that impacts efficiency (Whaley, 2014).

In terms of methodology there are various approaches, including literary examination of interviews and focus groups, case studies, and ethnographic research. Additionally, interpersonal exchanges include narrative, conversational, physician-patient interaction, and content analysis. Also, casual exposition will include the assessment of experimental communication research and meta-analysis of existent medical data (Whaley, 2014).

1.3 DATA COLLECTION

Data collection will utilize a mixed method approach that considers both qualitative and quantitative data. For example in the qualitative examination the focus will be on focus groups, organic detailed interviews, observations, self-analysis, recording, and transcript examination (Whaley, 2014). This data collection process will enable researchers to better understand patterns that are currently existent within the healthcare setting. It will be important to glean information from various stakeholders in order to understand relevant relationship dynamics. The emergent narrative and themes will be appropriately complemented with amalgamated quantitative data.

Quantitative data will provide a comprehensive understanding of healthcare challenges by examining statistical and numerical data. For example one goal will be to drill down skyrocketing healthcare costs to the granular level of specific services. Where there are incidents of duplicated services or unnecessary services then critical questions need to be addressed. One such question would be why are superfluous services being provided within a healthcare facility for a large number of patients? Additionally, who is authorizing such services and are there checkpoints of accountability? When there are quantitative statistics that reveal elevated levels of hospital induced infections, then critical questions also need to be addressed. For example, where are the points of communication breakdown in the workflow process? Also, who are the persons that are ultimately responsible for sterilization procedures and what are barriers to effective service?

From a micro perspective the mixed method approach will be foundational to an effective research project. However there will also be the inclusion of macro methods such as ethnography. Currently there are numerous industries, using ethnographic strategies as part of a comprehensive research approach. Ethnography is qualitative in nature in the sense that it enables companies to find out pragmatic needs of patients (Anderson, 2009). So for example, when looking at healthcare it is not just an internal audit that needs to take place. While acknowledging the value of improving internal processes, it is equally important to understand how such processes impact patients directly.

Companies like Intel have found that becoming more enlightened about a customer’s needs relative to a product or service is critical. Without such information long-term planning becomes extremely difficult and laborious. In fact it could be argued that without such qualitative data emergent strategies are ineffective in addressing the primary needs of the patient-consumer. Intel found Ethnographic research so critical to their planning; they set up a business unit that focused on data collection using ethnographic strategies (Anderson, 2009).

1.4 STUDY OUTCOMES

When synthesizing study outcomes, there are diverse issues that are discovered and discussed. The healthcare industry as a whole is very complex and often involves efforts to appease numerous stakeholders. The National Institute of Health record has identified significant increase in healthcare costs over the years. Such increases include traditional operational expenses and also pharmaceutical research and development (National Academy Press 2001, pg. 2). In order for a healthcare company to remain profitable significant efforts must be made to develop its most significant asset, the employees.

In order to create and sustain an environment of safety and value organizations must carefully assess internal and external relationships. An example of an external relationship would be how the organization engages community and patient shareholders. Internal relationships would include an assessment of how physicians and nurses engage one another. Critical research questions include, “How much do physicians respect nurses and vice versa. At the surface level nurse abuse can appear to be isolated and an issue requiring minimal focus. However this report acknowledges the fact that there are systemic issues that must be addressed. Failure to appropriately address issues like nurse abuse can lead to staff burnout, high turnover rates, fiscal impact, and patient safety issues.

Within the context of discussing the aforementioned issues the report also seeks to carefully examine group dynamics. According to one report productivity and performance has historically been a significant focus of organizational behavior literature. This is especially important in healthcare as the continuum of care involves physicians, nurses, and a growing number of specialists. Two proposed group structures are egalitarian or hierarchical organizations. Generally a hierarchical structure is understood as a multi-tiered form of management. In this type of structure power is positional and naturally there is a correlation between the level of feedback and associated corporate position. In contrast an egalitarian style position is defined as one where all individuals are equal. Naturally it is assumed that in egalitarian system collaboration and engagement levels are higher.

It should be noted that hierarchical structures enhance coordination of efforts and could even be considered more systematic. Many organizations can attest to the fact that the improved coordination results in enhanced performance on established metrics. However, those supporting an egalitarian group would argue that similar coordination can occur in that setting. On philosophy is that satisfaction level can be identified based on the engagement of personality and organizational structure. In fact every organization should seek to find a reasonable measure of compatibility between organization and personality structure. This is because higher productivity and personal employee satisfaction are more likely (Edge & Remus, 1984).

Another component of organizational success is found in the practice and the study of six sigma principles. There was a study that took place where data was collected from a sample of 226 manufacturing plants. The implementation of six sigma addresses two areas of concern for healthcare organizations including quality practice and cultural implementation. As such there are four cultural orientations that are analyzed within the report. Those cultural orientations include group culture, development culture, rational culture, and hierarchical culture. Out of those four cultural orientations all except hierarchical culture are related to quality practice studied in the report (Zu, Fredendall, & Robbins, 2006 pg. 1).

Healthcare organizations must continue to seek the balance between service quality and satisfaction of the internal and external customer. Six sigma is a quality management program that can accomplish both goals. The defects that such an approach can eliminate include lapses in service and a decrease in morbidity and mortality rates. Six sigma will systematically identify and eliminate causes of defect by focusing on critical inputs and outputs relative to healthcare service. This quality management approach is focused on improvement at multiple organizational levels. It leverages scientific and statistical data to significantly mitigate workflow and defect rates (Zu, Fredendall, & Robbins, 2006 pg. 3).

Study outcomes also revealed the value of assertiveness training. It is especially important for women in healthcare to develop advanced assertiveness skills. As part of the overall staff development training organizations must facilitate assertiveness training. The more organizations engage employees in equitable relationships the greater satisfaction levels.

CHAPTER 2: LITERATURE REVIEW

2.1 WHAT IS QUALITY HEALTH CARE?

An accurate assessment of quality healthcare requires first defining key terms. Healthcare is a systematic delivery of services that are interconnected (James 1989, pg. 2). This means that one component of service is dependent upon the successful execution of another. If for example a patient has a negative experience with a phlebotomist then it could adversely affect how they feel about subsequent care. They may question the validity of test results, or they may assume that the overall continuum of care will be negative. This means that both the Doctor and the nurse will be dealing with a patient who is already skeptical and possibly resistant to healthcare recommendations.

Quality is both subjective and objective in nature. From a subjective standpoint the patient will evaluate care based on the output of personal engagement occurring with each touch point. It is important to note that the patient’s experience is based on current and historic moments of engagement in the healthcare facility (James 1989, pg. 2). Naturally the patient has fundamental values that determine how they interpret their healthcare experience. So the combination of their fundamental values and the pragmatic experience will equal their subjective determination of quality.

This is why ethnographic and qualitative methodology is so vital. It is not simply the hospitals interpretation of the patient experience; the information needs to come directly from the patient. Also, noteworthy is the fact that within every healthcare organization there are also internal customers. This includes the nurses and other healthcare providers. As such if they feel that they are being treated unfairly then the “culture” of care will be negative. They will translate the output of negativity into viewing the service experience as poor. That is why healthcare organizations need to utilize a multi-prong approach when assessing quality.

From a quantitative perspective the healthcare organization can measure, and theoretically influence variables that determine quality. However they cannot force or manipulate the subsequent value system that internal and external customers have. Therefore it is important that healthcare organizations focus on the aspects of quality improvement that they can influence. So the quantitative data and metrics that are measurable should be used as data for process and people improvement.

Quality is comprised of two critical components, content and delivery. Content quality is quantitative as it pertains to the measurement of medical outcomes (James 1989, pgs. 2-3). That is why many healthcare organizations are focused on preemptive care measures as a means of improving quality care. Preemptive measurements could include medical procedures like blood screenings to determine glucose or cholesterol levels. Interestingly enough organizations like JCAHO also use such quantitative measurements as a determinant of quality of care. JCAHO and other organizations are important accrediting bodies within the medical field. As such, their policies and associated evaluations are highly regarded by facilities, patients, and payers as well.

In contrast, delivery quality is qualitative as it assesses a patient’s interaction with healthcare facilities. This involves questions such as hospital cleanliness, level of care from hospital staff, and the speed of service delivery (James 1989, pg. 2). Although this process is subjective and based on individual patient preference, the cumulative results can have far reaching effects on a healthcare facility. If a patient subjectively feels as though their experience was inappropriate then they are going to use other healthcare facilities. This means that revenue coming from payer organizations like insurance companies will go to healthcare facilities providing the highest level of care.

Therefore, the relationship between quality and cost is implicit. The higher the quality of service, the more revenue a healthcare facility receives from payer organizations. Consequently, those healthcare organizations offering undesirable service will have difficulty retaining customers. The revenue will be adversely impacted causing undesirable consequences such as union fights over wages, layoffs, and other undesirable operational cuts. There are direct costs and indirect costs associated with quality. Direct costs would include resources used to address processes with low quality. Indirect costs would include revenue loss due to poor quality and manpower hours addressing customer complaints (James 1989, pgs. 2-3).

Optimal healthcare service throughout the continuum of care ensures higher quality and lower costs. With the government seeking effective strategies for cost mitigation and higher care quality, lean operations are essential. Healthcare organizations that can effectively find the balance between care quality and cost-appropriate care will emerge as successful organizations in the competitive landscape. This will require waste elimination, improved productivity, decreasing work redundancy (i.e. readmission, errors, and retesting).

Eliminating waste and improving healthcare quality requires assessment of the interaction between nurses and doctors. Quality care requires improving the interconnectedness between various healthcare departments. Infrastructure and technology improvements are important from a delivery standpoint. However, leaders must pay equal attention to the condition of frontline staff, and seek ways to assess and improve service delivery. If healing and trust are key objectives within the healthcare process then a holistic team approach is necessary. Care providers who feel like they are within a system that is restrictive or punitive are less likely to provide holistic patient care.

Healthcare organizations must operate from a position of transparency and accurate reporting, in order to build trust. Although patient trust is important, it is equally important that other shareholders (i.e. nurses, phlebotomists, & respiratory therapists) trust the process. Accurate reporting will help to identify and eliminate the root causes of systematic problems threatening patient safety. The Joint Commission has emphasized the significance of appropriate communication among caregivers.

Therefore certain intimidating behaviors such as oral outbursts, somatic threats, and disobliging insolences are counterproductive to establishing quality and trust. Recent reports have indicated that various healthcare improvement advisors have not felt support when reporting quality or safety issues. This culture of mistrust or intimidation will often cause critical issues to go unreported for lengthy periods of time. The shareholder that suffers the most in this process unfortunately is the patient (National Association for Healthcare Quality 2012, Pg. 7).

The National Association for Healthcare Quality includes the Joint Commission, The National Patient Safety Foundation and the American Society for Healthcare Risk Management. It is an independent non-profit organization founded in 1951. The mission of the organization is healthcare improvement, utilizing a collaborative approach involving all shareholders. When accrediting more than 20,500 organizations the focus is quality and value (The Joint Commission, 2014).

2.3 HEALTHCARE COST IN THE UNITED STATES (3 pages)

Healthcare cost in the United States is currently the highest in the world. Forbes reports the current annual U.S. healthcare spending to be $3.8 trillion, with much of the deficit growth directly related to healthcare expenditures. One positive statistical metric, is the annual growth rate, which has slowed to approximately 3.7 percent. Although a slowing growth rate is significant, that rate could increase depending on the direction of future legislation. Currently there is a growing consensus on the need to increase certain healthcare related payouts. One such payout is the current Medicare physician payment formula (Munroe, 2014). If such legislation is finally approved then it will require Congress to figure out how to fund such increases.

The Center for Medicaid and Medicare Services projects an average annual growth rate of 5.8% from 2012 to 2022. The report also claims that this growth rate is 1 percentage point faster than expected average annual growth in the country’s Gross Domestic Product (GDP) (CMS.GOV, 2012). While such statistics are alarming the trend moving forward is even more significant. There is an anticipated fiscal spike for 2014, due to the several significant factors.

Although 2013 has a projected annual growth rate of 4.0 percent due to the economic recovery, 2014 rates are expected to be approximately 6.1 percent. Much of the increase will be attributed to upward trending economic conditions; greater cost-sharing for those privately insured and slowed Medicare and Medicaid growth (CMS.GOV, 2012). With the country’s current economic climate and skyrocketing healthcare cost, the federal government spends a tremendous amount of effort, in improving healthcare delivery and also decreasing cost.

President Obama’s Affordable Care Act enacted in March 2012, provides Americans with better health security and expanded insurance options. It also increases accountability of insurance companies, guarantees more healthcare options, lower health care costs, and improves quality (Medicaid.Gov, 2014). However, the benefits gained by the Affordable Care Act come at a cost. Although financial projections for healthcare expenses vary, the data provided by the Congressional Budget Office (CBO) is substantial. In most circles the CBO is viewed as a trustworthy and nonpartisan source.

According to the CBO, net expenditures will increase by $2.3 trillion dollars or 5.2 percent annually. The projected financial increase is attributed to the aging population, the expansion of federal health insurance subsidies, and increasing health expenses per beneficiary. Those three factors are viewed as the fastest rising components of the overall budget. When you combine those factors with compounding interest of federal debt, the aforementioned factors represent 85 percent of total increased costs (Congressional Budget Office, 2014). Further, Medicare, Medicaid, and the Children’s Health Insurance Program are programs that will have a significant impact on total GDP (Gross Domestic Product). The CBO anticipates associated costs of those healthcare programs to rise by at least 85 percent, over the next few years. From a macro perspective this would represent an increase from 4.9 percent to almost 6 percent of GDP (Congressional Budget Office, 2014).

Therefore, cost management becomes the responsibility of the healthcare organizations that service the end user. The importance of healthcare organizations taking ownership of cost containment efforts cannot be overstated. Especially when considering variables that are consistent and expected to continue to drive healthcare costs. One factor that will remain consistent is the aging population which is expanding due to enriched medication, exercise, technological advances, and other life extending factors.

There are certain deductive assumptions that can be drawn from the empirical data outlining healthcare expenses. Federal health insurance subsidies and increased health expense costs are driven by consumer demand. The consumer demand will decrease as healthcare facilities provide consumers with more cost effective treatment. Preemptive care, additional safety measures, and higher levels of service including sterilization will decrease per beneficiary costs.

It can also be safely assumed that a successful healthcare system requires the majority of insured to be relatively healthy. Relatively healthy could be defined as not requiring major medical procedures. This enables the system to support the lesser percentage requiring thousands of dollars in payouts for inpatient hospitalization, expensive medication, and other associated costs. Hospitals are actively seeking strategies for quality improvement strategies for the past thirty years. Yet despite best efforts there have been more than 200,000 Americans that have died from medical errors that are avoidable. Of the associated costs about 90 percent were attributed to medical cost such as auxiliary services, prescription drugs, and inpatient or outpatient costs (Andel, Davidow, Hollander, & Moreno, 2012).

The sky rocketing cost of healthcare is also partially attributed to hospital error, which according to a 2008 report is estimated at $19.5 billion. According to recent report by the Society of Actuaries the three most costly medical errors include pressure ulcers, postoperative infections, and mechanical complications of device, implant or graft. The pressure of cost containment is further compounded by the required technological advancements. This includes the integration of electronic medical records and other associated process improvements (Surgical Information Systems, 2012).

According to one report there were an estimated 166,655 and 170,201 medical errors in the years 2008 and 2009 respectively. Also in the same years median costs per error were $892 and $939 respectively. From a macro perspective there were approximately one million reported medical errors throughout the United States. The identified errors when monetized cost approximately $985 million and more than $1 billion in the same years (David, Gunnarsson, Waters, Horblyuk, & Kaplan 2013, pg. 307).

Medicare maintains strict reimbursement requirements due to the adverse impact of medical errors on patient outcomes. As previously stated the median and macro costs to healthcare organizations for errors are costly. Therefore to receive reimbursements and contracts with Medicaid and Medicare Services, hospitals must be accountable. Accountability includes concerted efforts to assess and aptly mitigate causes related to medical errors. In addition to analysis Hospitals must incorporate preventative programs to address incidents. This is especially important given the fact the financial burden can significantly affect operational budget (David, Gunnarsson, Waters, Horblyuk, & Kaplan 2013, pg. 307).

Medical errors represent the 3^rd leading cause of mortality in the U.S. behind cancer and heart disease. It affects 400, 000 persons per year. It is a crisis so significant it was recently discussed in a Senate hearing where collaborative ideas were discussed. Proposed solutions must include the mobilization of frontline staff and the appropriate leveraging of medical technology. Technology is useful as it enables healthcare providers to appropriately track and document incidents and also review and address patterns of deficiency (McCann, 2014).

2.4 HOSPITAL ERROR RATES

The Leapfrog Group is a consumer resource for information on hospital safety ratings. It recently conducted a study of more than 2,500 general hospitals and evaluated them based on a grading scale of A-F according to ability to prevent errors, harm, and infections. In total there are approximately fifteen process measurements that Leapfrog examines as a tool for determining the hospital’s grade. Critical areas include hand hygiene and doctor staffing in intensive care departments (Hospital Safety Score, 2014).

According to the reported data there are procedural improvements in the areas of care and safety. Yet there is insufficient gain from critical outcomes such as the prevention of infections following major surgeries (Hospital Safety Score, 2014). This highlights the need for hospital staff to continually engage in strategies for further process improvement and collaboration. This is because at the core of every process are teams of staff that must work cooperatively to provide the highest level of patient service.

Approximately 31 percent of graded hospitals received an A score, while 27 percent received a B, 34 percent earned a C, while approximately 7 percent earned either a D or F. In addition to hand cleanliness and appropriate staffing, medication reconciliation was a critical metric. While statistics vary from hospital to hospital there was only one outcome that was universally identified as showing marked improvement. That is in the area of central line-associated bloodstream infections (CLABSI). This metric was evaluated in the intensive care departments at various hospitals (Hospital Safety Score, 2014). Hospitals are encouraged to evaluate strategies and processes that have enabled them to minimize CLABSI infections. Such strategies are useful indicators for addressing outcomes that are currently deficient.

Looking at hospital scores from a State by State basis revealed some interesting patterns. In the District of Columbia and North Dakota there were no hospitals that received an A grade. However in a previous report there were four States plus the District of Columbia that were without an A grade. The State with the highest percentage hospitals receiving an A grade was Maine. The report stated that twelve out of eighteen hospitals or 67 percent received that honor (Hospital Safety Score, 2014).

Wisconsin and Florida have hospitals receiving A scores. This moves them into the top 10 of safest hospitals. Virgina and New Jersey have shown improvement as evident by top five rankings. For 97 percent of the hospitals (2,428 hospitals) there was minimal fluctuation up or down. However for the remaining 3 percent of (72 hospitals), there was a shift of two or more grades (Hospital Safety Score, 2014). Obviously there are important lessons from each represented group.

Out of the 72 hospitals, the group that had a downward shift in grade needs to reevaluate their processes. One recommendation is more consistent inter-departmental meetings to address the glaring issues. Perhaps there also needs to be more investment in technology, or they could discover there is insufficient collaboration among co-workers. Since healthcare isn’t an entirely automated process, the assumption is that better collaboration is necessary.

In contrast, a percentage the 72 hospitals showed vast improvement in grades. This upward shift reveals a commitment to improving quality and safety metrics within healthcare facility. These hospitals have found a way to elevate the consumers’ healthcare experience, through innovation, collaboration, and better communication. Direct benefits include greater customer satisfaction, employee retention, cost savings, and increased revenue.

According to a report by the Agency for Healthcare Research and Quality there was a 17 percent decrease in hospital acquired conditions from 2010-2013. This is significant as it represents an estimated 50,000 preventable deaths. This signifies approximately $12 billion in terms of healthcare related savings from 2010-2013 (Agency for Healthcare Research and Quality, 2014). Although there is a noted decline it is important to aptly identify the specific variables causing the improved hospital safety procedures.

While the same report did not provide specific causes associated with the decline, there are external influential factors. From 2008-2012, there has been fiscal incentives offered by Medicare. Additionally, the United States Department of Health and Human Services and the (CMS) Partnership for Patient’s Initiative have ramped up compliance efforts.

In March 2014, CDC conducted a report that addressed the current outlook of healthcare associated infections. Between 2008 and 2012 variables driving the lowered mortality rates include central line-associated bloodstream infections (CLABSIs) which were reduced by 44 percent. That same percentage was noted by an AHRQ study at looked at Safety trends. During that same period there was an approximate 20 percent decline of surgical site infections (SSI’s) (ahrq.gov, 2013).

PfP a national learning collaborative seeks improved safety in acute care hospitals and also coordination of care discharge to prevent readmission. Coordination included enrollment of 3, 700 acute care hospitals aimed at accomplishing the stated initiatives. The enrolled facilities represent approximately 80 percent of the Nations acute care discharge. Simultaneously CMS designed policy changes and worked collaboratively with the Nation’s Quality Improvement Organization to improve safety (ahrq.gov, 2013).

2.5 HOSPITAL CULTURE (5 pages)

The culture of healthcare is one that is traditionally based on a tiered management approach. This management model originated from the 19^th century industrial age. However, it does not currently position healthcare organizations for success moving into the 21^st century. Historically healthcare professionals have operated within a culture based on a hierarchical philosophy. These traditional cultures are designed to maximize control, efficacy and permanence (Bell, 2013).

In the old paradigm the administration of clinical outcomes and business viability was the responsibility of a select few. Further, this approach focused on producing high volume service, and quality became a secondary concern. This approach is problematic because it limits innovation and growth necessary for business expansion. Those who are not part of the administrative management team often have no voice regarding clinical decisions (Bell, 2013).

Moving into the 21^st century healthcare organizations need to operate within a culture of invention, risk taking, and transformation. The primary focus of the new healthcare organization should be the formation of a value-centric system. Value–centric healthcare service only occurs as organizations provide formal leadership educations. Leadership education establishes a culture that encourages collaboration among all stakeholders (Bell, 2013).

Many healthcare professionals coming from well-known educational institutes often did not receive formal leadership education. Even residencies, fellowships, and mentorship relationships typically did not address the necessity of a culture of collaboration. In fact the dominant message is one that places the physician at the top of the organizational structure overseeing a clinical team. Further, the physician understands that business or operative functions are the responsibility of administrative leaders (Bell, 2013).

Non-physician clinicians such as nurses do receive some organizational leadership information. However much of the information on leadership operates from the standard hierarchical approach and customary expectations taught to physicians. Within the customary approach there are assumptions that a system is required to manage disorderly clinical staff. When healthcare organizations implement such a system it causes hostility and frustration between nurses and doctors. Those employed in clinical diagnostic or technical roles even receive less formal leadership development than nurses or physicians (Bell, 2013).

Health care management has traditionally separated the functional roles of administrative operations. In this model doctors and nurses focus on the clinical well-being of the patient while the administrators focus on the operational aspects. One flaw of this approach is that administrators are often unfamiliar with the challenges faced by clinical staff. Since doctors and nurses have daily interaction with patients, they are most equipped to provide feedback regarding the healthcare delivery processes. Another flaw of this approach is that operational units operating under a bureaucratic model are skewed (Bell, 2013).

A study by McKinsey and London school of Economics confirmed that a collaborative administrative model is effective. Hospitals where clinicians were actively engaged in management decisions scored fifty percent higher in key performance metrics. Within healthcare organizations some level of hierarchy is necessary. However, a new administrative paradigm focused on collaboration will achieve greater results. Professionals that feel they are part of a collaborative workforce will naturally engage at a higher level (Bell, 2013).

According to a recent Journal report leader inclusiveness must entail a combination of words and deeds. As organizations focus on formal leadership training the emergent leaders can effectively empower cross-disciplinary teams. The goal is to ensure all team members are not restrained based on formal roles, but have equitable engagement in process development. The report further predicts that there is a correlation between psychological safety and leader inclusiveness. As such the greater the level of psychological safety an employee feels, the more engaged they are in process improvement (Nembhard & Edmondson, 2006 pg. 941).

The importance of cross-collaboration is significantly higher in healthcare than most industries. Cross-disciplinary teams provide indispensable services to patients in assorted care settings including primary, critical acute, chronic, geriatrics, and end of life care. With accumulative expansion in the areas of medical specialization and knowledge, integrative strategies become paramount. Each team member brings a unique perspective and knowledge base to the provision of care. Teamwork and learning are key drivers in determining how effective cross-disciplinary teams will be. According to research seventy to eighty percent of medical errors occur based on exchanges within the health care team (Nembhard & Edmondson, 2006 pg. 942).

Medical knowledge is constantly changing, which is evident by the fact that the Medline bibliographic database is growing by approximately 30,000 new references each month. Additionally the Federal Drug Administration examines thousands of applications for new devices and drugs on a yearly basis. Although no single individual has the capacity to retain the extensive volume of information, it must be integrated in medical services. Without integration of such medical information, healthcare organizations lose their effectiveness in treating emergent symptoms and conditions (Nembhard & Edmondson, 2006 pg. 942).

In addition to the expansion of medical knowledge the number of specialties is growing at an accelerated rate. Prior to 1930 the only two medical specialties were ophthalmology and otolaryngology. Presently there are a total of 26 specialties and 93 subspecialties. Implicit within this data is a realization of the waning sphere of physician expertise. Also, implicit within the data is an awareness of the physicians’ dependence on other specialties to effectively service the patient. One emergent group within the healthcare continuum is those considered non-physician caregivers. These are specialties including nutrition, respiratory therapy, and physical therapy (Nembhard & Edmondson, 2006 pg. 942).

In 1900 there was a 1 to 3 ratio when it came to physicians versus non-physicians. Since 2000 that ratio has grown to a 1 to 16 ratio meaning there are a growing number of non-physicians now working with physicians. An interconnected care plan requires feedback and data from all medical stakeholders. Also, there is an increasing level of interdependence where one phase of care will inform subsequent medical interactions. In fact it is generally understood that a primary care physician requires detailed medical history when diagnosing a patient. That medical history comes from feedback and data from a number of medical providers. Collaborative learning must become central to the culture of healthcare. It is necessary for the quality of the patient experience and also the psychological wellbeing of the medical providers (Nembhard & Edmondson, 2006 pg. 942).

Although there are identified benefits to collaboration in the healthcare setting there are also understood risks. Healthcare professionals are more likely to avoid risks associated with brainstorming and experimentation. If a process is unsuccessful or it results in an adverse medical condition, no medical provider wants to be held responsible. Also, healthcare by its very nature is a high stress environment since human lives are at stake. In such a high stress situation medical developments tend to be centralized and hierarchical as opposed to collective and democratic (Nembhard & Edmondson, 2006 pg. 943).

Although the goal may be integration of knowledge from diverse expertise, the pragmatic application of such an approach is challenging. Merging the specialized knowledge of physicians and nurses is challenging because they are often engaged at different points of the patient care experience. The physician may be considered the medical manager with a broad range of medical expertise, while the nurses and allied care professionals are well versed in daily patient engagement (Nembhard & Edmondson, 2006 pg. 943).

However, for those healthcare facilities that are willing to take calculated risks and pursue a collaborative model they operate within a wide-ranging information base. For example evidence found in a recent report notes the unique approach and creativity used by nurses in addressing emergent issues. However, these creative medical solutions are often not shared by nurses to other healthcare providers due to the traditional hierarchical, control-based model typically seen in healthcare (Nembhard & Edmondson, 2006 pg. 943).

It is necessary for medical schools and educational hospitals to review current teaching methodologies. Often those within the medical field struggle to transition from an academic culture to a corporate culture. The academic culture values independent research, patient care, and minimal hierarchy. In contrast the corporate culture, teaches practitioners to operate in a top down model with increased accountability and focus on profitability (Sherwin, 2011).

The hospital culture that is successful moving forward will find a way to actively engage all stakeholders in a team-based approach. One of the benefits of aptly balancing elements from the corporate and academic cultures is efficiency. Additionally as there is greater input from a comprehensive medical team the level of patient care increases. This naturally results in higher revenue sharing for the medical facility (Sherwin, 2011).

It is disadvantageous for leaders to belittle subordinates or cause them to feel invaluable. What this creates is a culture of underachievers who eventually become invaluable to the organization (Conniff 2005 pg. 103). In other words the leaders’ lack of empathy creates a psychological burden of insecurity on the subordinates. The employees will respond by becoming less receptive to constructive feedback and rather than view it objectively, they will take it personally. Often bosses are victims of unhealthy habits including imposing stereotypes on subordinates or dominating with aggressive personalities. The danger of this practice is that the same subordinates are often unwilling to share information even to the detriment of the organization. Subordinates are also unwilling to risk suggesting innovative ideas for fear of castigation (Conniff 2005 pg. 113).

For leaders wishing to change the culture into one that is more supportive and engaging there are certain behaviors they must watch. The posture, vocal tone, and facial expressions are often the signals that subordinates observe. If the tone is warm and the body posture is inviting then the subordinates will respond accordingly. However, if the body language is imposing and the tone is harsh then subordinates will also respond based on those signals (Conniff 2005 pg. 119). This leadership style is typically viewed as an autocratic leadership approach. A harsh tone and intimidating physical presence will have an adverse impact on employees.

Collaborative engagement must be a principle that is applied at all leadership levels. The modification of the traditional culture will ensure the organization’s long-term healthiness. Collaborative management configurations and tactics will effectively engage the organization in a transformative way. Silos designed in a hierarchical structure must be eliminated and replaced with cross-specialty alliance. Anticipated outcomes include quality advancement and the mitigation of errors. Within this transformative silo, nurses and other healthcare professionals see themselves as integral to the overall healthcare mission. In addition to quality and safety, the wellbeing of the patient is central to all decision making (O'Grady 2011 pg. 36).

When considering transformative leadership nurses are aptly prepared for such a role. They have the capacity to display situational leadership due to their unique skill set. For example their direct engagement in patient care allows for enhanced skills in the areas of coordination, integration and facilitation of workflow practices. They also have a general understanding of how the various clinical disciplines will impact the patient and how to ensure quality care. Nurse leaders are especially equipped with the ability to implement whatever workflow improvements are necessary to increase access and value in the patient-centered culture (O'Grady 2011 pg. 34).

Where nurses and other clinical leaders may need support is in the development of other management and leadership techniques. What could be effective is in-service training on variable leadership strategies. Variable leadership or situational leadership encourages the implementation of an assortment of leadership styles (laissez faire, autocratic, or participative) based on the situation. It is generally understood as an adaptable form of leadership that would be effective when the leadership technique is appropriate for the cultural situation.

2.5.1 HISTORICAL VIEW (2 pages)

Historical views about healthcare from a patient-centered perspective are based on diverse belief systems. For example there are specific beliefs within the Western biomedical model that influence how care is provided. In contrast in the Eastern biomedical model there may be modifications in treatment based on the culturally specific disease model. There may often be a distinction between the traditional and indigenous healthcare approaches. According to Helman the factors that can impact illness includes a person’s habits or adverse emotional condition, or even the natural environment. Helman also considers social factors and supernatural occurrences such as God, destiny, and witchcraft (Vaughn, Jacquez, & Baker 2009, pg. 65).

When looking at the formulation of Western healthcare practices the causation of illness is often attributed to the individual or natural world. In contrast social and supernatural causes are often the proposed causation for non-industrialized groups. Also noteworthy is the fact that minority groups have a greater tendency to attribute supernatural factors to illness than White Americans. Both groups (White Americans and Minorities) seem to associate illness with factors such as interpersonal stress, lifestyle, and environment (Vaughn, Jacquez, & Baker 2009, pg. 65).

So what does this information reveal about healthcare from a historical perspective? When looking at the administration of healthcare services nurses who have a clinical background become more essential to administration. Nurses and other clinical staff that have a cultural awareness of the population they service become even more valuable. This does not negate or mitigate the value of physicians it simply indicates the importance of a well-rounded clinical team when treating patient illnesses.

There are two other historical factors that are worth noting at the present time. The first is that our current educational system which trains healthcare providers is modeled in a hierarchical system. Freire developed a participatory literacy model which he articulated in the book, “Pedagogy of the Oppressed” (1970). The overall premise of the book was an articulation of the idea known as the banking model. Banking is used as a metaphor to describe students who regurgitate information that is provided incorporating a formula of memorize and repeat (Vaughn, Jacquez, & Baker 2009, pg. 71).

The problem with this one-way form of educational engagement is that it creates passive students who often lack critical problem solving skills. In a dynamic healthcare environment such a learning approach is disadvantageous when dealing with a very dynamic and culturally diverse population. Those students become clinical staff ill equipped to provide equitable engagement within the healthcare setting, creating a sub-par healthcare experience for the patient (Vaughn, Jacquez, & Baker 2009, pg. 71).

Another historical factor worth noting is that often cultural context within a healthcare setting is influenced by learned social factors. What are needed are progressive social models that encourage greater collaboration and non-traditional approaches to communication. German philosopher and sociologist, Jürgen Habermas offered such a collaborative social model. His social model is applicable to corporate culture and can offer great insight. The Habermas social model is a blend of systems theory, logicality, and investigative beliefs. Although his approach incorporated Marx’s ideologies many concepts within Marxism were rejected (Vaughn, Jacquez, & Baker 2009, pg. 71).

The key concepts within the Habermas model included self-reflection and dialogue. In fact these components are understood as critical to member empowerment and a more equitable society. The antagonist in the story is the powerful government systems and corporations. They are accused of manipulating individuals and adversely affecting the needs of the customer. In this context Habermas views communication as a form of manipulation where customers are provided a certain message that may not be advantageous to them. In other words it is a one-sided message that only benefits those crafting the message (Vaughn, Jacquez, & Baker 2009, pg. 71).

In response the consumer should seek communicative action, which is understood as constructive dialogue. Such an approach is reminiscent of the mutual rewards Theory which appropriately proposes shared value among all stakeholders. By engaging in such transparent constructive dialogue the consumer becomes informed and actively engaged in a more equitable solution. This concept is especially applied to those healthcare workers who feel marginalized and uninformed, regarding administrative practices and policies. Locating both traditional and non-traditional channels for communication will ensure policy and cultural changes within the organization. Persistence is critical as some healthcare organizations may resist changing from current operational practices. Habermas encourages continuous action against such a hegemonic system. It is highly detrimental to a collaborative and innovative health care experience.

2.5.2 The Power Struggle between Doctors and Nurses

There is a normative tension between Doctors and nurses that can create a hostile work environment. What is fascinating about this power struggle in the healthcare arena is that there are both biological and external stimuli that can either positively or adversely impact the culture. For example Oxytocin is a natural hormone that is biologically created in the brain. It has the capacity to lower heart rate, respiration and blood pressure. It is typically stimulated by a small act of trust. This means that when leaders (i.e. Physicians and other administrators) are proactive in displaying acts of trust they can trigger the creation of Oxytocin (Conniff, 2005 pg. 26).

Social dominance is a concept that although invisible can have a tremendous impact on individuals psychologically. It becomes frustrating since most individuals do not want to feel like losers in a work environment. Despite this psychological frustration employees often consider an organizational hierarchy to be a normative practice. This resignation displayed by employees to comply with directives is evident both in body language and facial expression (Conniff, 2005 pgs. 86-87). Emotional contagion is the process of adopting the emotional mind-set of individuals around us. In healthcare, employees usually care for depressed and sick patients. Therefore if they are unhappy due to hostile or unequitable work situations then that depression becomes contagious to all healthcare workers (Conniff, 2005 pg. 216).

Most organizations have individuals with diminished creativity, who engage in little collaborative communication. In fact a significant portion of individuals have toxic traits whether they are aware of it or not (Lubit, 2004 pg. 3). Further, there is a distinct correlation between emotional intelligence and social proficiency. Success within an organization requires strong interpersonal skills that include a capacity to manage personal feelings. Individuals are encouraged to pursue expert counsel in order to insure they have proficiency in the area of emotional intelligence (Lubit, 2004 pgs. 4-6). Implicit is the fact that effective leadership includes the ability to seek to understand the emotional state of other co-workers. This could leave to construction of activities and the implementation of a leadership approach that considers all appropriate factors. It is important that organizations are cognizant of toxic managers and employees within the organization. Failure to quickly identify such individuals can result in a far reaching impact to the organization as a whole.

Historically there are numerous incidents where communication between physicians and nurses is unproductive. Especially in instances where the physician displays a significant level of narcissistic behavior, communication breakdown occurs. The consequence of such behavior is that nurses and other clinical staff ae often hesitant to challenge orders that may be inappropriate or pose a risk to the patient. The fear of retaliation or public disgrace in the healthcare setting is avoided (Vonfrolio, 2004).

The solution is not a snappy comeback, but rather the initiation of constructive dialogue that keeps the patient at the center of the conversation. There also needs to be communication of boundaries and what constitutes unacceptable behavior. Although this may initially be uncomfortable for nurses, the long-term benefit is the eventual elimination of condescending, abusive, and volatile discourse (Vonfrolio, 2004).

From a macro perspective there are two common issues that must be addressed when dealing with nurse and physician engagement. The first issue is communication. Currently there is unsatisfactory communication between physicians and nurses according to nurses. Nurses who conduct bedside rounds are often hindered due to busy schedules. In this instance a two-minute phone call can provide the physicians with the information necessary to stay abreast of customer condition (Secemsky, 2013).

The second step in effective communication is the notification by physicians of modifications in patient objectives. Patient objectives could include any medical documentation or plans of care including imaging or lab work. It is important to note that the signing of an order is insufficient communication by a physician as it does not enable nurses to provide critical feedback and ask questions for clarification. The third step in effective communication is to establish rules of engagement where physicians and nurses understand that questions regarding decision making are essential for successful patient care. In other words a physician should not take it personally if a nurse asks them a question or needs further clarification regarding provided care (Secemsky, 2013).

The second critical issue is seeking to understand the roles of other care providers. Going through medical school does not create a sense of awareness concerning the process that nurses go through in order to fulfill their job requirements. Not taking the time to ask nurses about some of the challenges that they face in the workflow can result in setting and communicating unreasonable expectations (Secemsky, 2013).

For example ordering scattered labs versus sets or asking nurses to unkink an IV are time consuming. Although they are necessary for patient care, if a physician is aware of other pressing demands then they will seek to minimize and not compound the nurses’ workload. Often the failure of physicians to gain better understanding of the nature of a nurses position is due to lack of respect for the clinical training. In many cases it is not just the traditional training that nurses go through, they often have advanced training and on-the job experience (Secemsky, 2013).

According to a recent survey targeting prospective patients, many felt the relationship between physicians and nurses was poor to average at best. This reality is further validates by 25% of physicians surveyed who acknowledged disruptive and hostile relations as a cause of significant concern. Hospital workers have gone on record to share instances of physical and psychological abuse within the workplace. The results of such conflict include staff burnout and emergent frustration. In contrast addressing such systematic issues can actually enhance patient safety, and employee satisfaction (The Advisory Board Company, 2013).

The Nursing Executive Center recently conducted a survey on discourse and cooperation in the healthcare field. There were approximately 1289 surveyed participants. Out of those participants approximately 97% identified some level of conflict between physicians and nurses with 31% acknowledging such negative engagement as being excessive. Subsequently only 3% of polled readers identified a positive or strong relationship between physicians and nurses, which is quite telling (The Advisory Board Company, 2013).

Statistical evidence would indicate the need for concerned healthcare organizations to consider conducting a SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis. As part of such an analysis there should be careful examination of all stakeholders with decision making capabilities. Those individuals with critical decision making capabilities should be held accountable for allowing unprofessional physician-nurse engagement. Obviously showing impartiality in the determination of consequences would ensure no employee felt singled out. There also needed to be a renewed sense of collaborative, cross-cultural communication by administration. Such an adopted philosophy would ensure the trickling down effect whereby equitable engagement became the norm.

The necessity for reconciliation and improvement in the doctor-nurse relationship is due to the essential working relationship. The common goal is extraordinary patient care, and this can only be accomplished by leveraging the collective experiences. Social ritual and etiquette are often unspoken and therefore not always critically assessed for appropriate levels of effectiveness. This dynamic is further compounded by the fact that there are often class and gender distinctions within the relational dynamic of nurses and physicians (Fagin & Garelick 2004 pg. 282).

Additionally there is often a disproportionate amount of focus on the perceived intellectual capacity versus the technical capacity of the healthcare worker. In other words the unspoken assumption is that the more schooling that a medical professional has, the more value they hold in the decision making process. This stands in staunch opposition to the reality that quality patient care requires competencies from individuals across the continuum of health care services (Fagin & Garelick 2004 pg. 282).

In many instances the inexperienced physician is completely reliant upon experienced nurses to become acclimated with certain patients and procedures. Yet despite this corporate experience the perception of power based on their roles and relevant disciplines does not change. This is not to indicate that physicians should not be afforded certain privileges and responsibilities proportionate to their position. It simply indicates that nurses are often underappreciated and the value they bring to the healthcare field is often not recognized (Fagin & Garelick 2004 pg. 283).

From the perspective of a learned behavior, many nurses have countered this corporate culture by simply deferring to the physician. Although there may be a public deferral by the nurse there may be the implementation of subtle techniques to accomplish critical decisions concerning patient care. These savvy nurses are rewarded by being lauded as consummate team professionals who display mutual respect. In contrast failure to show appropriate respect and deference results in minimal career growth opportunities. However this learned behavior is simply a surface response to more deeply rooted issues that must eventually be addressed. Not only have nurses learned unhealthy coping mechanisms, they have also given physicians false security (Fagin & Garelick 2004 pg. 283).

As long as physicians are open to critical feedback and input patient safety metrics will remain at the forefront of care. However, when nurses indirectly protect physician shortcomings and fail to challenge mistakes then everyone suffers. Equally damaging are instances when nurses refuse to defer to or acclimate inexperienced physicians with certain healthcare procedures. This can result in distrust by the inexperienced physician who feels that the nurse is trying to sabotage their success. Several interesting trends are emerging in the healthcare profession. This includes a shift in the gender-role dynamic where female doctors often deal with male nurses (Fagin & Garelick 2004 pg. 283).

There is another trend impacting the traditional nurse-physician role. Many nurses are moving towards specialized roles and clinical expertise. As a result, they are frequently seeking greater autonomy and mutual interdependence as opposed to dependency in the healthcare setting. Nurses are also starting to advocate more for a holistic approach to care that seeks greater levels of prevention, education, and management of chronic conditions. This results in resistance to incidents where physicians prescribe a healthcare solution that has a narrow focus when looking at healthcare solutions (Fagin & Garelick 2004 pg. 283).

According to another survey conducted in the United Kingdom Nursing Times Survey, approximately 50% of nurses felt their relationship with physicians was poor. The determining metrics were in the areas of power differential which can be defined as status, prestige, and economics. This was especially true in teaching hospitals due to the competitive nature. In the same survey 31% viewed their role with physicians as a subordinate one, whereas 42% viewed it as a partnership. Also, two-thirds of nurses feel that physicians misunderstand their role as evident by associated behaviors. Approximately 60% of nurses felt that they were not consulted regarding clinical decisions and approximately 50% did not feel physicians reviewed their notes. Naturally nurses felt a greater comfort level when engaging with junior physicians as it often placed them in a consultative role (Fagin & Garelick 2004 pg. 283).

David Hughes presented an interesting report on nurse and physician engagement specifically in the casualty department. However, Hughes points out the fact that within the aforementioned clinical setting diagnosis and treatment are responsibilities more closely linked to nurse tasks. This understanding is at odds with the traditional subordinate and manager role that is often seen in the physician and nurse interaction (Hughes, 2008 pg. 1).

The research project seeks to highlight the variant types of clinical tasks and associated resources that exist. Variant resources include space, skills, and ratios of labor force for example. The proposed suggestion is that nurses are engaged in the decision making regarding diagnosis and treatment in an increased capacity. There is also a proposal for a qualitative modification in the value-based relationship between nurses and other clinical staff (especially physicians). This is not to eliminate the existent of the necessary organizational structure as much as it is an enhancement of interpersonal interaction (Hughes, 2008 pg. 16).

The casualty department is an ideal contextual case study as there are critical decision making processes occurring continuously. Also, due to the short-term nature of most appointments the role of the nurse in diagnosis and critical decision making cannot be overstated. Therefore this contextual reality should be supported within the culture, including the development of associated policies and procedures. Failure to consider a qualitative shift will create a disparity between practice and theoretical framework. This could inevitably result in nurses being less inclined to continue operating in such a critical role (Hughes, 2008 pg. 16).

According to Goffman deferential behavior is not reflective of a single relationship, but rather is a microcosm of a collective disregard for appropriate interaction. Such blatant failure and disregard is the responsibility of those within the organization at every level. As previously mentioned the consequences include higher levels of safety risk in patient care. There are also the psychological implications as nurses are frustrated in the forced nature of subservience (Hughes, 2008 pg. 16).

Dr. Lubit wrote a book that addresses the dynamics of subordinates and toxic managers. Some of the setbacks that organizations have when dealing with toxic managers are the loss of incentives by employees, minimal creativity, irritability, resistance, and the desire to leave an organization (Lubit 2004, pg. 2). However Lubit (2004) further implies that toxic traits are existent in every team.

Further Lubit (2004) addresses the components of emotional intelligence, and personal and social proficiency. Personal proficiency involves identification of feelings relative to both strengths and weaknesses. Once feelings are appropriately identified then Lubit warns against inappropriate behaviors especially within a professional context. Social competence is the capacity to identify the feelings of others and operate effectively with other individuals. In the work place this is also understood as the development of soft skills. Working with others includes the formation of cooperative relationships which are understood as leadership skills (Lubit 2004, pg. 4).

Lubit also is bemused by the fact that we pursue advice on everything from enhancing a golf swing to presentation skills but avoid advice on interpersonal skills. Comparatively speaking the identification of personal emotions and dealing with others far exceeds the need to improve a golf swing. Particularly since these soft skills are not typically addressed during formalized education and training (Lubit 2004, pg. 6).

Toxic managers often display narcissistic personalities. The personality traits easily identifiable include arrogance, minimal empathy, and the devaluation of others. Based on their perception of reality they feel minimal restraint when it comes to aggressive, controlling and unethical behaviors. Through the process of personal counseling toxic managers can effectively learn how to identify and mitigate such behavior. This requires very specific and detailed mechanisms of intervention (Lubit 2004, pg. 8).

Further, there is not necessarily a direct correlation between elevated self-esteem and narcissistic behaviors. Often the exact opposite is true for the toxic manager. Their narcissism is often a result of a fragile level of self-esteem. Psychologically by devaluing others they feel more confident and powerful. It is a sad but poignant truth but must be deal with at the root level (Lubit 2004, pg. 17).

2.6 ORGANIZATIONAL CULTURES IN NON HEALTHCARE COMPANIES

The organizational culture of a non-healthcare organization has both distinct differences and similarities to the healthcare organization. Hagberg Consulting Group (HCG) (2003) conducted research on 59 diverse companies from around the world. One emergent pattern was the tendency for management to make critical organizational decisions without a clear understanding of organizational culture. This pattern or tendency represents an unhealthy trait within any organization and has the same toxic effect on employees. One subsequent hypothesis is that there is a direct correlation between employee productivity and satisfaction and their level of ownership in company decisions. Especially if the outcome of the decisions are adverse and don’t take into consideration employee perspective and valuable insight.

One positive management trait is the ability to observe external variables such as industry markets, competitive factors, and customer issues. While there is a noticeable deficiency in the area of the internal climate an accurate synthesis of external data is valuable. It enables companies to understand existent patterns and industry cycles. That industry insight naturally translates into specific strategies necessary for strong market positioning. However, the external awareness does not mitigate or lessen the importance of internal perception. The level of internal insight can determine the quality of management decisions, and fallacies about the particular business. From a valuation standpoint the quality of management decisions are often directly connected to the company’s equitable fiscal worth (Leader Values, 2003).

As part of the study HCG conducted a qualitative study known as the Cultural Assessment Tool (CAT). The CAT consisted of 120 questions and was conducted over a period of three years. The objective of the survey was to determine the difference in perception of organizational culture based on level of responsibility within the company. The results revealed diverse responses between senior, mid-level management, and subordinates (Leader Values, 2003).

The areas of distinct difference are significant and reveal areas of bias within corporate culture collectively. One component of the study addressed perception regarding decision making. Senior management had a particular viewpoint about the quality of decision making that was significantly different than employees. Senior and mid-level managers believe that they highly value and pursue employee feedback regarding key decisions. They are also of the opinion that they are open to constructive feedback and differing viewpoints. However, this opinion is not supported by employees. In fact employees have expressed that fair consideration and openness to other viewpoints are not accurate traits of management (Leader Values, 2003).

One of the most significant factors effecting the interaction between management and subordinates is the traditional organizational chart. Historically employees have been treated as subordinates and had a self-perception that they were only to fulfill functional roles. However, in the last twenty years employees have become more educated and now expect greater involvement in decision making. Barriers to increased involvement include resistance from management. Mid-level managers are possibly in the most precarious position as they are often uncomfortable with disagreeing with senior management (Leader Values, 2003).

Often the failure of senior management is the inability to identify their positional power and how that can adversely affect employee engagement. Therefore, it is up to senior management to set the tone for employee engagement. Employees for their part are hesitant to disagree with managers even if they have valuable feedback. The end result is often executive decisions that don’t consider the perspective of front line employees. This distorted view typically results in narcissistic behaviors leading to minimal risk taking and innovative behaviors (Leader Values, 2003).

While management incorrectly perceives the existence of a collaborative environment this is often incorrect. Conflict and nonconformity are necessary for innovation and management is uncomfortable with such behaviors. In fact management falsely assumes that lack of conflict and minimal resistance are a result of employee trust. In contrast employees are aware that risk taking is discouraged and even sharing poor performance observations is discouraged. Further employees don’t believe that management takes the necessary steps to mitigate conflict and incongruity. The perceived level of trust, and open expression experienced by management and subordinates is distinctly different also (Leader Values, 2003).

The culture is further compounded by adverse external factors such as layoffs and mergers. Employee skepticism is further compounded when presented with narratives about management’s unethical behavior. If management was wise they would place employee interest and feedback higher on their list. Not only does this result in more effective workflow, it can increase company morale (Leader Values, 2003).

In examining certain company decisions there are certain subjects where employees are completely uninformed. Comparative data reveals that executives are much more proficient at the interpretation of financial goals and future projections. In contrast the employees are often unaware of company financial data including goals, revenue, and profitability. Therefore the organization must share financial data, relevant non-financial goals, and the purpose of organizational activity. This will minimize the perception of employees that management is only concerned with financial matters and bottom line profitability (Leader Values, 2003).

Finally there are conflicts in the corporate standards and the establishment of individual performance goals. Management falsely assumes that employees adequately understand how personal performance goals are connected to broader business intentions. This leads to the assumption that employees are equally invested in ensuring daily activities support the broader business goals. Regarding quality of standards there is significant pressure for employees to quickly produce products or services. This manufacturing mentality creates unbearable pressure that can result in the implosion of employee and supervisor relationships. Employees are naturally observing management looking for unethical compromise of standards. Such behaviors will compound efforts to create trust and quality products or services (Leader Values, 2003).

The way to counter such false beliefs when it comes to the establishment of organizational goals is to establish a strategic form of communication. In regards to internal communication there are two models or viewpoints. The most popular approach is where communication is viewed as an occurrence that is present within a company. Metaphorically speaking the organization operates like a container where information is confined. A contrasting approach is where internal communication becomes the central hub for engagement of data and the establishment of value-based relationships. From those value-based relationships the establishment of organizational culture and values forms. This process is an organic combination of individuals, information sharing, interpretive analysis, practice, and purpose. In the evolution of present day organizations such engagement is critical. This is also where traditional practice can be evaluated objectively and when necessary appropriately modified (Berger, 2011).

Organizations have very specific goals that must be met. The first is the establishment of an organizational identify. There is an understood correlation between organizational identify and social identity theory. Social identity theory was proposed by individuals’ like Taifel and Turner as far back as 1976. This theory suggests that an individual’s self-concept is formed from their connection to affinity social groups. In contrast group identify seeks to define what characteristics makes a particular group different from other groups. These theories establish the foundation for certain situations where employees establish identities as part of an organization. Further Ashforth and Haslam discovered that communication is pivotal in the establishment of social identities which builds trust and common understanding (Berger, 2011).

Although organizations falsely assume that employees are engaged and vested in organizational goals, this is often untrue. The provided definition of engagement is the unbridling of complete energy and talents of individuals in a corporate setting. Although employee engagement has historically been an issue the importance of it is extremely significant now. Employees are inundated with a continually evolving workplace and overwhelmed with downsizing, restructuring, and corporate ascendancy issues. Quantitative data reveals that an engaged workforce creates 50 percent higher rates of productivity. Also, the retention rates of engaged employees is 44 percent higher than non-engaged employees. The benefit to the company is two-fold greater fiscal return and increased employee contributions (Berger, 2011).

Successful organizations effectively measure production standards and yet the results are often more premeditated than strategic and continuous. There are useful guidelines for conducting audits, developing surveys, and measurement tools established by Sinickas and Williams. There are also guidelines that enable organizations to objectively evaluate and validate program results and report relevant data. An organization should evaluate internal processes for developing cost savings measures, employee feedback, and business outcome measures. Critical business metrics include employee retention, throughput, customer approval, and various quality factors. Also noteworthy, is the importance of minimizing cycle time regarding mergers, acquisitions, and other initiatives that affect the culture (Berger, 2011).

Finally organizations need to evaluate the importance of leveraging social media for communication. A document known as the Cluetrain Manifesto urged organizations to implement the internet and intranet in cultivating stakeholder relationships. The value of a global conversation that is not limited by positional authority is encouraged. The capacity of an organization to circumvent traditional gatekeepers will result in increased creativity, leveraging the power of technology (Berger, 2011).

The Institute for public relations discovered the value of simultaneously integrating internal and external public relations programs. Internal relations programs enabled employees to be active participants in the establishment of networks through shared public relations projects. Externally when the community and other external stakeholders are able to establish value-based relationships with employees their perception of the organization is positive.

One case study outlining the importance of internal and external public relations programs is the 1990’s incident experienced by Brookhaven National Laboratory (BNL). Located in Long Island, New York the lab experienced a major crisis when a nuclear reactor leaked tritium (a radioactive chemical). The result of the public announcement environmental activists began protesting and the lab was subject to negative news including an unwanted story on a television talk show (Montel Williams) in 1998. Although the lab conducted an environmental investigation that revealed the actual volume of leaked tritium amounted to a 10^th of water, the public’s perception was guilt by association (Rhee, 2004).

Since BNL is one of the foremost laboratories for the Department of Energy they realized they needed to do something to regain the public’s trust. Therefore they terminated the existent contract with Associated Universities, Inc. and hired Brookhaven Science Associates (BSA). BSA was a conglomerate formed by Battelle and the State University of New York. The principle task of BSA was to repair fragmented relationships with the community. The two prong approach utilized included the enactment of pilot programs and the augmentation of present programs. The desired outcome was achieved three years later in 2001 when the lab was awarded Organization of the Year. The award came from the International Association for Public Participation (Rhee, 2004).

The salient point is that the implementation of these programs involved significant employee engagement. The three applicable programs implemented were the Community Advisory Council (CAC), Envoy Program, and the Summer Sundays. The CAC was a program established following the environmental debacle that occurred between the years 1997-1998. The members of the group were stakeholders that included local activist groups, civic associations, and employees. The CAC which meets monthly has become a platform and vehicle for ensuring the interests of the Brookhaven National Laboratory’s (BNL) communities are at the center of the decision making process. Specifically decisions related to critical policies and operations concerning the environment and public health matters (Rhee, 2004).

The Envoy program was a vehicle that enabled companies to identify existent relationships that employees had established outside the organization. The stated goal of the Envoy program is to inspire and solidify two-way, face-to-face personal engagement between Brookhaven National Laboratory staff and critical public opinion leaders. Each envoy is provided with an issues notebook that has BNL data such as press releases, fact sheets, reports and newsletters. This notebook provides critical information enabling Envoy’s to respond to community inquiries concerning the lab (Rhee, 2004).

Summer Sundays provides an opportunity for the community to truly interact with the lab through various platforms. It is an outreach program consisting of tours of the research facility, interactive educational science shows, and the opportunity for the community to engage. Approximately 500-1500 community members are also able to interact with scientists and their families on an annual basis (Rhee, 2004).

When considering the value in interaction between an organization, para-organizations, and the community there are many models. As such, one recommended model is the cascade model. This model is structured based on the assumption that messages trickle down from the top of an organization. Metaphorically speaking it is similar to a sprinkler spreading water to moisturize a field. In the healthcare field one important initial step is the determination of where cultural messages will originate from. Suggested sources include the policy and procedures committee or the customer account manager. As the message trickles down throughout the organization it is important that there is consistency (Jordan, 2006).

Although the specific information that is communicated will vary it typically includes training programs, emergent projects, ingenuities, beliefs, tenets, and vision. When such information has been identified as originating from the top it is considered as coming from an authoritative source. Another value of it originating from the top is that the message can be communicated to the most appropriate individuals for that specific message. Also, there is a systemized process for communicating the message which ensures that all employees operate with a greater level of awareness (Jordan, 2006).

When an organization considers the establishment of procedures and company policies, flexibility and homogeneity are critical. Empirical data such as profitability statistics, market forecasts, competitive analysis, and production information. Also, an assessment of pending business deals and acquisitions are noteworthy. Each organization will interpret and use such quantitative data according to their corporate philosophy. Such measurable data is only useful to the degree it is an integral part of the community practice. There has to be a clear application of how to incorporate such practices in the workplace (Jordan, 2006).

According to the Opinion Research Cooperation (ORC) greater than 50% of employees are dissatisfied with downward and upward communication. ORC has conducted interviews on corporate employees for fifty years, accumulating insights on internal communication. Horizontal and diagonal communication is types of dialogue that are not as frequently discussed. Approximately half of communication involves listening which is vital to learning, understanding, and conflict resolution. Listening is also useful in the areas of team work, employee morale, and retention (Jordan, 2006).

In a report that examined employee silence there were fundamental reasons identified for failure to communicate. In instances where employees want to discuss organization issues they are often hesitant to divulge such information. There were approximately 40 study participants representing a variety of employees from different organizations. The most significant reason provided for employee silence was the fear of being identified in a negative way, or punitive consequences for speaking out. This begins to shed light on how social and relational assumptions can impact employee behavior (Milliken, Morrison, & Hewlin, 2003, pg. 2).

When examining the interaction between subordinates and supervisors there is a direct correlation between the perception of power and the level of employee engagement. There are identified assumptions associated with the existent hierarchical relationship. According to Festinger (1950) the process of structuring groups into hierarchies inherently creates a culture of restraint. Criticism that flows from the bottom to the top is discouraged and subsequently avoided. Further, Athanassiades (1973) implies that such a response to a hierarchical organizational structure is considered self-protective behavior (Milliken, Morrison, & Hewlin, 2003, pg. 4).

One of the other drivers in addition to self-protective behavior is the desire to maintain high mobility aspirations. If an employee considers a supervisor to be untrustworthy then they are even more prone to refrain from behavior that could appear threatening. Argyris (1977) identified influential norms that become embedded within organizations and reinforce employee lack of authentic communication. For example if an organization is intolerant of criticism and dissent, employees interpret vocalizing opinions as creating conflict. Further, Hirshman (1970) introduced a model known as (EVL) exit, voice, and loyalty. According to the EVL model although voice is a viable response to displeasing conditions, it is typically not the option selected (Milliken, Morrison, & Hewlin, 2003, pg. 4).

In comparative surveys 30% of employees were afraid of labels such as troublemaker or complainer. This fear is valid especially given the fact that such labels could remain with an employee throughout the duration of their employment. Also, there were fears associated with maintaining important relationships. Approximately 27.5% of employees were concerned that critical discourse could impair relationships with individuals that have information necessary for completing work. Another concern was regarding the ineffectuality of discussion that would not ultimately lead to corporate change (Milliken, Morrison, & Hewlin, 2003, pg. 13).

2.7 COMMUNICATION AND PATIENT SAFETY

Presently there are communication issues between nurses and physicians which lead to minimal staff productivity. Often nurses have difficulty identifying the appropriate physician to contact and the preferred method of communication. According to one survey 375 nurses working in long-term care facilities in Connecticut often would not receive timely call backs for physicians. Although there may eventually be intervention by a nurse manager or another physician delays in patient care may occur. The result is often deplorable productivity, staff disenchantment, and deteriorating clinical circumstances. Diminished productivity is further realized in another study where 40 percent of nurse worktime was spent trying to connect with physicians for consultation regarding patients (Shannon & Myers, 2009).

A three pronged strategy is recommended to improve nurse-physician communication and avoid potential gaps in care. The first prong is identified as cultural change which is understood as patient centric, safety-centered, collaborative, and supportive. It is vitally important that leaders are advocates of the process of cultural change. The Joint Commission recommended a central focus on the needs of the patients. As the patients’ needs become the primary focus then physicians will desire to create a continuum of care that is safe and effectual. Since nurses are part of that continuum of care the belief is that physicians will begin to have a greater respect and affinity towards them (Shannon & Myers, 2009).

Administration should consider several strategic steps in order to ensure authentic communication and collaborative teamwork is occurring. Appropriate policies must determine how the organization will deal with disruptive physician behavior. Also, the organizational structure must be guided by philosophies of respectful engagement and alliance. This is significantly improved as nurses and physicians each have platforms for knowledge sharing. Dialogue between nurses and physicians must also allow for authentic sharing of conflicts in order to eliminate negative interpersonal dynamics (Shannon & Myers, 2009).

Healthcare organizations should also develop nurses by providing continuing education, opportunities for involvement on multidisciplinary committees, and specialty certifications. One recommended certification is Magnet designation which is focused on enhancing work environments. Nurses working in Magnet designated hospitals have reported better engagement levels with physicians. Also the establishment of interdisciplinary patient care teams will ensure better coordination of patient care. In addition to the aforementioned strategies there are useful communication tools. One such tool is TeamSTEPPS, which addresses four critical competencies.

Governance, situation checking, reciprocated support, and communication are the areas that TeamSTEPP’s focuses on. The program was a collaborative effort by the Department of Defense and the Agency for Healthcare Research and Quality. Team-based communication is further enriched with the SBAR tool. This is described as a systematic way for care providers to huddle and share critical information relative to patient care. The SBAR is a standardized process that outlines the Situation, Background, Assessment, and Recommendations. SBAR enables the nurse to quickly share a comprehensive report with the physician for recommendations (Shannon & Myers, 2009).

Communication must also include use of standard email, text, phone, and descriptive notes in the EMR (Electronic Medical Records). In order to ensure patient privacy and HIPAA (Health Insurance Portability and Accountability Act) compliance, a secure network must be utilized. Another communication tool that should be considered is a wireless, voice controlled system. This allows for physician and nurse dialogue while maintaining bedside support. An effective communication platform standardizes communication between stakeholders. It also addresses any barriers that are existent within the normative workflow. Healthcare organizations must enhance organizational culture, implement appropriate communication tools, and ensure the communication platform is secure and efficient. By appropriately addressing these concerns effective nurse-physician engagement will occur (Shannon & Myers, 2009).

2.8 BENEFITS OF ASSERTIVENESS TRAINING

Before beginning conversation about assertiveness training there must be an understanding of the purpose. Assertiveness training is a response to the historical and prevalent issue of nurse abuse. The issue of nurse abuse has been alluded to and attributed to various factors within the medical field. Presently there are approximately five or six categories relative to nurse abuse. The categories include nurse-to nurse abuse, physician to nurse abuse, administration to nurse abuse, environment to nurse abuse, financial abuse, and media abuse (Swirsky, Stearley, & Vonfrolio 1996, pg. 31).

Within the context of the nursing profession there are countless hours, critical life-and-death decision making, ethical decisions, and a multiplicity of demands. In such a demanding environment there are often abuses that occur from home health care, hospital, ambulatory care and even physician-office nursing. Although nurse abuse has long been an unwanted reality within the profession there is little information about what constitutes abuse. A synthesized understanding of nurse abuse is the mistreatment, neglect, exploitation, and devaluation of nurses. However, in review of existent literature there is a desire to gain an expanded understanding of abuse. In reality it is a systemic disease that unless detected will leave damaging effects that are far reaching (Swirsky, Stearley, & Vonfrolio 1996, pg. 32-33).

According to Swirsky et. al, the abuse of nurses begins from the point of engagement as a student nurse. During the educational process there is often the elimination of a social life as the focus is retaining information in a wide range of subjects. Those subjects include everything from biology, chemistry, psychology, and psychology. The academic stresses and demands of nursing students are not readily identified as abuse. However, the environment creates the condition where nurses begin to accept a culture of compounded stresses (Swirsky, Stearley, & Vonfrolio 1996, pg. 37).

As previously mentioned nurse-to-nurse abuse is often a by-product of the different programs that are offered. From LPN’s to RN’s there is an unspoken caste system that exists within nursing, based on divergent educational backgrounds. Within the field of healthcare animosity is often a result of the value that organizations give to nurses. In the 1980’s it was the R.N who was viewed as a central position driving the Total Patient Care delivery model. In contrast the model shifted to a focus on economics where the LPN and the nursing assistants became the central positional focus (Swirsky, Stearley, & Vonfrolio 1996, pgs. 38-39).

Further there are efforts by physicians to de-license certain nursing activities in order to be able to pay less per hour for the same tasks. The danger of such an approach is that the patient morbidity and mortality rates are adversely affected. Disparate viewpoints regarding which nurse (i.e. RN with a baccalaureate or masters, BSN, etc.) is most qualified often occurs. So in an environment where sexism, animosity, and job related stresses exist, nursing abuse occurs (Swirsky, Stearley, & Vonfrolio 1996, pgs. 39-40).

The existence of Physician-to-Nurse Abuse has been prevalent throughout the history of medicine. In fact according Lovell (1981), many nurses are unaware that they are under the control and domination of a system of medical patriarchy. A description of abuses faced by nurses includes condescending attitudes, public humiliation, and temper tantrums by physicians. It often appears to be a double standard as nurses who displayed similar behaviors as physicians would find themselves disciplined or unemployed. Healthcare organizations have elevated nurses from a servant role to an interdisciplinary caregiver. However, they are still viewed as subservient to the position even though they are instrumental in facilitating numerous facets of patient care (Swirsky, Stearley, & Vonfrolio 1996, pgs. 42-43).

Administration-to-Nurse Abuse is possibly the most significant form of abuse extant today. Critical areas of abuse include salaries, hours, employment, and a genuine sense of respect. In surveys conducted and distributed to nurses, administrative abuse ranks extremely high in terms of job discontent. Often nursing positions become eliminated due to Diagnostic-Related Groupings (DRG’s). What is disconcerting is the fact that while nursing positions are eliminated administrators often receive perks and bonuses. Incongruously, DRG’s have resulted in a gap in care that can only be filled by skilled nurses. Moving into the 21^st Century the need for skilled nurses will only increase due to long-term care for elderly and chronic patients (Swirsky, Stearley, & Vonfrolio 1996, pgs. 44-45).

Nurses must come together either as a union or a nursing organization in order to leverage power and gain a voice. Institutions often focus on spending millions of dollars fighting the unionization process rather than improve conditions. Additionally nurses often are given job duties that are outside the normative scope of job duties. Such roles include housekeeper, secretary, transporter, dietician, police officer, and handyman (Swirsky, Stearley, & Vonfrolio 1996, pg. 46).

Also the projection of required nursing staff is often insufficient. Although nursing administrators use software that measures routine nursing duties it does not consider other relevant variables. Emergencies, family engagement, and preparation for diagnostic procedures are also part of the daily duties. When these unanticipated demands occur then the nurses must respond resulting in understaffed hospitals (Swirsky, Stearley, & Vonfrolio 1996, pg. 47)

Although difficult to envisage the physical and environmental abuse of nurses is a common reality. Often the abuse is undetected and nurses who seek job security may not readily reveal existent data. For example one study predicted that two nurses will lift approximately two and a half tons of patient weight in the span of one hour. According to another study with 500 participants, approximately half acknowledged back pain associated with work. Many also added that the pain typically lasted fourteen days or more. What is even more alarming is that 83 percent of the surveyed nurses were under 30 years old. The three activities that are attributed to the back pain include lifting patients, assisting patients out of bed, and moving a bed. In hospitals where there is a shortage of nurses there are greater incidents of injuries (i.e. foot and leg ailments, cervical strain, and tendinitis). Instead of the organization seeking to address the causative factors and variables the nurse often takes the brunt of the blame. Also, healthcare organizations rather than focus on risk management they often pursue avoidance (Swirsky, Stearley, & Vonfrolio 1996, pgs. 50-51).

Another form of environmental abuse is that which is resultant from psychotic, or drug induced, or confused patients. A patient under such a condition can respond by punching, kicking, and even engaging in strangulation attempts. Other existent hazards include X-ray machines, radiation implants, and radioisotopes used for tests. Also, bacterial and viral agents are copious in health care. Additional dangers include bacterial, viral agents, and exposure through blood, sputum, and excrement. Nurses have some protection due to the OSHA right to know regulations. This requires hospitals to produce material safety-data sheets, educate staff about hazardous chemicals, and provide protective equipment including googles, face masks, and respirators (Swirsky, Stearley, & Vonfrolio 1996, pgs. 54-55).

The Psychological impact of abuse is far reaching. Some of the associated defense mechanisms include introjection (internalization), identification, projection, and reaction formation. Additional defense mechanisms include displacement, rationalization, regression, denial, and sublimation. Since the unconscious mental activity associated with trauma and abuse occurs in a work setting it can be detrimental to patient care. For example, according to Freud repression can lead to psychological strategies that are often irrational and unsafe. If a nurse or medical staff is dealing with psychological pain and repression then work-related stress can trigger dangerous behaviors. Such behaviors can include lashing out, displacement, and minimal engagement in the work place (Swirsky, Stearley, & Vonfrolio 1996, pg. 120-121).

Author Natalie Shainess in a book called Sweet Suffering outlined defensive maneuvers and the need for others to identify self-defeating signals. Some of the signals include capitulation, accommodation, letting others off the hook, covering up excuses of others, excessive apology, and avoidance of questions. Women who are nurses are often unable to identify or clarify needs when in this condition. It is up to organizations to have mechanisms in place including counseling services, and platforms for collaborative engagement to change oppressive and unhealthy workplace environments (Swirsky, Stearley, & Vonfrolio 1996, pgs. 132-133).

In terms of solutions there needs to be systematic change in a number of areas. One of the areas that change needs to occur is in the academic arena. Educational policies need to incorporate goals that will enable nursing students to be able to transition into the bureaucratic healthcare environment. Educational policies need to reflect social shifts, changes in economics, feminist philosophy, technology and law. The educational institution can begin by implementing training and classes that train and inform nursing students on the aforementioned areas. In present nursing schools for example there needs to be a basic review of legal channels to address human resource grievances (Swirsky, Stearley, & Vonfrolio 1996, pg. 151-152).

Although we have addressed abuses in healthcare from a number of perspectives there is another important statistic. Some reports have suggested that approximately 80 percent of physicians are men while 97 percent of nurses are women. Although this statistic may have since changed the disparity is significant and revealing. This would explain why in many instances what begins as an organizational or positional struggle can easily morph into a sexist power struggle. Within the context of the existent power struggle there are also incidents of sexual harassment. In fact one example is the Stanford University neurosurgeon Frances Conley who resigned her position to protest the appointment of a male chief of neurosurgery. Conley believed that such an appointment would propagate sexism in the workplace (Chenevert, 1994 pg. 31).

Another disturbing example took place over the course of a decade and gained national prominence in 1993. The incidents occurred at the Veterans Affairs Medical Center in Atlanta and involved an assortment of inappropriate sexual advances including comments, touching, touching. The women who were victims had a dilemma since complaints needed to be filed by those supervisors who were the perpetrators. Women are often hesitant to dialogue with male counterparts (i.e. physicians) in a way that could appear assertive. In contrast men who become nurses have an inborn and socially accepted level of assertiveness. Therefore assertiveness training needs to be provided for women, in order to ensure they have an active voice. In the 21^st Century if male and female healthcare providers utilize assertiveness training, then the result is constructive dialogue (Chenevert, 1994 pg. 32).

The assertiveness training outlines basic rights for women that include the following:

Ten Basic rights for women in the health professions

1. The right to be treated with respect

2. The right to a reasonable work load

3. The right to an equitable wage

4. The right to determine their own priorities

5. The right to ask for what they want

6. The right to refuse without making excuses without making excuses or feeling guilty

7. The right to make mistakes and be responsible for them

8. The right to give and receive information as a professional

9. The right to act in the best interest of the patient

10. The right to be human

Source: (Chenevert, 1994 pg. 44)

According to one nurse she was being criticized by a physician for the method of care when dealing with a patient diagnosed with decubitus ulcer. The physician specifically disliked the method for putting on the dressing. When the nurse asked for a demonstration the physician discovered the difficulty and the nurse discovered he had a weak stomach. In another testimonial a nurse lamented the fact that she was exposed to elevated levels of radiation. Although she was aware of the contact she regretted not being more assertive regarding precautions and the time of exposure (Chenevert, 1994 pg. 46).

A survey conducted by Dr. Jonathan Freedman, professor of psychology at Columbia University further revealed existent disparities. The report polled 2000 physicians, patients, and nurses for a survey size of 6000. The objective of the self-assessment survey was to determine the perceptions that physicians had about nurses and vice versa. Resulted revealed that 87 percent of physicians considered nurses easy to work with but did not respect them. In contrast nurses respected physicians but did not feel they were easy to work with. This contrary perspective further complicated the work relationship and respect level between nurses and physicians (Chenevert, 1994 pg. 46).

One of the recommendations of assertiveness training is to speak up when your well-being is at risk or you are not properly respected. Part of respecting oneself is obtaining critical information about job duties or relevant tasks. Complete reliance upon others can result in distorted information and disrespect from others. Another recommendation is to communicate any personal feelings, particularly if they can hinder work performance. Given the fact most healthcare professionals work in a collaborative environment having mutual respect is vital. Also it is important not to internalize words like superior to the point an individual feels inferior. When there are those within a profession (i.e. nursing) who have advanced degrees it’s recommended that a nurse initiate compliments (Chenevert, 1994 pg. 31).

Another area where assertiveness training is necessary is in the area of workload. Chenevert mentioned a nurse who was exhausted from various calls and took her phone off the hook. At 6 am she found a police officer at her door who instructed her to call the hospital because they were trying to reach her. Such a story highlights the systemic issue of recurrent staffing crisis. Nurses respond to such stress in numerous ways including burnout, working in a disengaged manner, and even quitting. Physical attributes that are indicators of burnout include dull eyes, slouched shoulders, and little resistance to the status quo. To make matters worse it is often difficult or even impossible to delegate certain tasks that ease labor concerns (Chenevert, 1994 pgs. 48-49).

Many healthcare organizations must accept responsibility for unendurable work loads of employees. In many instances healthcare organizations reward high performing employees with more work, and underperformers with less work. However, such a response does not aptly address the issue of performance. At a certain point there needs to be greater focus on additional training for low performers, and strategies to ensure nurses and other healthcare professionals don’t burnout. There are at several ways that employees respond to the issue of heavy workloads. One employee response is to simply take on the additional work and compensate by putting in extra hours. This is dangerous as it often results in physical and mental health issues. Nurses and other staff must ensure that delegation is taking place whenever possible to ensure shared workload. Another response is for a nurse or other staff to simply get frustrated and either reject the additional work assignments or eventually quit. The bottom line is that women in healthcare need to be aware of their rights and fight to maintain those rights (Chenevert, 1994 pgs. 49-50).

When looking at assertiveness there are four associated levels. The first level is remedial assertiveness. This is understood as unwillingness to say no, and is normally associated with employees displaying low self-esteem. In many instances the person with remedial assertiveness prefers allowing others to define goals and does not communicate desires. The external locus of control is typically hourly or daily planning. The second level is basic assertiveness which occurs when an employee begins to value their own time, capacity, education and skill sets. They are able to handle basic conflict with ease. An employee with basic assertiveness is also comfortable defining and executing their own goals. The external locus of control is usually monthly or yearly planning (Chenevert, 1994 pg. 149).

The third level is advanced assertiveness. This is defined as someone who displays high self-esteem and the individual is at also at ease saying no. There is also an independence and existence of self-directed behaviors, which allows the individual to recognize and chose from available alternatives. The internal locus of control is usually anywhere from 3-10 years of planning. The fourth level is beyond assertiveness and that is defined as someone who has a high esteem for others and also delights in saying yes. As such there is a constant movement towards inventive alternatives which makes them attractive leaders. Naturally others seek their counsel and advice as they are a good sounding board. Ultimately those within the nursing profession and healthcare in general should seek to eventually get to the stage of beyond assertiveness. At this stage there is a level of freedom combined with clarity of lifetime goals (Chenevert, 1994 pgs. 49-50). One assumption that can be made concerning this level of assertiveness is that such individuals are continually achieving success.

2.9 CONCLUSION

The objective of this report has been to challenge the existent healthcare culture. Currently in many healthcare organizations there is a myriad of issues that affect organizational results. The goal for healthcare organizations should be to assess the results that they are getting and seek to improve on the existent model. One tool helpful in the establishment of an appropriately designed culture is the Results Pyramid. This is a visual tool that examines the components of organizational culture experiences, beliefs, and actions. Essentially and organizations collective experiences and beliefs will dictate subsequent actions (Connors & Smith, 2011 pg. 11)

The leadership within an organization becomes the catalyst for implementing the theories central to the Results Pyramid. The Results Pyramid is an effective tool in ensuring that the culture creates the desired results. A Results Pyramid also enables an organization to move from complacency to a culture of accountability. There are five principles that an organization must consider for bringing about full enrollment in transformational change. The five principles are as follows:

1. Begin with accountability
2. Prepare people beforehand for change
3. Start with the relative top and intact teams
4. Establish a control mechanisms and operate with honesty
5. Design strategies for maximum engagement and creativity

Source: (Connors & Smith, 2011 pg. 196)

The first principle accountability is requires an organization to establish and communicate clearly defined goals. An example is the Kimberly-Clark Health Care (KCHC) organization that was struggling with meeting budget targets for net sales and operating profit. Working with a consulting company called Partners in Leadership KCHC was advised to establish just three objectives. They decided to focus on net sales, operating profit, and gross margin. Those three goals began to penetrate the culture in various ways (Connors & Smith, 2011 pg. 197).

This included being printed on binders and being placed on labels and packages. As employees at every level of the organization began to buy in to the concepts the results were remarkable. Net sales exceeded prior year sales by 12 percent and budget by 10 percent. In addition, operating profit increased from the previous year by 65 percent and budget by 19 percent. As a testament to organizational success KCHC was also able to acquire two attract technologies as part of their portfolio of medical devices (Connors & Smith, 2011 pg. 198).

The organization must be cognizant of operating above the line and also incorporating the steps to accountability. When they operate below the line then they are subject to employees who display counterproductive behaviors such as the blame game. In contrast when they operate above the line then they are able to visually (see the goal, own it, solve it, and do it). Those philosophies of change will cause an organization to operate in a collective process of accountability. When there are issues for example within one department the solution emerges through cross collaborative, respectful communication. Qualitative tools such as surveys and face to face interviews will enable the organization to assess progress. The quantitative metrics will subsequently reveal how effective they were in achieving their organizational strategies (Connors & Smith, 2011 pg. 198-200).

The second principle is really focused on levels of ownership. It is with the understanding that cultural change is not a spectator sport it involves comprehensive organizational commitment. As such there are four levels of ownership when it comes to goal attainment. In the first level individuals within an organization either resist and or resent the requested change. Just because an individual does not express resistance does not mean that they are on board with cultural change. Administration must be sensitive to behaviors indicating such resistance. During the first level the minds and the hearts of the employee are still bought into the old paradigm of doing business. Perhaps an employee may say, “We have done it this way for years and I don’t see why we need to change our process.” Applied in a healthcare setting it could mean that a physician does not feel that nurses are underappreciated or that better communication and respect need to occur (Connors & Smith, 2011 pg. 203).

During the second level individuals either see themselves as exempt or make excuses. At this level there may be some level of agreement but that often does not lead to involvement. In other words the intellectual buy-in may be existent but emotional involvement is lacking. When an employee views themselves as exempt it is usually due to feelings of being overwhelmed. At this level of engagement an organization must remove barriers to buy-in. In a healthcare setting for example, this could include making certain cross-collaborative sessions or assertiveness training mandatory. Organizational change strategies must simultaneously focus on the components of agreement and involvement (Connors & Smith, 2011 pg. 203).

The third level is where the employee is beginning to engage the process intellectually and emotionally. They meet the aforementioned dualistic objectives of agreement and engagement. During this stage some employees may disagree with aspect of the requested change but their actions are based on their sense of corporate duty or loyalty. During this stage a company can assist such individuals by providing greater reasoning behind certain corporate goals. It is important that the company continues to re-engage such individuals to ensure that each person consistently improves. The fourth level there is complete buy in both emotionally and intellectually. The employees are committed to personal change and collective efforts to achieve company objectives. Part of the buy-in comes from the employee belief that implemented changes will produce positive and necessary outcomes (Connors & Smith, 2011 pgs. 203-204).

The third principle is beginning the process of cultural change from the relative top. Relative top is defined as cultural change that occurs within a division or team instrumental to policy or procedure establishment. In other words it is concerned with targeting leaders that have subordinates who are critical to successful implementation. It might be easier for an organization to begin the process within an administrative department for a predesignated period. Subsequently those changes will begin to expand until they are effectively implemented throughout the organization. What is fundamentally critical is that leadership operates at the fourth level of ownership. This administrative buy-in is signified by emotional and intellectual engagement and consistent actions. Resistance to change at any level by leaders will signal similar behaviors from subordinates and other employees (Connors & Smith, 2011 pg. 205).

The third principle is also defined by engagement by intact teams. Intact teams are groups that have historically worked towards producing cultural change. This is important because inevitably they will already have a significant lesson of trust with one another. In addition, there is already a level of peer-to-peer accountability existent. Intact teams can be effective in using the Culture Management Tools and associated skills. Once they have mastered the process and have obtained some initial results then they can help others within the organization (Connors & Smith, 2011 pg. 205-206).

The fourth principle is where an organization develops and implements control mechanisms. The development of such mechanisms is critical in order to change long-held beliefs and actions. In other words each employee has traditionally operated according to a traditional mindset. In order to change existent behaviors a paradigm shift must take place. In order for newly formed behaviors to be consistent process controls must be established. However, it is important to note that changing cultural beliefs requires self-management. In other words the organization is responsible for establishing the framework governing cultural change. However, it is the individual’s responsibility to then take personal accountability for the consistent implementation of those new behaviors. Cultural management tools enable individuals and intact groups to periodically gauge success levels (Connors & Smith, 2011 pgs. 206-207).

The ability of individuals and intact groups to identify cultural change is an internal process. At the same time there are indicators or milestones that will reveal levels of process change. One common process control is embedding the language of the tools and models. In other words there are new key phrases and terms that an organization uses in the new culture. The aforementioned tools are also naturally integrated into the workflow of the company. Another process control is the establishment of tools that track progress towards the stated goals. Organizations cannot afford to have actions towards stated goals (R results) without properly tracking them. Many organizations are only concerned with performance metrics both qualitative & quantitative (Connors & Smith, 2011 pgs. 207-208).

Another process control mechanism is the use of online assessment tools to capture insights regarding advancement towards the adoption of cultural beliefs. This can easily be illustrated within the context of a healthcare environment. Nurses and physicians can complete the assessment at period points of the cultural change process. The organization can then synthesize the feedback to gauge success levels. The assessment tool could reveal that employees have completely bought into the requested change (Connors & Smith, 2011 pg. 208).

Even if the organization does not initially see advancement in terms of bottom line profitability, it will eventually happen. Another process control mechanism is the development of milestones for process enactment and amalgamation. Leaders must ensure that they are not trying to completely dominate the cultural change efforts with too many processes. At the lower level of the Results Pyramid individual and collective experiences are important. As employees organically and consciously embrace the emergent ideologies they will become self-motivated towards fulfillment of stated objectives (Connors & Smith, 2011 pg. 208).

Another process control mechanism is the continual communication of the integration plan. Belief is maintained as employees at every organizational level see results begin to manifest. By consistently communicating the desired change, the targeted goals, and intermediary successes, individuals will increase personal ownership levels. The ultimate goal is to shift from a process centered approach to a principle centered process. In a process there is ongoing activity or operation that mandates a participant response. Processes are integrated throughout most traditional organizational cultures. In fact, the absence of formalized processes can often lead to corporate chaos and ineffectiveness. Organizations that lack processes have an inability to consistently duplicate service or product offerings (Connors & Smith, 2011 pg. 208).

In contrast principles are defined as fundamental philosophies for operational activity. In other words there is an existent structure but there is also significant flexibility. In order for companies to evolve and establish cultural change and innovation they must be principle-driven. Essentially there must be an appropriate level of process and principle. For example, one vital process is the establishment of enrollment in the proposed changes. Employees need to have specific and detailed steps for engaging the proposed process. Once there is a process for engagement then principles become the primary drivers towards achievement. This is important because every individual, department, and interactive group will have different roles or functions. An approach that is completely process driven may not be appropriate for every stakeholder to accomplish their job functions (Connors & Smith, 2011 pg. 208).

One example of how process and principle can work interactively is the story of the HSG Company. Although the northeast management company was committed to cultural change they were trying to assess the value of a new process called “storytelling.” The goal of the storytelling process was to celebrate moments identified as evidence of cultural shifts. However, they were getting feedback from employees indicating that behaviors illustrated in the stories were normative. They were trying to make sure that the stories represented cultural shifts, and yet did not appear unattainable. The solution that they came up with was to continue the storytelling process while offering critical feedback. So they kept the process of storytelling in place, but simultaneously incorporated critical feedback. It also kept employees thinking about and identifying what constituted exceptional cultural behavior (Connors & Smith, 2011 pg. 209).

In a healthcare environment as part of the team huddles storytelling could provide a great platform for authentic sharing. Nurses and Physicians could share examples where another employee displayed exceptional behavior. This would provide employees with opportunities to celebrate one another and also learn effective strategies for appropriate behavior change. Organizations like Kaiser have mastered the art of storytelling and they have even taken it to the next level. As part of their cultural shift they have incorporated acknowledgement of Every Day Heroes who make a difference in the lives of their patients. Not only do they acknowledge them within the hospital there are pictures sharing some of their stories hanging up in the Kaiser facilities (Howard, 2003).

According to the Director Jeffrey Weisz, MD it is important to acknowledge those individuals that are typically invisible. He further suggested that most heroes have a common trait and that is humility. They are driven by a sense of duty and that is something that is critical within the healthcare profession. Imagine how many nurses begin their professional career with a desire to be an everyday hero but due to toxic behaviors within the organization lose their momentum. The fact that they are nominated by coworkers, recognized by corporate leadership, and displayed on Kaiser’s hospital walls is significant. It communicates a message to all employees and patients of value and honor for those employees. Even those employees who are not nominated can gain important lessons. It subconsciously encourages all employees to strive for excellence every day in meeting the patients’ needs (Howard, 2003).

What is truly amazing about this process is that it involves the principle of honoring and sharing cultural expectations. However, it also has become a standardized process by taking the principle of honor and making it standard practice. By making it standard practice it becomes normative and able to be duplicated. In other words the expectation is that as employees continue doing their job in an excellent manner then there are rewards, acknowledgement, and even shared accountability. No longer will employees devalue each other because an employee can nominate another employee who may not even have the same job title. As a standard program there is even more perks and benefits from such a program. It can be a catalyst to inspire positive change and encouragement within departments as employees seek to uplift one another. Imagine if nurses and physicians rather than bicker and engage in power struggles sought to inspire one another?

As a program the Everyday Heroes can be honored with coverage in the local newspaper, acknowledgement on the Intranet portal, a pin with a logo display, and a certificate from regional leadership. This communicates to the employee that the value for their efforts is acknowledged at the highest level. It also ad’s something to their portfolio that can enhance opportunities for advancement and promotion. In this report there was discovery that employees often struggle with issues of low self-esteem (Howard, 2003).

Having such a program and acknowledgement can increase self-esteem and boost organizational morale. In a society where there are countless lawsuits and formation of unions, this could be a difference maker. While legal issues and employee work conditions will remain, this could mitigate an overabundance of unnecessary issues. Further, it could open the door to more constructive dialogue between key stakeholders such as physicians and nurses. This will ultimately lower instances of warring parties battling for position, power, and supremacy (Howard, 2003).

Another value of the Kaiser program comparative to other programs is that the visual representation is more permanent. Typically employee recognition projects are identifiable for a period of approximately one month and then rotate. In comparison the Kaiser program creates recognition panels that are on display permanently. Looking at this fascinating program further there are several interesting lessons. One is the power of coordinated efforts that begin at the top of an organization and then spread throughout the organization. In order to accomplish such a powerful display of employee recognition Kaiser Regional had to first buy into the value of an Everyday Hero program (Howard, 2003).

The stated values of the Kaiser Everyday Hero’s program are to promote the goals of quality and service. Once the goals of quality and service were established then the organization made an important decision to move forward. Since they are using professional photography then there has to be an outlay of costs and investment by the organization. Inevitably there also has to be a strategic planning process that includes ensuring the displays complement the existing architecture. The fact that these are real stories creates a compelling reason for internal and external stakeholders to stop and read the displays posted. This brings up another powerful benefit of the Everyday Hero’s program which is patient acknowledgement. If a new patient is unsure whether they selected the right healthcare organization then those displays are affirming (Howard, 2003).

Although individual accomplishments are important Kaiser also seeks to honor collaborative teams and efforts. One example is a group of employees at Mountain View pharmacy who respond to an assortment of patient needs. Pharmacist Amy Chih provides translation for multiple Chinese dialects. Pharmacy tech Jeannie Stamper provides stickers for children who come in, to let them know that all people in lab coats don’t give shots. Pharmacist Lucia Lim delivers medication to the elderly and disabled. This provides a valuable service to a population that would otherwise have difficulty obtaining services. This value of patient-centric service has permeated every component of the organization. In fact there is an army of senior volunteers that provide a support network for Kaiser Patients (Howard, 2003).

According to one report there are tremendous organizational benefits to empowering employees. Some of the identified benefits include enhanced work quality, employee satisfaction, collaboration, productivity, and costs. One of the most identifiable metrics of a healthy and vibrant organization is the work or service quality. When there is freedom and flexibility employees have a renewed commitment towards producing quality deliverables. One example is a company called HCL technologies. HCL’s empowerment philosophy included high quality customer service and engagement. The fiscal result of that commitment was triple revenues and a 73 percent increase in customer satisfaction over the last five years (www.saylor.org, 2013).

Another benefit is an increased level of employee satisfaction. Employees with greater organizational flexibility expressed greater satisfaction than companies with less flexibility and more traditional hierarchy. Within collaborative organizations employees readily identified problems, proposed solutions and are included in critical decision making. This article further enforced the idea that employees are empowered in a fun work environment where public recognition occurs. Increased employee satisfaction leads to greater retention and loyalty to the company. This inevitably leads to minimal product defects or substandard service issues. Collectively these factors ensure that the organization has improved profitability.

Another benefit of empowered employees is the value of collaborative engagement. When employees no longer feel threatened within an organization they are free to focus on positively impacting the organization. They also are more willing to share best practices which will ensure greater patient safety and efficient workflow. This is a logical response as employees who feel that their safety is threatened tend to withdraw. In contrast, confident employees have authentic dialogue that is guided by shared values and respect. The individual behaviors of empowered employees are contagious in producing teamwork. Teamwork is defined within this context as shared commitment to accomplish corporate goals. Successful organizations cannot achieve permanent success when the workforce is disjointed and non-committed (www.saylor.org, 2013).

Productivity is another quality that is found in empowered individuals and work groups. When employees feel increased obligation, accountability, and possession they give their best efforts. This is understood as an internal drive and commitment to meet deadlines, and accomplish organizational goals. Such empowerment does not occur by coincidence it is intentional. One case study of the value of employee empowerment is GE Corporation. GE incorporated a work-out program where employees were charged with the elimination of corporate waste. Instead of forcing employees to continue in activities that had little value they opened themselves up to constructive criticism (www.saylor.org, 2013).

Employees were charged with restructuring their daily tasks and processes, without fear of deleterious reprisal. The result was that employees throughout GE became energized and began to provide critical feedback that revolutionized the workplace. The result was that productivity elevated and GE became one of the most profitable and efficient companies in the world. By empowering their employees they facilitated the process of transformative leadership throughout the out the organization (www.saylor.org, 2013).

Another benefit of empowered employees is reduction of organizational costs. Reduced cost is a result of cumulative efforts that are impacted by many factors. For example as employees are energized and have an increased level of loyalty they contribute more. When there are employees that stay with an organization for extended periods there are less employee turnover costs. Also when employees are engaged and have greater accountability they are more inclined to save companies money. It is important to remember that front-line employees are more familiar with routine company functions. According to the Gallop Poll when organizations empower employees to recommend operational changes there can be profits as high as 27 percent or more (www.saylor.org, 2013).

Another benefit of empowered employees is that not only do they improve operational efficiency they can become customer advocates. As customer advocates they build relationships with customers and begin to gain trust. As they gain trust with customers then they are better able to understand and meet company needs. They can share critical feedback to corporate leaders who can establish policies that will address any customer issues. Ultimately that will lead to increased customer loyalty and retention. Increased customer retention results in lowered marketing costs necessary to obtain new customers. According to the same Gallop organization when employees are empowered there is a 50 percent higher level of customer loyalty (www.saylor.org, 2013).

In conclusion, the Healthcare field like every other industry is extremely competitive. Organizational change is not something that happens overnight. However, transformative organizations will seek the creation of transformative cultures. Transformative cultures will create powerful departments and divisions. Those transformative departments and divisions will be made up of transformative employees. This is the type of organization where physicians and nurses can work collaboratively. In a transformative culture there is buy-in, investment of time, energy, and resources. There is acknowledgement of each individual’s unique valuation at every level of the organization.

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