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CHAPTER 15

Day-to-Day Management for the Health Professional-as-Manager

CHAPTER OBJECTIVES

• Examine the dual role of the health professional working as a manager.

• Explore some potential problems and barriers often encountered by health professionals who enter management.

• Confirm the legitimacy of management, necessarily a second career for many health professionals, as a profession in its own right.

• Identify the nonmanagerial professional employee as a sometimes-scarce resource, suggesting a necessary focus on employee retention.

• Introduce the high-skill professional and review the special management problems of directing such personnel.

• Discuss several aspects of day-to-day management in which the manager must put more into the relationship with each employee because the employee is a professional.

• Establish the manager’s critical role as the essential link between the employees’ profession and the remainder of the organization.

• Address the need for the professional-as-manager to recognize the importance of self-development and active management of one’s own career progression.

A SECOND AND PARALLEL CAREER

It bears repeating that the professional who assumes a management role is adopting a second and parallel career of equal importance to his or her profession. Most such managers are well trained in their specialties but enter management with little or no preparation for running a department or supervising others. Lack of preparation and inadequate understanding of the requirements of the management side of the combined role often lead to uneasiness and indecision in management matters. This condition subsequently causes some managers to seek refuge in the familiar by emphasizing the profession at the expense of attention to management duties. The professionals who become most successful managers are invariably those who develop the ability to appropriately balance the sides of the dual role.

TWO HATS: SPECIALIST AND MANAGER

The professional who is asked to assume a management position is being asked to take on a second occupation and perhaps even pursue a second career. Management positions turn over as other positions do, and vacant management positions are often filled from within the ranks of the work group. There are both advantages and disadvantages to having a particular member of a work group step up to the position of group manager. On occasion, however, the new manager of a group will come from outside of the organization.

Although familiarity with the specific organizational setting may be helpful to the new manager, such familiarity is certainly not a requirement of a group’s new manager. There is one firm requirement of the individual who is to assume command of any work group: the individual must be intimately knowledgeable of the kinds of work the group performs. Because many work groups within the healthcare institution include professional employees and because the manager’s technical qualifications must essentially be equivalent to the qualifications found in the department, the career ladder of a professional may logically be extended to include the management of that specialty.

The professional who enters management must exist ever after in a two-hat situation. This person must wear the hat of the professional—that is, the technical specialist—and render judgments on countless technical matters concerning the profession. At the same time, this person must also wear the hat of the manager and effect the application of generic techniques—processes that apply horizontally across the organization regardless of one’s individual specialty. The professional in a management role must be both specialist and generalist. As a professional, the person is trained as a specialist in a particular field. As a manager, however, it remains largely up to the individual to recognize the need to become a generalist and to independently seek out sources of education and assistance.

The average employee who progresses from the ranks into management is usually well grounded in a working specialty. In this sense all employees—professionals and nonprofessionals alike—are functional specialists. For instance, the individual who works for several years in the housekeeping department, performs a variety of housekeeping tasks, and becomes a specialist in the work of that department brings all this experience into supervision when promoted. At the least, the nonprofessional is a specialist by virtue of experience.

Although the professional employee is usually also a specialist by virtue of experience, that is only a part of the professional’s qualifications as a specialist; the remaining criteria defining the professional as a specialist are education and accreditation. The professional entering management brings both credentials and experience to the job. In this regard the person is usually eminently qualified to wear the manager’s technical hat but may not be nearly as well qualified to wear the managerial hat.

The professional who enters management is usually extremely well trained in the specialty but trained minimally or not at all in matters of management. Healthcare professionals become professionals by seeking out appropriate programs, gaining entry to them, and working toward the necessary qualifications. In contrast, these same people become managers by virtue of organizational edict; that is, they are simply appointed. Precisely at this stage some employees and organizations commit a classic error—assuming that because people have been promoted and given appropriate titles, they are suddenly managers in the true sense of the word. Unfortunately, organizational edict does not automatically make a manager out of someone who is not adequately trained or appropriately oriented to management, any more than the mere conferral of the title could turn an untrained person into a nurse, an accountant, a biomedical engineer, or any other professional.

The professional entering management, then, is usually well trained in wearing the hat of the specialist and trained little or not at all in wearing the hat of the manager. Although each aspect of the role is equally important, and even though one side or the other may dominate at times, many such persons exhibit a long-running tendency that is fully understandable under the circumstances. This is the tendency to favor the wearing of the hat that fits best, leaning toward the one of the two roles in which they find themselves more comfortable.

By listening carefully to some of the common complaints of certain managers, it is possible to identify the aspects of the management job that lie at the heart of these complaints. Such complaints will then identify the individuals on whom the management hat does not fit especially comfortably. Common areas of complaint that indicate the presence of ill-fitting management hats include the following:

• Budgeting. As one manager complained, “Budgeting is an annual chore that seems to come around every 2 or 3 months.” If the management hat does not fit well, budgeting is likely to be a dreaded chore filled with frustration and only partly understood.

• Performance appraisals. Appraisals are also a common annual responsibility that seems to come around sooner than it ought to. When the management hat does not fit well, appraisals are likewise dreaded, tend to run late or perhaps not get done at all and may make the manager feel uncomfortable and perhaps inadequate.

• Employee problems. The essence of the management role is getting things done through people, which requires maintenance of the manager’s most valuable resource—the employees. When the management hat does not fit well, the manager may exhibit a tendency to shy away from people problems and resent them as intrusions that keep the manager away from the “real work.”

• Identification with the work group. “Listen, gang, I know I’m the manager of this group but don’t forget that my background is the same as yours and I’m a lot more like you than those people in top management.” The tendency to identify with the group and join with them in condemnation of the infamous “they”—as in, “It’s not my fault; they made me do it”—is another sure sign of the ill-fitting management hat.

• Disciplinary issues. Rarely is any manager completely comfortable with exercising the disciplinary process; indeed, he or she should never become completely comfortable with something of such importance. Often, however, out of discomfort the manager wearing the ill-fitting management hat will ignore disciplinary issues altogether or take action that is too little or too late.

• Personnel policies. The wearer of the ill-fitting management hat may have little familiarity with pertinent personnel policies and thus may simply tell employees to “call human resources” rather than help them answer policy questions.

• Work priorities. One sure sign of the ill-fitting management hat is the apparent inability to plan one’s work and establish priorities. The manager so afflicted will often seem to be spending each day reacting to crises or continually responding to the demands of the moment regardless of their relative importance.

• Delegation failure. The manager who is constantly juggling an overload because of inability to delegate, or whose behavior seems to be saying, “If you want something done right, you’d better do it yourself,” is wearing the ill-fitting management hat. This manager is failing to use staff to the full extent of their capabilities and is overlooking the important employee-development role of the manager.

This list could be longer, but the point is made. When such symptoms appear, the manager is feeling the pinch of the management hat, reacting out of frustration and insecurity, and taking refuge under the technical hat. Those processes that can be described as generic to management—because they apply across the organization regardless of the function managed, such as budgeting and performance appraisal—appear as mysterious, somewhat misunderstood activities. They come to be regarded as elements of interference rather than the vital elements of management. Disciplinary problems and other people problems are likewise seen as annoyances rather than as legitimate obstacles to overcome in the process of getting things done through people. What is seen as “real” work is the basic work of the technical specialty. Overlooked is the reality that the true task of the manager is largely to serve as a facilitator in the process of getting the real work done by the employees.

The signs of the ill-fitting management hat are numerous, and many managers continually take refuge under the hat of the technical specialist. This tendency is understandable considering the professional employee’s degree of familiarity with the occupation and his or her unfamiliarity and discomfort with some of the processes of management. Yet simply being aware of the likely imbalance between the two halves of the role should be sufficient to inspire some managers to improve their capability and performance in the management sphere. Both sides of the manager’s role are extremely important. A working knowledge of the technical specialty remains important at most levels in the health care hierarchy. Particularly in the lower levels of management, the generalist side of the role—that is, the management side—is neither more nor less important than the specialist side; it is simply different.

Although most managers in the healthcare organization’s hierarchy have a need to be both technical specialist and management generalist, just as there is a place in the working ranks for the pure technical specialist, so there is also a place in the management hierarchy for the pure management generalist. However, the few management generalists in the organization are usually found in the upper reaches of the hierarchy in positions of multidepartmental responsibility.

In the healthcare organization, administration is the province of the pure management generalist. Administrators of health institutions come from a variety of backgrounds, with many of them arising out of the management of certain specialties and having perhaps broadened their scope through studies in administration. It matters little whether the institution’s chief executive officer may have originally trained as an accountant, a registered nurse, an attorney, or a physician, as long as that person made the necessary transition from specialist to generalist while rising toward the top. Even so, it is rare to encounter, for example, a director of nursing service who is not a registered nurse, a health information manager who was not first a health information practitioner, a director of finance who was not an accountant, or a manager of physical therapy who was not a physical therapist.

A CONSTANT BALANCING ACT

Some professionals who take on the management of departments never completely adapt to the dual role of professional and manager and never develop an appropriate balance between the two sides of the role. Their behavior often sums up their attitude: once a specialist, always a specialist. Such persons tend to give the technical side of the role the majority of their interest and attention, their priority treatment, and certainly their favor. Never having become sufficiently comfortable with the management role to enjoy what they are doing, they take refuge in their strengths and minimize the importance of their weaknesses.

The dedicated professional often has far more difficulty than the nonprofessional in balancing the roles of professional and manager. The professional has devoted far more time, effort, and commitment to becoming a specialist and has probably done so at least partly because of an attraction to or an aptitude for that kind of work. Some may like their work so well that, although they do not necessarily refuse promotion to management, they show an inclination to subordinate the management side of the role so that it does not intrude too far into their favored territory.

Just as a liking for an individual specialties is important to success in one’s basic fields, so, too, is a liking for management essential for success in management. Usually a liking for a given activity is strongly influenced by one’s degree of familiarity or level of comfort with the elements of that activity. Quite simply, the more a person knows about a given activity, the more the person is inclined to like that activity. Conversely, an individual may be more readily inclined to dislike an activity that seems bewildering, strange, or discomforting.

It has been suggested that the professional who enters management faces the challenges of becoming grounded in management and getting up to speed. Once in management, the individual discovers that to remain effective both as a technical professional and as a manager, it is necessary to try to remain current in two career fields.

Staying current with the latest developments in a technical specialty is a sizable task in itself; getting fully up to speed and remaining current with the elements of one’s management role is an unending task, considering the scope and breadth of management. Often, both sides of the role suffer to some extent. Nevertheless, the technical side is more likely to receive most of the conscientious attention. The professional employed as a manager has all the problems of any other manager as well as most of the problems that confront the working professional who is not a manager.

THE EGO BARRIER

Probably few, if any, health professionals do not believe that their professions are of considerable importance to their organizations. This is to be expected; to find any significant measure of fulfillment in their work, healthcare professionals must regard their occupations as being of significant value to the organization and its patients. The potential for problems exists when an individual professional behaves as though his or her particular working specialty is more important than other occupations in the organization. If a professional who carries an inflated regard for the importance of a given profession happens to be the manager of a department, the potential for interdepartmental conflict is present.

Both generalist managers and technical-specialist managers can display self-serving tendencies at times. Managers, however, frequently differ in how they pursue their objectives of service according to whether they see themselves as generalists or technical specialists.

The generalist who is on a self-serving track often tends toward empire-building, working to acquire every function or responsibility that can in any way be connected under a common head. This manager is working toward elevation of self by achieving far-reaching control throughout the organization, much as some nations once extended their authority by acquiring colonies throughout the world.

The self-serving technical-specialist manager, by comparison, is often limited by the inability to absorb functions that are not technically related to the profession of the manager. Rather than building an empire, these managers act much like the feudal baron who remained in his castle but devoted most of his time and energies to making it the grandest and strongest castle in the country. That is, the manager strives to build an elegant structure whose glory will surely dwarf that of its neighbors. Thus the “most important” specialty eventually has the most well-appointed quarters, the most generous budget, the most favorable staffing relative to the amount of work to be done, and the strongest voice in influencing institution policy. These results convey the belief that the technical-specialist manager’s own profession is somehow better than the other professions in the organization.

Another ego-related problem to which the technical-specialist manager may fall victim, and one of perhaps significantly more impact than the preceding effect, is found in the tendency to place management in an inferior role relative to the profession. This may also appear as a tendency to consider the profession itself as so necessary to management that one could not possibly be an accomplished manager of anything without knowledge of this particular profession. The behavioral message sent by some technical-specialist managers is this: knowledge of my technical specialty is critically important in healthcare management. Therefore, it is implied that you must originally be a social worker, psychologist, registered nurse, physical therapist, registered health information administrator, or whatever to become fully effective as a manager in health care.

In fact, to become a well-rounded and effective healthcare manager, one need not be a social worker, speech pathologist, laboratory technologist, registered nurse, or any other healthcare specialist. It is automatically conceded that in all but the most general of support activities the manager must be some kind of specialist as well as a manager; in reality, no one specialty has a monopoly or even a modest edge regarding management expertise. The fundamental task of management—getting things done through people—is reflected in practices such as proper delegation, clear and open two-way communication, budgeting and cost control, scheduling, handling employee problems, and applying disciplinary action. All true management practices are transportable across departmental lines, and to believe otherwise is to fall into the ego trap of the technical specialist.

The professional employee who enters management is literally jumping into a second career. If a potential manager thinks of management as a profession—and to many people, management is, indeed, a profession of considerable breadth and depth—then he or she must recognize the necessity to enter management with as much preparation as possible. In their academic training, most professionals receive a few credit hours in management courses. On this basis, some then claim expertise as management generalists. But consider the reverse situation: assume that a student of general business managed to take a couple of social work courses (perhaps as electives) and after graduation claimed to be a social worker as well as a management generalist. The individual’s claim to social work expertise would be automatically rejected, of course. Yet time and again, the technical specialist who has had a management course or two lays claim to equivalent expertise in management.

To summarize, the ego barrier to managerial effectiveness can surface in two important dimensions:

1. An inflated view of the importance of one’s profession relative to the importance of management

2. The failure to recognize management, devoid of all implications of any other particular occupation, as a specialty in its own right

The obstacles presented by ego are overcome with great difficulty. In fact, in many instances they are never overcome. This is unfortunate because the most significant effects of the ego barrier are the tendency to place organizational interests second to departmental interests, and the proliferation and perpetuation of middle-management mediocrity.

THE PROFESSIONAL MANAGING THE PROFESSIONAL

The Professional as a Scarce Resource

From time to time, some healthcare specialties experience conditions of oversupply. Conversely, on numerous occasions many parts of the country experience shortages of certain skills, and organizations are forced to compete for the services of available workers. Once a department’s personnel needs have been met, however, the focus of the manager—and certainly much of the focus of the organization’s human resources department—should turn from recruitment to the important matter of retention. In short, when certain human resources are scarce, it is necessary to concentrate on keeping the people who are already in the organization.

Consider, for example, professional nurses. The management of professional nurses, especially in the hospital setting, has become increasingly complex over the years. Financial restrictions, technological innovations, professional labor unions, and the changing attitudes of nurses have had a considerable impact on the practice of nursing. In some parts of the country, the recruitment of professional nurses has become highly competitive and is likely to remain that way for some time.

The retention of professional employees is emerging as one of the more challenging tasks faced by health administrators. Where once it was possible to accept relatively high turnover among some professionals—for example, many nurses were seen as entering or leaving the work force essentially at will—organizations have been finding supplies of help drying up and have therefore turned their attention to reducing turnover. Thus attention naturally shifts to factors and conditions that have a bearing on job satisfaction, such as better pay scales, more generous benefits, more attractive schedules, additional compensation for less desirable assignments, a more clearly defined role for the professional, and a stronger voice in matters of patient care.

Generally, the healthcare organization should be interested in retaining employees who are functioning satisfactorily, but the organization may not be inclined to do any more about retention than has already been done as long as replacement employees are available. When a particular specialty is in short supply, however, an organization should do what it can to retain those skilled employees—but always within limits, because to take steps that seem to favor one class or group of employees over others is to invite trouble; what is done for one group is often done for others as well.

There are costs associated with active retention efforts; after all, improved benefits and generous staffing patterns certainly cost money. For specialties in short supply, however, the cost of retaining employees is not nearly as high as the ongoing cost of continually recruiting, hiring, orienting, and training replacements. It is true that some professionals may be considered scarce resources because of their limited numbers; even so, it behooves the manager to consider all steadily and satisfactorily performing employees, professional and otherwise, as equally worthy of the best efforts at retention.

The High-Skill Professional: Some Special Management Problems

The high-skill professional usually has extensive education, frequently possesses a master’s degree or a doctorate (medical or otherwise), and is likely to work in a position that entails the exercise of a great deal of operating autonomy. High-skill professionals found in health care might include the following individuals:

• An employed physician or dentist

• A professional administrator engaged to operate a hospital or to run a major organizational unit

• A certified public accountant engaged to audit the organization or perhaps to oversee the organization’s finance division

• A chemist, physicist, physician, or other scientist engaged in research or in day-to-day operations

• A management consultant engaged to solve a problem for the organization

Such persons have two obvious factors in common: they are extensively educated, and they are on their own much of the time in the performance of their work.

The high-skill professional often presents the manager with some special problems and unique challenges. Frequently these problems and challenges exist because of some of the same factors that contribute to the professional’s ability to perform as desired.

The high-skill professional may generally be described by some or perhaps all of the following:

• Like many employees, the high-skill professional is accountable for results; however, this person is primarily responsible for getting things done and then later, if at all, reporting the results. There is only limited or occasional need for clearing actions or decisions in advance. In this regard the high-skill professional possesses a significant degree of operating autonomy.

• The high-skill professional may have a great deal of geographic mobility, ranging throughout an entire facility or, as in the case of a management consultant or an auditor, from organization to organization and even from city to city.

• Being a solitary operator much of the time, the high-skill professional must consistently exercise individual discretion and judgment.

• The successful high-skill professional generally exhibits a high degree of self-confidence and independence of thought and action.

• The successful high-skill professional is a self-starter who is also highly self-sufficient in work performance. He or she is able to function with minimal supervision or direction, sometimes for prolonged periods.

In general, the high-skill professional is a highly educated specialist who largely operates independently, determining what needs to be done and doing it without direct management. Yet many of the same characteristics that make for an effective high-skill professional also tend to make such an employee difficult to manage at times. This is especially true of the characteristics related to independence—that is, those factors that make an individual an effective lone operator. Although it is certainly important to cultivate independence in persons who work on their own much of the time, at times even the lone operator must be counted on to be a team player.

Some might say that a person should also have a healthy ego to be able to presume to operate in a mode that can often be described as that of the visiting expert. The high-skill professional is, indeed, often viewed as needing to be in control of the situation. The healthy ego, so helpful to the professional while on assignment, can sometimes be troublesome to the manager, however. For these reasons, the successful manager of the high-skill professional must adhere to a number of guidelines:

• Be thorough and cautious in recruiting and selection, ensuring that educational requirements have been met and that all necessary credentials are possessed. For an experienced candidate, the manager should look for a demonstrated record of success and for sound reasons for wishing to make a change. For a newly graduated professional, the manager should look for self-confidence and a strong desire to do that particular kind of work.

• Try to learn what most strongly motivates the individual. Often the effective high-skill professional has a strong liking for the work and a strong desire for achievement and accomplishment. The best independently functioning professionals like the work, are driven to do the work their own way, and have a great need to see the results of their efforts.

• Pay close attention to the orientation of every new employee. Even the well-experienced professional, when new to the organization, needs to be thoroughly oriented to the organization, its policies, and its people before being turned loose.

• In addition to knowing the rules and policies of the organization, make certain that the new hire knows the results expected on each assignment. The manager should take care to thoroughly define the boundaries for independent action, such that the individual is able to develop a sense for how much may be done independently and when it is necessary to call for management assistance.

• Once the boundaries for independent action are established, give the professional employee complete freedom to operate within those boundaries. Strive to develop trust in the individual and, by reflecting this trust, endeavor to instill in this person the belief that management has confidence in his or her ability. Do not violate the boundaries by trying to dictate from afar; besides generally not working, absentee management serves to frustrate the employee.

• Introduce changes—whether changes in policies, practices, operating guidelines, or whatever—with plenty of advance notice. If at all possible, allow and even encourage the employee to take part in determining the scope and direction of each change.

A number of characteristics that make a high-skill professional an effective employee may also make the same person difficult to manage at times. On the one hand, independence and self-confidence must be encouraged. On the other hand, the same characteristics must be controlled. The manager is most likely to succeed with the high-skill professional by applying an open, participative approach to management.

Credibility of the Professional’s Superior

When a work group includes professionals, there is always the potential for differences in professional opinion, and there is always the possibility that the professionals will demonstrate varying degrees of unwillingness to accept direction from the manage.

Whether such credibility problems exist in a given work group depends on the background and qualifications of the employees. Problems may arise from the presence of a certain amount of ego—from the belief that one’s profession is at least a bit more important than other occupations. Some problems arise from a sense of territorialism exhibited by some professionals, the belief that no one should hold sway over any aspect of professional performance without being perceived as at least equal in professional status and capability to the perceiver.

Management credibility problems may exist when the manager is not of the same profession as the individual employee. For example, a professional trained as a chemist may have problems relating to an immediate superior whose background is that of a medical technologist. In all such cases there may be tendencies to differ on professional judgments—“He’s only a medical technologist, so who is he to tell me what I should be doing as a chemist?”—and there may be feelings of territorialism—“Chemistry is my area, and only a chemist can legitimately make judgments that involve chemistry.”

Credibility problems are also likely to arise when the manager is thought to be on a lower professional level than the employee. Thus, the clinical psychologist with a doctoral degree may be less than completely willing to accept the leadership of a manager whose education stopped at the master’s degree level, and the certified public accountant may balk at the direction of a managing accountant who is not similarly certified. It again becomes a matter of one person, the “higher” professional, being unwilling to accept the judgment of another person, who happens to be “lower” on the professional scale. In such situations, there are also more hints of territorialism: there appear to be more exclusive territories within broader territories that are mentally reserved for those of greater status.

Problems of management credibility are highly likely in situations in which employees see their managers as nonprofessionals. To fully understand such credibility problems, one must appreciate that many individual professionals do not regard management as a profession in its own right. Occasionally a nonmanagerial professional must report directly to a nonprofessional. In one organization, for example, a registered health information administrator and a utilization review coordinator who was a registered nurse reported to the director of health information services, who was a management generalist and held no professional credentials. These two professionals were inevitably in some degree of conflict with their manager and frequently questioned the manager’s direction. A direct reporting relationship between a nonmanagerial technical specialist and a generalist manager is often marked by many disputes concerning managerial judgments; in addition, it may be marked by strong territorialism on the part of the professional.

Automatic management credibility is likely to be greatest when the manager is a professional of obviously higher standing than the employee. At the other extreme, management credibility is most strained when the manager’s standing is rejected by the professional as being nonprofessional.

LEADERSHIP AND THE PROFESSIONAL

Leadership style may be simply described as that pattern of behavior projected by the leader in working with group members. Leadership styles run the gamut from completely closed to thoroughly open. At the closed end of the scale are the autocratic leaders, those who rule by order and edict. The harshest style is that of the exploitative autocrat, a leader who literally exploits the followers primarily in the service of self-interest. One major step along the scale takes one to the style of the benevolent autocrat. The benevolent autocrat also rules by order and edict, but it is a paternalistic rule imposed supposedly for the good of all.

Approaching the middle of the scale of leadership styles, one encounters the bureaucratic style. In many ways fully as onerous as the autocratic styles, the bureaucratic style ordinarily subordinates human considerations to the service of the “system” or the “book.”

Toward the open end of the scale, one encounters the consultative style of leadership. Under this approach the employees are often given the opportunity to provide their thoughts, ideas, and suggestions, but the ground rules are such that the leader recognizes no obligation to use anything the employees provide. In this style, the guiding philosophy of management is “the buck stops here,” and management reserves the right to make all decisions at all times regardless of employee input.

Consultative leadership often exists when management claims to practice true participative leadership, the most open style on the leadership scale. With participative leadership, all members are included in all decision-making processes so that all members own a piece of all decisions. The greatest flaw of participative leadership is the ease with which managers, most of whom grew into their positions under authoritarian role models, can unconsciously hinder participative processes such that they become consultative and perhaps even manipulative at times.

The higher the professional level of a work group, the more the manager will find it necessary to move toward the open end of the scale of leadership types to accomplish the work of the department. Given the nature of professional work and the advanced state of most professionals’ education, the average professional does not willingly suffer authoritarian management. It falls to the manager to examine basic assumptions about human behavior, to get beyond mere verbal tribute to modern management, and to take some of the risks inherent in open leadership styles.

SOME ASSUMPTIONS ABOUT PEOPLE

Douglas McGregor, in his landmark work The Human Side of Enterprise, wrote of two opposing approaches to management: Theory X and Theory Y.1 Pure Theory X is autocratic leadership. Pure Theory Y is participative leadership. Each of these management theories is based on a number of assumptions. The first, relating to management in general, is common to both and states that management remains responsible for organizing the elements of all productive activity—that is, bringing together the money, people, equipment, and supplies needed to accomplish the organization’s goals. Beyond this assumption, however, the theories diverge.

Theory X assumes the following:

• People must be actively managed. They must be directed and motivated, and their actions must be controlled and their behavior modified to fit the needs of the organization. Without this active intervention by management, people would be passive and even resistant to organizational needs. Therefore, people must be persuaded, controlled, rewarded, or punished as necessary to accomplish the aims of the organization.

• The average person is by nature indolent, working as little as possible. The average person lacks ambition, shuns responsibility, and in general prefers to be led.

• The average person is inherently self-centered, resistant to change, and indifferent to the needs of the organization.

In contrast, Theory Y includes the following assumptions:

• People are not naturally passive or resistant to organizational needs. If they appear to have become so, this condition is a response to their experience in organizations.

• Motivation, development potential, willingness to assume responsibility, and readiness to work toward organizational goals are present in most people. It is management’s responsibility to enable people to recognize and develop these characteristics for themselves.

• The essential task of management is to arrange organizational conditions and methods of operation so that people can best achieve their own goals by directing their efforts toward the goals of the organization.

STYLE AND CIRCUMSTANCES

Professional or not, not every employee responds to the same leadership style; however, the average professional is generally more receptive to open styles—to Theory Y approaches. Thus, it is in the manager’s best interest to begin a manager—employee relationship with reliance on an open style. Management style may depend largely on the individual circumstances, but in starting the relationship with an employee the manager should initially extend every benefit of the doubt regarding the employee’s motives.

The manager has a choice of leadership styles, ranging from extremely closed to extremely open. The trick is to know which style to apply and when to apply it. There may be some Theory X—style people in the department; these are the few who actually prefer to be led and have their thinking done for them. There may also be a number of Theory Y—style people who are self-motivated and capable of significant self-direction. Their presence should be especially notable in departments employing large numbers of professionals. Although the same personnel policies apply uniformly to all employees, the manager deals differently with individuals in other ways. Some the manager consults with and invites their participation; others the manager simply directs.

Theories aside, a manager must avoid making assumptions about people. Rather, it is necessary to know the employees and to try to understand each one as both a person and a producer. By working with people over a period of time, and especially by working at the business of getting to know them, the manager can learn a great deal about individual likes, dislikes, and capabilities. Learn about the people as individuals and lead accordingly. If a certain employee genuinely prefers orders and instructions, and this attitude is not inconsistent with job requirements, then use orders and instructions. Although many healthcare workers seem to prefer participative leadership, not everyone desires this same consideration. Sufficient flexibility must be maintained to accommodate the employee who wants or requires authoritarian supervision. It is fully as unfair to expect people to become what they do not want to be as it is to allow a rigid structure to stifle those other employees who feel they have something to contribute.

No single style of leadership is appropriate for all people and situations at all times. Today there are more reasons than ever to believe that the consultative and participative leadership approaches are most appropriate to modern healthcare organizations and today’s educated workers.

Much can be said about what leadership is and what it is not, but in the end, only a single factor characterizes or defines a leader. That factor is acceptance of the followers. For this critical factor to be present in the manager—employee relationship, the professional employee must do the following:

• Respect the manager’s technical knowledge

• Accept the manager’s organizational authority and respect the manager’s skill in utilizing that authority

• Respect the manager’s ability to blend the technical and managerial sides of the management role fairly and justly

The manager accrues little, if any, acceptance by virtue of organizational authority. Most of what the manager acquires in the way of willing acceptance must be earned. It can thus be suggested that to lead the professional employee successfully, the manager must provide a broad framework for employee action. As a consequence, it is necessary to provide the employee with every opportunity to be self-led and to impose specific direction only after all else has failed and the employee has demonstrated the need to be taken by the hand.

THE PROFESSIONAL AND CHANGE

No single group or classification of employee has a monopoly on resistance to change. Indeed, rigidity and inflexibility are found at all levels of the organization. This being stated, the professional employee is expected to be on the average more amenable to change because of the professional’s advanced education and broader perspective. Unfortunately, as many managers have discovered to their chagrin, the professional employee may be as fully resistant to change as any other employee. It depends entirely on how the employee is approached and how the particular change is presented.

The Basis for Resistance

As far as the majority of people are concerned, change is threatening. Change threatens one’s security by altering the environment; it disturbs one’s equilibrium, the state of balance that most people automatically seek to maintain with their surroundings.

Most people tend to seek a state of equilibrium with their surroundings, and they continually make adjustments intended to preserve their equilibrium. Unwanted or unheralded change threatens to disturb this equilibrium, thereby posing a threat to a person’s sense of security. People often react to change in completely human fashion by countering the threat with resistance. (See the section concerned with change.)

It is primarily the unknown that fosters resistance or intensifies what otherwise might be nominal resistance. In short, almost any change can generate resistance even if approached with full knowledge and plenty of warning, but if it comes by surprise, then intense resistance is almost certain. When a change is not a surprise, when it is approached in the full knowledge of everyone involved, much of the unknown becomes known and the chances of success are greatly increased.

The Manager’s Approach

In approaching the employees with a change, the manager can take either of three paths: tell them what to do, convince them of what must be done, or try to involve them in assessing the need for the change and in determining the form and substance of the change. Yet the manager—who, after all, is but another employee and susceptible to the same fears and insecurities as rank-and-file workers—may also automatically tend toward resistance. An earlier section discusses this idea.

The manager must strive to overcome the tendency toward resistance that likely afflicts the majority of employees. It is an important part of the managerial role to be a driver of change and at times even an originator of change. Therefore, there is no room in the effective manager’s approach to the job for automatic or unfounded resistance. Rather, the truly effective manager recognizes his or her responsibilities as an agent of change.

To enjoy the greatest chance of successfully functioning as a change agent, the manager should follow these guidelines:

• Inform employees, as early as possible, of what is likely to happen.

• Plan thoroughly.

• Communicate fully.

• Convince employees as necessary.

• Involve employees whenever circumstances permit.

• Monitor implementation and ensure that decisions are adjusted and plans are fine-tuned as necessary.

Employee knowledge and involvement are the keys to success in managing change. The employee who knows what is happening and is involved in making it happen is less likely to resist.

Organizational Change, the Manager, and the Professional

Recent years have seen significant organizational change in health care. Mergers and other affiliations, the formation of health systems, hospital closures, downsizing, and other reorganizing activities are altering what had been long-standing organizational arrangements. Many such changes have affected the ways in which managers run their departments and how they relate to individual employees.

Consider an example. Two small-town hospitals some 15 miles apart merged into a single corporate entity and combined activities such that each service became a single department with two locations. Where once there had been two physical therapy managers, a single manager became responsible for overseeing staff in two separate locations. The manager’s span of control was significantly altered, so that this person was now responsible for more employees, approximately half of whom were 15 miles away at any given time. This arrangement, and a number of others like it, had the following effects on the relationships between manager and employees:

• The self-starting and independent-operating tendencies of the affected nonmanagerial professionals became far more important because direct supervision of their activities decreased significantly.

• Because employees now had to function more independently, the manager need ed to pay more attention to effective delegation so that employees always knew what was expected of them, whether or not the manager was actually present at the site.

• The manager now had twice as many employees as previously under her span of control and thus had more employee-related activities to address (performance appraisals, for example).

• Running a two-location department necessitated—one might even say, “forced adoption of”—an open style of management; there was no possibility of providing close supervision to employees who were some distance away much of the time.

• With the manager permanently “spread thin,” professional employees had to function as true professionals and the manager had to treat the employees as true professionals.

Such organizational changes will inevitably influence a manager’s span of control and scope of responsibility and will necessitate the manager’s increasing reliance on the self-governing, semiautonomous professional employee.

METHODS IMPROVEMENT

Every worker has a potentially valuable role in methods improvement. No one knows the inner workings of a job nearly as well as the people who do it every day. This detailed knowledge is essential in methods improvement activities. Precisely how a task is performed is the necessary starting point in working to improve the performance of that task. The professional, whether employee or manager, is especially important in methods improvement; the professional’s depth of knowledge in the field, both theoretical and practical, is a critical source of work-improvement options. In addition, the creative nature of much professional work suggests that the professional knows not just what to do but also how to determine what to do.

The professional employee is often a key person in a methods improvement undertaking, such as in chairing a quality circle or leading a work simplification team. In all probability, the professional knows the work far better than the manager does. The manager, even though a professional as well, has necessarily been moving away from the technical work in some respects while growing as a manager. To succeed in improving the methods by which the work is accomplished, the manager must regard the department’s professionals as the most potentially valuable source of improvement knowledge.

EMPLOYEE PROBLEMS

Occasionally, managers tend to treat their professional employees much like parents often treat the older children in the family: “you’re more advanced, so we can expect more of you.” The you-should-know-better attitude is fine as long as it is expressed properly and is not carried to extremes, at least in regard to the technical work of the profession. Conversely, this attitude is not generally appropriate regarding adherence to the policies and work rules of the organization.

Rules and policies must be applied consistently to all employees. The professional employee should not be held to more rigid standards of behavior simply because of being professional—but neither should the professional be allowed to get away with more simply because of his or her professional status. Rather, policies and work rules must apply equally to all employees regardless of their qualifications or classification, and the manager must take pains to ensure that all receive equal treatment.

The professional is as fully human and unpredictable as any other employee when it comes to the likelihood of personal problems, variations in personality, and behavior that might give rise to employee problems. The manager’s long-run experience will likely demonstrate that professional employees are just as much of a source of discipline and behavior problems as nonprofessional employees. In fact, when the kinds of problems presented by employees are considered, one often finds that the problems presented by professionals are more complex and more difficult to deal with than the problems presented by others. Especially troublesome is the occasional professional who takes advantage of his or her professional status to demand professional treatment without extending the appropriate behavior in return.

COMMUNICATION AND THE LANGUAGE OF THE PROFESSIONAL

For the professional who manages professionals, it would be pertinent to pass along all of the additional advice that can be offered about communication as it applies to the manager of any employees, professional or otherwise. This discussion, however, is limited to a few aspects of organizational communication in which professional status or professionalism may make a difference.

Each function within the modern healthcare organization includes a certain amount of what can be called “inside language.” Those who work in rehabilitation services, for example, have special terms that they use regularly. A few of these terms may be unfamiliar to persons who work in other areas and completely foreign to persons not involved in health care. Likewise, health information practitioners, respiratory therapists, computer specialists, microbiologists, and numerous others have inside languages that have evolved within their respective disciplines.

Inside languages are an inevitable outgrowth of the development of any area of concentrated specialized activity. The more concentrated the specialty and, in the case of health professions, the higher on the professional scale an occupation resides, the more extensive this inside language is and the more incomprehensible it is to outsiders. Inside languages evolve for perfectly logical reasons: as advances are made in any aspect of life or any area of business activity, needs arise for describing concepts, conditions, problems, and even physical objects in a way that clearly identifies these within the context of the growing specialty as different from anything else in the world.

The needed words come from two sources: (1) existing words that are given new meanings for specific purposes and (2) new words that are coined to represent new concepts. As a simple example, consider a small part of the effects on the English language in the 20th century caused by the internal combustion engine and specifically by the automobile. The automobile gave us terms such as overdrive, carburetor, spark plug, headlight, and crankshaft that may not have previously existed or that resulted from the combination of existing words in a new context. The automobile also gave new meaning to old words in the language such as bumper, starter, distributor, and transmission. Every bit of advancing technology has thus expanded the language, and every profession that has emerged and evolved has built its special language along the way.

Clearly, language must be dynamic; it must be able to shift and expand as knowledge increases. It is thus fully understandable that an inside language should develop within any activity. Such language serves a clear purpose in describing, in terms as specific as possible, what goes on within that activity. Some might also say, however, that the purpose of the inside language is to elevate the specialty and define it as a closed club of sorts. Although probably not a specific purpose of an inside language, this is undoubtedly an effect of such a language. An inside language heightens the mystique surrounding any given occupation and helps define the territory surrounding that occupation. Relative to territory, the presence of the inside language is a qualification—admittedly superficial but certainly highly visible—for entry into another’s territory.

Nurses have a language of their own, and human resources practitioners have a language of their own. Laboratory employees, radiology employees, physical therapists, psychologists, social workers, occupational therapists, physicians, and many others have their own inside languages. Fortunately, many of these inside languages have some terms in common so they are not entirely different from one another. For example, some of the nurse’s inside language is the same as part of the physician’s inside language, and it is largely these areas of overlap that provide the interprofessional points of contact through which much communication flows. Occasionally, however, there emerges an inside language that has few, if any, points of overlap with other inside languages.

A glaring example of a highly restrictive inside language is found in computer science. This specialty area is filled with terms and abbreviations and acronyms that are used freely in normal interchange, often without explanation. Old, otherwise familiar words are used in new combinations and with entirely new meaning, such as terminal, disk, peripheral, online, and real time. Beyond the limited number of terms that many of us manage to absorb as computer users, “computerese” stands as very nearly a language in its own right.

One of the major problems commonly encountered in communication involving professionals is disregard for the need to structure any given communication to suit the needs and capabilities of the audience. In communicating, the professional:

• May freely use inside language when communicating with others in the same specialty

• Must use a lesser level of special terminology when relating to persons who are outside of the specific specialty but still within the realm of health care

• Must use a third and general level of language when relating to persons outside of both the specialty and the industry

The manager has a key role to fill in professional communication. It is all too easy for the manager to perpetuate foggy communication by simply joining in with other professionals in the group and relying on restrictive inside language in all contacts. This behavior is not unusual when the manager has risen from the ranks in the same profession. Ideally, however, it should fall to the manager to serve as a facilitator and a translator in communication between the professional group and others. This role should extend to instruction and guidance in how to structure reports, memoranda, and other documentation to best meet the needs of a specific audience and how to do likewise for the audiences for the professionals’ oral presentations.

Some professionals tend to use language to make themselves appear knowledgeable and important, to elevate the mystique of the profession, and to isolate and protect their territory, but the primary purpose of language should be to communicate—that is, to transfer meaning. As a primary source of worker guidance and the department’s major point of contact with the rest of the organization, the manager has a strong interest in ensuring that the department’s contributions are presented so that they are completely understood by those who need to know.

AN OPEN-ENDED TASK

On any given day, the professional employee can present the manager with a problem or challenge that can be brought by the nonprofessional—and then some. Any advice that may apply to the management of anyone can apply to the management of the professional. Additional requirements on the manager call for the constant awareness of the sometimes subtle and sometimes glaring differences presented by the professional employee. In addition to the normal requirements of managing any employee, in the day-to-day management of the health care professional, the manager has several key objectives:

• Help the professional employee identify and pursue objectives that are consistent with the objectives of the department and the objectives of the organization

• Work to ensure consistency between the priorities of the employee’s profession and the priorities of the department and the organization

• Strive to establish and maintain management credibility in a clear leadership role relative to the individual professional employee

• Establish and maintain a working communications link between the individual professional and all other employees

THE NEXT STEP?

The growth-oriented manager cannot help possessing a split focus as far as employment is concerned. Although every manager should of course be largely attentive to the job at hand, the growth-oriented manager can be expected to have two important concerns: (1) performing the present job and (2) preparing for the next job.

Is it best to seek the next upward move within one’s present organization or elsewhere? Some will extend their loyalty to a particular organization and seek to advance within that organization. Others, perhaps identifying more closely with a profession than an organization, will envision themselves readily going to another employer. Still others will remain open to either possibility.

It is not possible to say that either the inside focus or the outside focus is best. Although there can be distinct advantages to remaining with the same organization, this is not always possible. Also, staying with the same employer is not always advisable when one considers that more opportunity and more rapid advancement may exist elsewhere.

Careers: Ladders and Tracks

Within certain areas of health care, the available career ladders or career paths may be perceived as both limited and limiting. There are a number of relatively short career ladders in health care. For example, in a mid-size hospital, the entire career ladder in the diagnostic imaging department may consist of only two or three levels, including the management level. The same may be true in the laboratory department. When a person reaches the top of a short career ladder, there are but a few steps remaining: moving to another hospital department that has a longer career ladder, working in general management or administration, or going to another organization that has a longer career ladder in one’s specialty.

Moving to another department usually requires re-education in a completely new field. Entering administration also in most instances requires additional education and is a move not readily made. Moving to another, usually larger, organization that has a longer career ladder in one’s specialty may work for some for a while. However, because the longer career ladder usually contains only an additional one or two steps, this eventually frustrates the growth-oriented individual, who again “tops out” and may again be faced with changing fields or striving for administration.

Career tracks are also affected by the essential pyramidal structure of most business organizations. As one goes up the pyramid, there are fewer positions available, so at each succeeding level, the competition is greater. This situation has been worsened in recent years by the tendency toward organizational flattening, which has resulted in the reduction in the numbers of available positions in first-line and middle management.

Whether you envision your next career step with your present employer or elsewhere, there is always the potential for a conflict in focus. If you think your next position will be in your present organization, the conflict of focus is upward versus downward. This is most pertinent to the positions of first-line and middle managers. If you think your next position will be in another organization, the conflict of focus is inside versus outside. The inside—outside conflict is most pertinent to department-head and top management positions.

Upward Versus Downward

At any given time, the first-line or middle manager may tend to face upward, toward higher management and the rest of the hierarchy, or face downward, toward the work group. Certain factors may cause individuals to face in a particular direction at a given time, and certain tendencies in individuals favor one direction or the other. The pressures to face upward or downward are rarely equivalent, and there are no guarantees that one is facing in the appropriate direction.

Facing Downward

The downward-facing pressures consist of the needs of one’s direct-reporting employees; the needs of the department’s clients, patients, or customers; and generally all of the responsibilities of one’s present position. Downward is, in fact, the direction in which most managers of people should face most of the time. This is especially true of first-line managers, who may often be as much working professionals as managers. It is necessary to face toward the staff and be a functioning part of the staff to best fulfill the responsibilities of the position. Success in the management role depends on the manager’s maximum visibility and availability to staff. However, facing downward runs counter to a number of frequently encountered tendencies resulting from pressure or forces that encourage many managers to face upward.

Facing Upward

Facing upward is a natural inclination of many managers, but it occurs for a few largely personal reasons. In organizational hierarchy, it quickly becomes evident that one’s reward and recognition and most positive strokes come from above. Therefore, to enhance one’s chances of advancement, to assist in building a career, it is necessary to be known and appreciated at higher levels. Sometimes facing upward is appropriate and may even be essential. It is necessary in fulfilling responsibilities to one’s immediate superior, and some is essential to the manager’s growth and development through delegation and empowerment. However, facing upward must be accomplished in ways that do not detract from the manager’s responsibilities to the employees.

Which Way?

Which way the individual manager tends to face depends largely on that person’s psychological needs. One’s inclinations may be different whether the results tend to be upward or downward. For example, an individual who obtains the most personal satisfaction by doing hands-on work may well face completely downward and identify with the work group to the extent of being nearly invisible to the hierarchy. On the other hand, one who obtains maximum ego gratification through identification with higher management may face upward, even to the extent of ignoring the work group most of the time.

A Matter of Human Motivation

It invariably becomes a matter of individual motivation when a person responds to what are essentially psychological needs. People are dramatically different from each other in terms of what they respond to most readily. In planning out a supposedly desired career path, it is not simply where a person—such as yourself—think he or she wants to go that is important. Rather, it is necessary with each move you make to reassess yet again where you are and where you want to go. This is so because your ultimate objective is only what you believe you want; you will never know for certain until you get there. Also, each intervening step on the way to your ultimate objective is something that you must be motivated to attain. However, each step has a different set of responsibilities and challenges that might represent a motivational turnoff (sending you in new career directions) or with insurmountable obstacles (suggesting you may have reached a career peak in spite of loftier desires). As far as career growth is concerned, that to which people think they aspire and that which they actually attain is most often not the same.

Consolidate Before the Next Reach

It is unfortunately a fairly common circumstance for managers’ aspirations to extend beyond their capabilities. Also, it is also fairly common to learn that what we managers think we want, we discover we do not really want when we get it. However, what some individuals believe they want can carry them too far too fast, setting them up for eventual failure. Some “fast-track” performers rise at a rate that outstrips the attainment of full control of their present positions.

A number of years ago, Laurence J. Peter proclaimed that in a hierarchy, people tended to rise to their level of incompetence.2 He thus concluded that in time, all positions would be held by incompetent people who could not perform their jobs properly. Perhaps managers become incompetent by being too focused on their next upward move to fully internalize and competently address their present roles. However, proper career advancement is somewhat like walking—it is not possible to step out with the left foot until the right foot is firmly planted from the previous step. It is always necessary to consolidate one’s position and achieve working control of one’s present job before addressing opportunities for climbing still higher.

Dedication—and the Balancing Act

Total or near-total dedication to self over all else is of course an inappropriate strategy. Individuals who are fully focused on developing and advancing to the extent of subordinating all other considerations is making a number of crucial errors. However, because so many people ascribe, at least generally, to the perceived need to “look out for number one,” there is a tendency exhibited by some to place themselves ahead of other considerations at all times. Individuals who behave in this manner are concentrating more on making the next upward move than on mastering their present roles.

However, total dedication to one’s employer not an appropriate strategy. Far too many managers allow themselves to become so completely controlled by the job that they are willfully managing very little. The job is managing them. Unfortunately, many work organizations readily accept, and some even demand, this total dedication, which can prevail to the extent of impairing or endangering people’s health and family and personal relationships.

Some degree of dedication to both self and employer is of course necessary, but there must be a healthy balance between the two: loyalty of the employer to the employee and the loyalty of the employee to the organization. It might be suggested that loyalty of the organization to the employee is often more perception than reality, a product of a relatively stable period that some industries enjoyed over two, three, or four decades. It was only natural that as times changed and the perception of organizational loyalty diminished, individuals began to be less loyal to their employers. Loyalty in work life is very much a two-way street.

Many individuals, however, seem to need to be loyal to something or someone, even if only to themselves. This need frequently translates to a dedication to one’s own career or to one’s particular profession. It has become especially evident that a growing number of technical, professional, and specialized employees identify more with an occupation than with an organization. From the employing organization’s point of view, this dedication to occupation translates into dedication to self.

Balancing one’s own needs with the needs of the organization can be a difficult task. The majority of managerial and professional jobs are by nature somewhat open-ended; there is always something to be done, whether urgent, essential, marginally important, or just simply desirable. There is usually enough to be done in such jobs that one runs the risk of following an endless thread from task to task to task in a never-ending quest to get “caught up.” In this direction lies the risk of being consumed by the job. A genuine balance of service to the job and to one’s self is a necessity for personal health and survival.

Goal Alignment

It has been suggested that the manager who wishes to advance throughout the course of a career must develop a workable mix of attention to one’s present job and preparation for the next upward move. This mix is best achieved when one’s goals are at least partly consistent with the goals of the organization.

You, the manager, should examine your goals and determine how consistent they are with your employer’s goals. Will conscientious pursuit of your employer’s goals also result in progress toward your own goals? If some of your goals seem to match up with some of the organization’s goals, working toward these mutual goals will benefit both you and your employer. For example, consider the physical therapist and physical therapy manager who wishes to grow in that field and who is employed by a health system that has declared one of its goals to be the establishment and maintenance of the most comprehensive physical rehabilitation center in the region. Here, pursuing the goal of growth and advancement in physical therapy is consistent with pursuing the systems goal in physical rehabilitation.

However, if your goals do not align with those of your employer, you are faced with other necessary choices. Consider, for example, the environmental services manager who would like to work in accounting. Assume this manager is studying accounting part-time and is looking for ways to expand on job-related tasks that would support that particular goal. If this individual is significantly driven by this goal, the employer’s goal for environmental services—keeping the facility sparkling clean—may well become secondary; pursuit of this organizational goal nets the manager nothing toward the personal goal. This is, of course, an extreme example of goal inconsistency, suggesting that both individual and organization know it is likely this person will leave in the foreseeable future to pursue his or her personal goal. Fortunately, for most managers and professionals, the inconsistencies are not nearly this pronounced. So it is usually possible to uncover or perhaps even create a few areas in which some of your goals can be made consistent with some of the organization’s goals.

Some Unchanging Fundamentals

Remember the Supporting Skills

Certain skills will always be important in helping managers perform their present job and making them more valuable for advancement. Certainly all of the basic management skills are applicable here, as are especially the communications skills. Any person who wishes to rise at all in management must of course master the basic management skills and must also develop a degree of mastery in writing, public speaking, and interpersonal communication.

Of course, interpersonal skills are important to managers and professionals at all levels. Writing and speaking are also important at all levels but seem to increase in importance as one ascends the organizational hierarchy. Public speaking, if only to the extent of running meetings, often presents a case in point. More than a few individuals have lost out on potential promotions by exhibiting unwillingness to speak in front of a group. This suggests immediately that the goals of one who would wish to rise in organizational life should include improvement in writing, making presentations, and dealing with other people.

Improvement in working with people is an aspect of job performance often overlooked or at least assumed out of existence. After all, managers do all tend, individually, to believe they are better communicators than they actually are. However, all managers constantly deal with people—employees, peers, superiors, clients, customers, whomever—and should ideally do so in ways that allow those they have contact with to feel respected and important. This is especially significant where employees are concerned. An age-old bit of anonymous wisdom suggests that a manager should be extremely careful how he or she deals with people at all times, because he or she might meet them again. For example, one manager who was twice demoted in successive reorganizing exercises said she never fully appreciated the truth of this until she wound up working side by side with people who had previously reported to her. She was very glad she had always treated people as she wished to be treated herself.

Become Valuable

In pursuing goals of career advancement, it surely helps one’s cause if he or she has a superior who delegates well, truly empowers, and generally believes in employee development. In fact, a good manager with strong feelings for employee development, who is confident and unafraid of having sharp, strong, fast-moving subordinates, is one of the greatest advantages an individuals can have at work.

One way in which any individual can be valuable is to know enough about the manager’s job to make him or herself useful, to make it easier for the manager to delegate. Much of what a person may be able to do of course depends on the kind of manager he or she answers to. One of the most valuable functions a person can perform, preventing the boss from making an obvious mistake or stepping unknowingly into a dangerous situation, is appreciated by a strong, confident manager.

Pursuing one’s desire to advance may be more or less difficult depending on the attitude of one’s immediate superior’s toward employee development and on one’s relationship with that manager. Although advancement is the goal, first get one’s present job responsibilities well under control. A deliberate downward focus may be necessary to obtain full control of one’s basic responsibilities. When that control is achieved, however, it it is possible to then carefully select those opportunities to focus or upward that seem to hold the most potential to do good. However, while balancing downward with upward, it helps to appreciate that in the long run the best and most lasting way to to career advancement is through a track record of demonstrated success in fulfilling job responsibilities and meeting the expectations of employers.

CASE: PROFESSIONAL BEHAVIOR—THE BUMPING GAME

Background

Dr. Gable, chief of anesthesiology, said to vice president Arthur Phillips and human resources director Carl Miller, “There are no two ways about it. We’re going to have to raise the pay of our nurse anesthetists by at least 10%. With Don Williams leaving us and going to Midstate Hospital for a lot more money, we’re going to have to pay more than we’re now paying to fill that spot. Among the nine hospitals in this city, our nurse anesthetists are by far the lowest paid.”

Miller said, “Since we spoke of this issue a week ago, I personally surveyed every hospital compensation manager in town. We’re not the lowest paying of the nine. In fact, we’re the third highest paying.”

Dr. Gable shook his head. “That doesn’t wash,” he said. “Some of our people moonlight at other hospitals and they’ve told me the hourly rates they’re getting for part-time work. They said they’d bring in pay stubs to prove it.”

Phillips said, “A week ago you said you were going to bring in some of those pay stubs from other places. Did you get them?”

“No. They forgot.”

Miller said, “Moonlighting rates aren’t relevant. Most of these places pay their part-time or casual nurse anesthetists a rate that amounts to more than their full-time employees get. That’s because these casuals work only when called and they don’t receive vacation, sick time, or other benefits, and they don’t get retirement credit.”

Phillips asked, “How about Midstate? I understand it has more than one scale for nurse anesthetists, with a second scale that might not readily be shared with other places.”

Miller nodded and said, “That’s right. Midstate is the highest-paying hospital in the area, based on this sort of hidden scale that it applies to some of its people. It pays up to 15% more for this one small group, all of whom have agreed to an extra-long workweek and a certain amount of weekend call. But it’s not really comparable to our situation.”

Phillips said, “In all the years I’ve been here, it seems I can depend on this same exercise coming up every time one of our nurse anesthetists leaves. I’ve also come to count on it happening with the pathologists and radiologists every few years—they go to work at one hospital to get their compensation increased, then they use this new pay leader as a wedge to get the other hospitals to pay more.”

Miller said, “I’m sure that all of the nurse anesthetists in town know what the others earn. All it takes is a few people in one hospital to get a strong advocate to go to bat for them, and the pressure to bump pay rates is felt throughout the region.”

Dr. Gable said, “I take it that you’re seeing me in that strong advocate role.” Miller did not respond.

Phillips said, “Anyway, Dr. Gable, you obviously see the nurse anesthetist pay rates as a problem and we’re willing to listen to any potential solutions that you may have to offer. However, the budget year is barely one-third over and there is no more money to play with until the first of next year. As a first pass at the problem, we’ll be happy to take a close look at any creative solutions you can come up with that lie within the limits of this year’s budget.”

Questions

1. What does this case say about the supply of a particular skill—the nurse anesthetist—in the area? And what might come of Dr. Gable’s arguments if the realities of supply were different?

2. Do you believe that the interorganizational “bumping” of pay rates, if indeed a fact, constitutes professional behavior? Why or why not?

3. Because it might be reasonably suggested that the nurse anesthetists in the area are acting together, at least in a loosely organized way, one might be tempted to suggest that the area’s nine hospitals get together and establish fair and consistent pay rates for this occupation. Which hazards are inherent in this approach, and in what sense has one of the case’s participants already ventured into hazardous territory?

4. How would you suggest that Phillips and Miller proceed in their consideration of Dr. Gable’s request?

CASE: DELEGATION DIFFICULTIES—THE INEFFECTIVE SUBORDINATE

Background

Nursing supervisor Kate Dyer was finally forced to admit, at least to herself, that she was going nowhere in her attempt to get nurse manager Susan Foster to behave as a manager ought to behave. Summarizing the recent occasions on which Susan and her performance had come to Kate’s attention, Kate had assembled the following list:

• Whenever Kate went through Susan’s unit, she found Susan’s desk in disarray and invariably found Susan herself behind in her work.

• Susan seemed to experience a great deal of difficulty in making important meetings; she had missed three of the last four nursing management meetings, and at the one she did attend, she did not show up until it was half over.

• Kate’s specific suggestions as to tasks that Susan might consider delegating to some of her subordinates have apparently been ignored.

• Some weeks earlier Kate had asked Susan for a detailed written list showing how the various nursing duties on her floor might be divided among the unit’s staff members. Susan did not comply with the request.

In general, Susan seemed to have but two answers for many of the questions put to her by peers and supervisors alike. To questions that were general and nonthreatening, such as “How is everything going?” she would simply answer, “Just fine.” However, if a question seemed intended to determine why something had not been done, Susan could be counted on to answer, with a pained expression on her face, “I simply haven’t been able to get to it.”

Questions

1. Although Susan’s performance is obviously lacking in a number of ways, Kate might best begin by examining some elements of her own performance and her own leadership style. What are the elements of the case that may have prompted this statement, and what are the implications of those elements regarding Kate’s style and performance?

2. What appear to be the weakest elements in Kate’s style? Why are they weak?

3. Assuming that Kate is able to successfully address the deficiencies in her own approach to management, where should she begin in trying to determine whether Susan has the potential to become a truly effective nurse manager?

NOTES

1. Douglas M. McGregor, “The Human Side of Enterprise,” Management Review 46, no. 11 (November 1957): 22–28, 88–92.

2. Laurence J. Peter, The Peter Principle (New York: William Morrow & Company, 1969), 26.