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Leadership, Team Building, and Conflict Management Chapter Objectives After reading this chapter, you should be able to 1. Apply the various theories of leadership to medical organizations. 2. Build and use effective groups and teams in healthcare settings. 3. Resolve conflicts in medical organizations in constructive ways. 11 © iStockphoto/Thinkstock Leadership, Team Building, and Conflict Management Chapter 11 The next two chapters examine the management function of leadership. In some cases, lead- ership practice in healthcare settings can be similar to leadership practice in other organiza - tions; however, in other cases, it can be highly different. For example, many other organizations do not encounter circumstances in which life-or-death decisions must be made in a matter of minutes—which is something that routinely occurs in healthcare. In addition, a physician in an emergency or operating room may be called upon to direct the activities of individuals he or she does not directly employ and expect those orders to be carefully followed. Yet, such activities as nonemergency, day-to-day operations and making decisions regarding the healthcare organiza - tion’s strategic direction tend to be similar to the same actions in other companies.

For many years, a debate has taken place regarding the terms leadership and man - agement. A recent analysis by Simonet and Tett (in press) provides a lengthy review of the historical uses of the two terms. The authors suggested five possible conceptual - izations of the relationship between leader - ship and management.

The first, bipolarity, depicts a relationship in which leadership and management are viewed as completely distinct activities that are at odds with each other. In essence, managers maintain organizational stability, whereas leaders advocate change. Managing involves coping with complexity through standard organization mechanisms, such as planning, organizing, and controlling. Leadership, in contrast, incites change by creating a vision for the future (Kotter, 1990; House, 1977, 1996).

Unidimensionality portrays a relationship in which leadership and management are interchange- able parts of an integrated whole. In other words, they are one and the same.

Bidimensionality suggests that management and leadership are distinct, but often complemen - tary, processes in which both are part of a larger whole. In essence, although the two actions are different, they are both necessary elements of the same job or position.

The hierarchical management within leadership perspective argues that management is part of a larger leadership domain in which leaders must be able to implement their visions in order to be effective. Leadership becomes the dominant activity, and management (plan, organize, control) is relegated to being part of the leadership domain.

The hierarchical leadership within management conceptualization suggests that leadership is part of management’s “directing” function, which is one of the managerial components of plan, organize, direct, and control. Management represents the overarching occupation, and leader - ship, along with other activities, is subsumed as part of the management profession.

If these conceptualizations were depicted as Venn diagrams, bipolarity would suggest two com - pletely separate domains (circles that do not touch); unidimensionality would portray the rela - tionships as completely overlapping (one circle containing both); bidimensionality would result in two intersecting circles with some common ground and some different elements; hierarchi - cal management within leadership would display one larger circle (management) containing a © Michael S. Nolan/age fotostock/SuperStock ▲ ▲ Is a ship’s captain more of a leader or a manager? Application of Leadership Theories in Healthcare Chapter 11 smaller circle (leadership); and hierarchical leadership within management would display the large circle as leadership holding a smaller management circle.

Other perspectives suggest that the nature of these five relationships depends on various organi- zational circumstances, such as the size of the organization, the type of industry, the organiza - tion’s standing in a life cycle (see Chapter 8), the rank of the manager being examined, the goals of the manager, and the nature of what constitutes managerial or leadership “success” (Baack, 2013). What becomes clear is that a continuing discussion regarding the natures of the two con - cepts will undoubtedly take place, and that the two are both germane to management positions in healthcare organizations.

With these distinctions in mind, this chapter examines the nature of leadership in healthcare.

The opening section offers ideas about the application of various theories of leadership to medical circumstances. Then, the activities of teams and groups receive attention. Finally, the nature of conflict and conflict resolution is explored.

11 .1 Application of Leadership Theories in Healthcare Leadership is the process of influencing the behaviors of individuals and groups toward prede - termined goals in organizations. Note that effective leaders influence behaviors in positive ways.

Ineffective leaders also influence behavior but do not achieve desired results. For example, some leaders may seek goals that are unethical or not desired by an organization.

Types of Leaders and Leadership Theories Two types of leaders operate in organizations. Formal leaders have been elected, appointed, or promoted into the role. An organization chart often depicts the formal leadership hierarchy.

Informal leaders , or emergent leaders , arise from individual situations and circumstances. In a medical setting in which a patient requires immediate medical care with no formal leader pres - ent, informal leadership takes place through a person directing not only the patient’s care but also the activities of others.

In healthcare, leadership may be divided into two additional categories. Administrative leader- ship consists of individuals who develop and implement organizational strategies and provide support mechanisms for the operation of the overall organization. Clinical leadership applies to the direction and support of those providing medical patient care (Greenhalgh et al., 2004).

Current theories about the natures of leadership include the following:

• Trait theories • Behavioral theories • Situational and contingency theories • Recent theories Trait Theories Early theories, which originated in the mid-1800s and remained somewhat popular into the 1960s in the United States, suggested that certain traits emerge due to the physical and person - ality characteristics that differentiate leaders from followers. The dominant concept was that some people were born to lead and others to follow. From this perspective, it was believed that Application of Leadership Theories in Healthcare Chapter 11 leadership could not be taught, because it consists of inherent abilities. Furthermore, the abil- ity to lead was assumed to be a universally applicable skill. Thus, a leader who succeeds in one organization would be equally effective in any other, suggesting that all effective leaders share common traits. These theories informed the “great man” approach to leadership. Table 11.1 sum - marizes many of the items that were investigated in the search for common traits and character - istics among great leaders.

Table 11.1 Traits and characteristics of effective leaders Physical characteristics Personal traits Personality traits Social traits Height Strength Physical attractiveness Stamina Vitality Verbal skills Wisdom Judgment Intellect Capacity for workAmbition Confidence Initiative Persistence ImaginationEmpathy Ta c t Patience Tr u s t Status Although many of the traits and characteristics shown in Table 11.1 would be useful in a health - care setting, research has indicated that they are not universally present in successful leaders (Geier, 1967). As a result, interest in the “great man” approach has since waned (Kirkpatrick & Locke, 1991).

The Big Five A more recent trait theory suggests that leaders can be developed through experience and learn - ing. In many business organizations, the Myers-Briggs Type Indicator (MBTI) helps identify ele- ments of personality, including introversion/extroversion, sensing/intuition, thinking/feeling, and judging/perceiving characteristics (Quenk, 2000). Some have concluded that this instrument provides a pathway to self-awareness, which has implications for effective leadership (Gardner & Martinko, 1996). A closely related approach that has achieved positive research results is the five- factor or Big Five model of personality (McCrae, 1992), which suggests that five basic dimensions underlie all others, as displayed in Table 11.2.

These five factors, which are predictive of job performance and have been associated with leader - ship (Mount, Barrick, & Strauss, 1994; Schmidt & Hunter, 1998), are also useful characteristics for healthcare leaders. Although extroverts have proven to be the most likely to become leaders, extroversion does not guarantee effectiveness in a leadership role (Judge et al., 2002). Individuals who are agreeable and emotionally stable do not show as strong a tendency to become leaders as extroverts; however, those qualities are considered strengths in leadership. Therefore, the most effective leaders tend to display an appropriate mix of the five factors..

Personality and Leader Effectiveness Recent evidence suggests that conscientiousness and openness to experience are correlated with leader effectiveness (Judge et al., 2002). Other researchers have concluded that certain person - ality factors are better predictors of effectiveness (Judge, Colbert, & Ilies, 2004). One such fac - t or, emotional intelligence , or the ability to manage oneself and one’s relationships in mature and constructive ways, predicts leader success (Xavier, 2005). Political intelligence indicates the willingness to use power and intimidation to achieve various ends. Political intelligence may be useful when change is required, and subordinates are resistant to those changes (Kramer, 2006). Application of Leadership Theories in Healthcare Chapter 11 In healthcare organizations, emotional intelligence would be a valuable asset for nearly every employee, whereas political intelligence might have applications when a healthcare administra- tor implements major changes—although coercive political tactics usually inspire resistance and retaliation.

Behavioral Theories Behavioral theories differ from trait theories in one fundamental way. Instead of the goal being to find the right person for the job, it is to identify behaviors associated with successful leadership (Yukl, 1981). This approach, which involves training a person to become a more effective leader, diminishes the role of personality factors in selection processes, while enhancing the role of lead - ership training. Three behavioral theories of leadership include:

• The University of Michigan Study • The Ohio State University Studies • The Scandinavian Development-Oriented Approach The University of Michigan Study The University of Michigan Leadership Model emerged from the study of the effects of leader behavior on job performance. Researchers interviewed a number of managers and subordinates and identified two leadership styles: job centered and employee centered (Yukl, 1981).

Job-centered behaviors occur when managers pay attention to the job and related work behaviors.

Production-oriented leaders concentrate on technical aspects of the job, including finding better methods of operation, with the goal of increasing output. In a healthcare setting, this behavior Table 11.2 The Big Five model of personality Factor Description Tra i t s ExtroversionMeasures one’s comfort level with relationships. Extroverts tend to be outgoing, assertive, and social.

Introverts tend to be reserved, timid, and quiet.

Agreeableness Measures one’s tendency to defer to others. Highly agreeable people are cooperative and trusting.

People who are less agreeable tend to be antagonistic, cold, and untrusting.

Conscientiousness Measures personal reliability. A highly conscientious individual is responsible, organized, and dependable.

Less conscientious people are easily distracted, disorga - nized, and often unreliable.

Emotional stability Measures one’s ability to deal with stress. Emotionally stable people tend to be calm, self- confident, and secure.

People who are less emotionally stable tend to be nervous, anxious, and insecure.

Openness to different experiences Measures one’s range of interests and curiosity regarding new experiences and adventures. Open people are creative and inquisitive and ask numerous questions.

People who are less open tend to be conventional and a bit rigid and prefer the status quo. Source: Adapted from McCrae & Costa, 1989. Application of Leadership Theories in Healthcare Chapter 11 would lead to an emphasis on efficient, effective patient treatment, billing systems, and materials management.

Employee-centered behaviors take place when managers pay attention to employee satisfaction and to making work groups more cohesive. Employee-oriented managers emphasize personal relationships with workers, take a personal interest in those individuals, and accept personality differences. By focusing on employee needs, managers hope to build effective work groups that will achieve at higher levels.

The Michigan researchers argued that employee-oriented leaders would be more effective. The dimensions they used to describe effectiveness include higher group satisfaction and higher indi - vidual job satisfaction. The researchers argued that production-oriented leaders would suppress these factors.

The Ohio State University Study The Ohio State University used surveys of leadership behavior to identify two major dimensions of leader behavior (Yukl, 1981). Initiating structure leadership behavior organizes and defines what group members should be doing. The leader makes efforts to get things done through such tactics as organizing work and setting goals for employees. Initiating structure is similar to job- centered behaviors.

Consideration is leadership behavior that expresses concern for employees by establishing a warm, supportive, friendly climate. Leaders exhibit consideration through concern for the com - fort, well-being, and satisfaction of workers. Consideration resembles the employee-centered behaviors.

The Ohio State researchers concluded that effective leaders demonstrate both initiating structure and consideration. Successful leaders tend to have positive, supportive, and employee-centered relationships. At the same time, however, they were able to focus on the accomplishment of tasks.

Research regarding these assertions yielded mixed results. At times, consideration might lead to lower performance ratings by a leader’s supervisor. In addition, initiating structure has been con - nected to higher levels of grievances and other indicators of employee dissatisfaction (Yukl, 1981).

In healthcare settings, high levels of initiating structure would be less effective when working with professionals such as surgeons, nurses, and medical technicians, because such positions, by their nature, require self-direction and autonomy. Furthermore, professional relationships that rely on trust, such as those between physicians and nurses, are not well served by directive leadership.

The Scandinavian Development-Oriented Approach Researchers in Sweden and Finland refined the people-oriented versus production behav - ioral model to incorporate a third dimension: development-oriented leader behavior (Ekvall & Arvonen, 1991). The underlying premise is that the world of commerce has changed sufficiently enough to demand behaviors that include starting new activities, as well as finding and advocat - ing for improved methods of performing work. The researchers suspected that such activities were of lesser necessity during the times in which the Ohio State and Michigan studies were being conducted.

Initial investigations suggested that this third dimension has value in explaining leader behavior.

The approach suggests that development-oriented leaders have more satisfied employees and that employees may view their leaders as being more competent (Lindell & Rosenqvist, 1992). In the healthcare setting, developmental activities play a key role in training employees, which suggests that leaders may be well served by paying attention to those activities. Application of Leadership Theories in Healthcare Chapter 11 Situational and Contingency Theories In the 1950s, the concept emerged that no one universal style of leadership can be effective.

Instead, leaders may be chosen because they “fit” a situation or can adapt their leadership styles to a situation. Theories with this perspective represent the situational approaches to leadership.

Contingency theory identifies the characteristics of specific instances in which a certain leader- ship style will be most appropriate.

Basic Situational Theories Robert Tannenbaum and Warren Schmidt (1973) proposed a new leadership variable: effective- ness . They examined a leader’s style in terms of the delegation of authority. At one extreme, an authoritarian leader retains total control, whereas a leader at the other extreme pushes for employee participation and autonomy. In between, a continuum notes the amount of delegation that would be most effective, depending on the situation.

William Reddin (1970) identified the two main dimensions of leadership as being relationship oriented and task oriented . In a manner similar to the original Ohio State studies, Reddin com - bined the two orientations to create four outcomes: low relationship/high task, low relationship/ low task, high relationship/low task, and high relationship/high task. Reddin prescribed the same concept as Tannenbaum and Schmidt—that is, the potential for effectiveness should determine the mix of task and relationship orientation according to the elements present in the workplace.

The approaches of Reddin and of Tannenbaum and Schmidt helped shape more intricate situ - ational and contingency models of leader effectiveness.

Hersey and Blanchard’s Situational Leadership Model A more complex situational leadership model suggests how a leader should adjust his or her leadership style (Hersey & Blanchard, 1974; Hersey, Blanchard, & Johnson, 2001). The authors argued that leaders should be flexible in choosing a leadership behavior style and should become sensitive to the readiness of the follower(s). Readiness refers to the extent to which a follower pos- sesses the ability and training or experience to perform a given task. Employees with a high level of readiness require a different leadership style than employees with low levels of readiness. Table 11.3 indicates relationships between employee readiness and subsequent leader responses.

Table 11.3 Employee readiness and leader responses Employees Leader Unable and unwilling Provide clear, specific instructions and details Unable but willing Explain tasks, but build relationships with workers to obtain their trust and increase their levels of effort Able and unwilling Provide supportive leadership that incorporates participation to increase willingness Able and willing Little response required Source: Adapted from Hershey & Blanchard.

The situational leadership model can be expanded to incorporate elements of task behavior and leader–member relationships. Leaders using this model implement alternative leadership styles as needed. The model implies that if the correct styles are used in lower readiness situations, then followers will start to mature and grow in ability, willingness, and confidence. Table 11.4 identi - fies the possible leadership styles that result from different combinations of task-oriented and relationship-oriented behaviors. Application of Leadership Theories in Healthcare Chapter 11 Table 11.4 Matching situations to leader styles Situation characteristicsLeader style High task behavior/Low relationship Telling and directing High task behavior/High relationship Selling and coaching Low task behavior/High relationship Facilitating and counseling Low task behavior/Low relationship Delegating Source: Adapted from Hershey & Blanchard.

In the telling and directing style, the leader uses one-way communication to tell followers what, how, when, and where to accomplish various tasks. This style fits straightforward, simple work in which the leader does not bond or relate to followers.

A leader using a selling and coaching style provides clear directions; however, he or she incor - porates two-way communication to get the followers to “buy into” decisions. This style is most effective when the work is straightforward and uncomplicated, and the leader intends to build bonds with followers.

The facilitating and counseling style involves leaders sharing decision-making tasks with follow - ers. Leaders emphasize building relationships with followers and exhibit facilitation behaviors in the belief that followers have the ability and knowledge to perform tasks.

In a delegating style, the leader lets the followers run the show. No strong relationships are built, and the followers have the ability and are both willing and able to perform the task at hand.

Situational leadership theory has enjoyed wide acceptance in the corporate community (Fernandez & Vecchio, 1997). Research supporting the propositions in this model, however, has been gener - ally disappointing (Graeff, 1997). Criticism of the model suggests that it is too ambiguous to effec - tively test. Critics also urge caution when seeking to apply its principles (Vecchio & Boatwright, 2002). As a result, this theory may have limited usefulness in many healthcare settings.

Fiedler’s Contingency Model Fred E. Fiedler’s (1967) contingency model suggests that leadership success depends on a match between the leadership style and the demands of the situation. Rather than try to train leaders to adapt a new style, Fiedler believed that leaders should match their styles with situations that are the best fit. Again, such an approach has limited value in healthcare leadership situations.

Recent Trends in Leadership Theory The past few decades have witnessed the development of several innovative approaches in the study of leadership. These approaches expand the views of how leaders operate within various environments and with other members of the organization. They also account for greater com - plexity in interactions among the various factors that influence leader effectiveness.

Substitutes for Leadership Steven Kerr and Richard Jermier (1978) noted that various factors often limit a leader’s ability to exert influence on individual employees. The net result may be circumstances in which a leader’s efforts are redundant or unnecessary. Substitutes for leadership include the following: Application of Leadership Theories in Healthcare Chapter 11 • Subordinate characteristics ͪ Experience ͪ Professionalism • Task characteristics ͪMachine-paced work ͪIntrinsically satisfying and motivating jobs • Organizational characteristics ͪCohesive work groups ͪStandardized jobs and formalized rules and procedures These substitution factors have clear implications for healthcare leadership. First, many healthcare employees possess high levels of experience and professionalism.

As such, strong, directive leaders are not advisable, as employees are often quite able to manage themselves and their activities. In contrast, however, physicians undergoing training still require careful, hands-on direction. Second, healthcare work can be character - ized as intrinsically satisfying and motivating across a wide spectrum of occupations. Once again, in many instances, this lessens the need for direct leadership. Third, cohesive teams treating patients are likely to be self-directed. Formalization of medical procedures and rules used to ensure quality patient care reduce the need for direct leader activity. Healthcare is unique in the number of substitutes for leadership that innately exist, which makes this approach highly applicable to those circumstances. Healthcare leaders are advised to carefully consider the ramifications of this analysis.

Leader–Member Exchange According to leader–member exchange theory, leaders tend to form special bonds with a small number of followers, called the leader’s in group. These individuals receive the greatest amount of attention and enjoy other privileges. Members of the leader’s out group, however, have lower access to the leader’s time, receive fewer organizational rewards, and tend to develop more formal interactions with the leader.

Normally, a leader selects members of the in and out group based on employee characteristics.

Those most compatible with the leader—and especially those the leader perceives will be higher performers—become members of the in group. Leader–member exchange theory posits that in- and out-group status remains relatively stable over time (Duchon, Green, & Taber, 1986).

Research supports the concept that leaders tend to favor certain employees and that those in the in group express higher levels of satisfaction with a supervisor, enjoy higher performance ratings, and become less likely to quit (Gerstner & Day, 1997). The reason may be as simple as a self- fulfilling prophecy in which the leader predetermines which employees will become most likely to succeed by granting them in-group status.

A healthcare leader should consider whether developing in-group relationships at the expense of those in the out group will be an advisable path. In many instances, doing so will simply lead to dissatisfaction by the disaffected individuals, with no positive outcome for the organization. © Fuse/Thinkstock ▲ ▲ Healthcare is unique in the number of sub- stitutes for leadership that innately exist in organizations. Application of Leadership Theories in Healthcare Chapter 11 Vertical Dyad Linkages An extension of the leader–member exchange approach considers another level in the organiza- tional hierarchy. Figure 11.1 displays the relationship a supervisor has with a higher-ranking man - ager and with employees at lower levels, thus becoming a linking pin between the two. Employees tend to examine the relationship their immediate supervisors have with those of higher rank.

When they believe a supervisor enjoys an in-group relationship with higher-level managers, the subordinates tend to view that supervisor in a more favorable light, believing the supervisor has the following characteristics:

• Superior technical knowledge • Access to information • Upward influence These factors encourage employees to build in-group relationships with the supervisor. When out-group status is perceived, employees tend to believe that their careers have lower chances of success (Dansereau, Graen, & Haga, 1975). Although the model describes how leader–member relations are formed through observations of the leader’s interaction with those at higher ranks, it does not prescribe ways to improve the relationship. It does, however, improve an understand - ing of how individuals interact with supervisors in the workplace. The application of this theory to healthcare would be in the analysis of relationships of employees such as nurses with those of higher rank as well as of some physician–leader relationships.

Path– Goal Theory Robert House (1971, 1974) proposed the path–goal theory, which suggests that effective leaders clarify paths for employees to accomplish their own personal and professional goals. Clearing the path refers to a leader who helps people move toward their goals, removes barriers, and provides appropriate rewards for accomplishing assigned tasks. House identified the following four leader - ship behaviors, all of which have useful applications to healthcare management:

Figure 11.1 Leaders as linking pins f11.01_HCA340.ai Application of Leadership Theories in Healthcare Chapter 11 • Directive leadership • Supportive leadership • Achievement-oriented leadership • Participative leadership In a directive leadership style, the leader informs employees regarding his or her expectations, provides directions on how and what to do, maintains standards of performance, and clarifies his or her role within the group. In healthcare settings, a directive leader would create value by implementing numerous procedures and tasks, such as instructions regarding infection control, confidentiality, and a variety of medical procedures.

Supportive leadership entails treating group members as equals, being approachable, and show - ing concern for the well-being of employees. Supportive leaders in healthcare assist in coping with the stressful circumstances that often emerge. Many patients encounter life-altering dis - eases and accidents, and some lose their lives. Supportive leaders help medical staff employees when even the best medical care does not deliver the desired outcome.

Achievement-oriented leadership involves setting challenging goals, expecting a high level of performance, and emphasizing continuous improvement in performance. Achievement-oriented leadership in healthcare encourages the highest levels of effort, including devising programs designed to improve employee health, assist in passing various certification examinations, and conduct various types of medical research and practice.

Participative leadership means including employees in decision making, consulting with employ - ees, and using employee suggestions when making decisions. Many times, a group of medical professionals will work together to achieve the best outcome for a patient; participative leadership considers the inputs of every person involved in the process.

House (1996) refined his original theory by establishing a series of additional factors to consider in a leadership situation and by suggesting that intrinsic motivation plays a key role in leader effectiveness, especially when this motivation develops through the empowerment of employ - ees. Research results regarding these revisions and additions have been mixed (Wofford & Liska, 1993). One response to these outcomes has been to return to the simplest propositions made in the theory—that is, effective managers clarify paths to goals by:

• Understanding the enticements and rewards that employees value • Clarifying jobs and assignments • Rewarding successful performance Such an approach has value for many leadership roles in healthcare, as in other organizations.

Transformational Leadership A contrast may be drawn between transactional leadership and transformational leadership.

Transactional leadership concentrates on clarif ying employee roles and providing job instructions.

Thus, transactional leaders establish contingent rewards based on performance and employee accomplishments, and managers actively search for exceptions to rules and standards and make corrections. Transactional leaders then intervene when standards are not met (Bass, 1990).

Transformational leaders engender trust, seek to develop leadership in others, exhibit self- sacrifice, and serve as moral agents, focusing themselves and their followers on objectives that Application of Leadership Theories in Healthcare Chapter 11 transcend the work group’s more immediate needs (Dumdum, Lowe, and Avolio, 2002). Key leader behaviors identified in the transformation leadership literature include the following:• Inspirational motivation • Idealized influence • Individual consideration • Intellectual stimulation Inspirational motivation establishes a leader who expresses an enticing vision of the future through persuasive and emotional arguments combined with enthusiasm and optimism. Idealized influ- ence refers to sacrificing for the good of the group, acting as a role model, and displaying high ethical standards. Individualized consideration includes providing support, encouragement, empowerment, and coaching of employees. Intellectual stimulation means the encouragement to question the status quo and seek innovative and creative solutions to organizational prob - lems. The transformational leader exhibits all of these behaviors, which, in turn, creates powerful effects on followers and subsequent outcomes (see Table 11.5).

Table 11.5 Transformational leadership processes Transformational effects on followers and work groups Outcomes Increased intrinsic motivation, achievement orientation, and goal pursuits Personal commitment to leader and his or her vision Increased identification and trust with the leader Self-sacrificial behavior Increased identification and cohesion with group members Organizational commitment Increased self-esteem, self-efficacy, and intrinsic interests in goal accomplishment Task meaningfulness and satisfaction Shared perceptions of goal importance Increased individual, group, and organizational performance Transformational leadership theory has gained a great deal of traction in the new millennium.

Many organizations, including those in healthcare, believe that finding such leaders and train - ing others in these behaviors are true keys to success, especially when implementing the major changes facing the healthcare industry today. Transformational leadership influences employee performance by lowering frustration and increasing optimism.

Charismatic Leadership Theory Charismatic leadership theory notes that many times, followers attribute heroic or extraordinary leadership abilities to some individuals as those individuals exhibit certain behaviors. Table 11.6 identifies charismatic leader characteristics.

A four-step process explains the ways in which charismatic leaders influence followers. First, the leader expresses an appealing vision that leads followers to believe a better future can be constructed. Second, the leader sets high performance expectations of others but also expresses confidence that those outcomes can be achieved. Third, the leader establishes, through words or actions, values for followers to emulate. Fourth, the personal sacrifices made by the leader chal - lenge others to be courageous to help achieve the vision. Application of Leadership Theories in Healthcare Chapter 11 Table 11.6 Charismatic leader characteristics CharacteristicsDescription Vision and articulation An idealized goal communicated to others Personal risk Willing to take high personal risks and engage in self-sacrifice Environmental sensitivity Makes realistic assessments about the environment and resources needed to make changes Sensitivity to follower needs Understand others’ abilities and responds to their needs Unconventional behavior Does things that are novel and counter to traditional norms Source: Conger & Kanungo, 1998.

Leadership experts suggest that a person becomes a charismatic leader by engaging in three activities. First, the individual creates enthusiasm and expresses ideas through deeds rather than through words, such that the leader’s entire set of communication skills develops an aura of enthusiasm. Second, the individual creates bonds with others to inspire action. Third, the leader taps into the emotions of others in a way that brings out their potential.

Yet, charismatic leadership may be situation specific—that is, what becomes inspirational to employees in one setting may not work as well in others. In addition, due to the nature of the vision needed to be perceived as charismatic, it may be that the behaviors are limited to those at the rank of chief executive officer (CEO) or top manager, as well as entrepreneurs. Not all health - care organizations would benefit from such an individual, though he or she may be beneficial to organizations in crisis or those requiring strong direction due to environmental challenges. CASE Choosing a Successor The Rosewood Mental Health Center is a not-for-profit medical facility in suburban Chicago. It opened nearly 50 years ago with the mission of serving the mental health needs of the metropoli - tan area. The center houses three major programs. One unit serves those who experience mental health crises, such as those with thoughts about or attempts at suicide, patients who experience nervous breakdowns, and other similar circumstances in which 24-hour lockdown care becomes necessary. The second unit offers individual and group therapy to individuals with addictions to drugs and alcohol. This unit serves the needs of those in recovery on an outpatient basis. The third unit provides mental health treatment to individuals suffering from depression and similar maladies that are not considered dangerous or at-risk of personal injury. These patients also have access to individual and group counseling.

Recently, the center’s CEO announced her retirement. She planned to step down in six months, thereby allowing the center sufficient time to find a successor. She also offered to serve as mentor to the new CEO during the transition.

The Rosewood Center’s board of directors examined several issues that might affect the selection of a successor. First, the directors believed the organization should expand by adding a fourth unit.

This new unit’s objective would be to serve children with mental health problems and at-risk teens (continued) Groups and Teams Chapter 11 11. 2 Groups and Teams Many people think that the terms team and group are the same, but recent management litera - ture suggests otherwise. Several nuances create distinctions between the two. Teams and groups are similar in that they both consist of a small set of people and they both seek to achieve goals.

At times, groups and teams also share additional elements. For example, they provide venues for socialization and assist in communication and decision-making processes. The following discus - sion delineates the differences between teams and groups.

Groups Understanding the nature and role of groups is a key aspect of leading people. A group consists of two or more people, interacting with a common purpose or goal (Schein, 1968). Groups may be formal or informal and distinguished by characteristics of formation, purpose, and membership.

Formal Groups A formal group is established by the organization and seeks to achieve formal goals and objec - tives. Evidence of the existence of a formal group can be found in company documents, including an organization chart, a management directive to form a group, or group meeting minutes. Three of the most common types of formal groups are work groups, committees, and project teams.

A work group consists of individuals who routinely perform organizational tasks and is identified by an organizational chart. In healthcare, work groups are created around the clinical, adminis - trative, and support functions.

Committees are groups assigned to various company operations and processes. Normally, com - mittees are ongoing groups, such as the set of individuals assigned to the workplace safety who were most likely to drop out of school, join gangs, take drugs, or engage in other dangerous activities. Part of the process to open the new unit would involve writing grants to obtain funding for the program.

Second, the center had experienced conflicts with two area hospitals over the issues of jurisdiction and final decision-making power when a patient received emergency care for a drug overdose or a clear attempt at suicide. Rosewood’s current plan dispatches a mental health expert to the hospital who is supposed to work in concert with the medical team to decide whether the person should be admitted to the hospital or immediately transferred to Rosewood’s lockdown facility. However, sev - eral confrontations have resulted from disagreements about where individuals should be sent.

Third, Rosewood’s image was damaged when the media published accounts of two incidents in which a staff member had physically abused a patient. Both employees were immediately termi - nated; however, news reports about the incidents had received widespread local attention. Board members were worried that perceptions of incompetent management were growing. The board also expressed concerns that the incidents would negatively affect fund-raising efforts.

1. What traits and characteristics would be best suited to the successor for CEO? Explain your choices. 2. Should the new CEO be a job-centered or employee-centered leader? Defend your choice. 3. How might the path–goal theory serve the new leader after he or she takes office? 4. Would this situation best match a transformational or a charismatic leader? Defend your answer. Groups and Teams Chapter 11 committee or the employee benefits committee. Committee members often have temporary assignments, such as a one- or two-year term; after that term, someone else takes the position within the group.

Project groups, or task forces , oversee a project or assignment until it is completed. A task force may be assigned to write a report about a disaster, such as a fire or accident in a healthcare facil - ity. Any unusual incident, such as an infectious outbreak that reaches patients or a large segment of the local community, may result in a project group or task force being assigned to identify the cause of the problem and methods to resolve it.

Informal Groups An informal group , or friendship group, emerges without the endorsement of organizational leaders. It does not have a designated structure, nor does it work toward any goals other than socialization and friendship (Shirky, 2004). Three forces tend to bring informal groups together:

activities, shared sentiments, and interactions.

Activities drive the formation of many informal groups and range from small groups that rou - tinely play cards together during breaks to more elaborate organizational volleyball, softball, or bowling teams. A “lunch bunch” that meets every day for meals has formed around an activity.

Shared sentiments suggest that people make friends with and socialize with people who have the same value sets. Some groups form because their members share similar political views, religious practices, or family situations (e.g., single, new parent, married, divorced).

Interactions result from close physical associations. People who work on the same floor of a hospital are more likely to socialize and form friendships. Those who labor at a remote location of a health system, such as an individual pharmacy, may also band together into an informal group.

Group Members Formal and informal groups consist of four types of members: the leader, opinion leaders, mem - bers in good standing, and the gatekeeper. The leader directs group activities. Formal leaders are assigned by the organization, whereas informal leaders emerge based on the group’s wishes.

Opinion leaders are those most closely aligned with the leader. The name opinion leaders comes from their willingness to express group values. Members in good standing are those included in the group who do not share in any leadership function. A member, opinion leader, or leader may also be the gatekeeper, whose role is to determine who will and will not be included in the group.

Sometimes, the entire group serves in the gatekeeper role, which is known as the gatekeeping function.

Te a m s Te a m s become distinct from groups when the synergies of the group emerge from greater inter - dependence and shared effort among members (Katzenbach & Smith, 1999). Characteristics of teams include the following:

• Sharing leadership responsibilities among members • Shifting to collective responsibility • Evaluating success based on team outcomes rather than individual performance • Improving collective problem solving Groups and Teams Chapter 11 Trust constitutes a key component of a team, because effective teams go beyond interaction and move to the point of collaboration.

Organizations use four common types of teams: self-managed work teams, problem-solving teams, cross-functional teams, and virtual teams. Each type presents potential benefits and chal- lenges to a healthcare organization.

Self-Managed Teams In the past few decades, many organizations have experimented with the idea that employees, rather than supervisors, can successfully direct certain types of work. A self-managed work team consists of a set of employees who are assigned both managerial responsibilities and work tasks.

The managerial activities include planning activities, scheduling work, assigning tasks to indi - vidual team members, overseeing the pace of work, making on-the-spot decisions, and facilitat - ing some elements of the control function. In some instances, self-managed teams even conduct internal performance evaluations. Self-managed work teams have better chances for success when employees are well trained and perform more sophisticated jobs.

In healthcare organizations, considerations related to accountability may limit the use of self- managed teams. Someone will be held accountable for the team’s actions, especially with regard to patient well-being, thereby lessening the chances that a manager or physician would be willing to simply relinquish control. In addition, healthcare providers exhibiting centralization or strong patterns of managerial control at top levels are not the best candidates for such programs.

Problem-Solving Teams When members of an organization are placed into groups to examine specific organizational problems or processes, a problem-solving team may emerge. Teamwork occurs when mem - bers are willing to share information, cooperate, and seek to achieve both group and individual objectives. The Mayo Clinic, among other healthcare providers, has made highly effective use of problem-solving teams for patient care, and their approach serves as a model for many other healthcare organizations (Mayo Clinic, n.d.).

Teams devoted to improving patient-centered care, infection control, or committees established to improve billing practices are examples of problem-solving teams. Chapters 13 and 14 discuss various forms of quality control and quality improvement programs. WEB FIELD TRIP For a more in-depth look at the Mayo Clinic model, visit http://w w w.mayo.edu .

In the Search field, type “Model of Care pdf.” On the Results page, click on “Mayo Clinic Model of Care—MC4270.” Read pages 7 and 15 of the PDF file.

• Which types of teams does the Mayo Clinic employ?

• The brochure stresses the benefits of working in teams. What types of challenges or conflicts do you think might arise among the individuals working on those teams?

• Does the Mayo Clinic seem to place a stronger focus on management or leadership among its physicians? Groups and Teams Chapter 11 Cross-Functional Teams A cross-functional team consists of employees who are from different areas in the company that are brought together for a specific purpose, such as combining experts to work on a problem, task, or issue.

Cross-functional teams resemble a task force. A cross-functional team would be effective in the installation of a new infor- mation technology system across clinical, administrative, and support functions for a healthcare provider. Any committee that serves the overall healthcare organization may function as a cross-functional team.

Note that problem-solving teams, such as an emergency room team working on a patient with multiple injuries, may also be cross-functional teams.

Virtual Teams Emerging technologies allow for members of groups to meet in cyberspace rather than in phys - ical space. Virtual teams employ Internet and digital technologies to achieve common goals, such as collaboration, information sharing, problem solving, and scheduling of activities. Virtual teams are formed for short-term projects and for long-range, ongoing issues. The advantages of virtual teams include reducing travel costs and allowing people from remote locations to par - ticipate. These teams are flexible in that meetings can be arranged fairly quickly, especially when compared with the necessity of traveling to a distant place for meetings. Virtual teams also facili - tate medical research in remote locations. Medical data and study results can be shared across long distances, such as recent research collaborations between the United States and Canada (MacPhail, 2007). Virtual teams are also now used in patient care settings for individuals in remote locations.

Team Building Tuckman and Jensen (1977) explained how teams and groups are built over time. Their model portrays the sequence in which individuals gradually surrender a sense of independence in favor of greater interdependence. Figure 8.4 depicted the stages of group development, which are described in the following sections.

Forming Initially, new members of a group tend to distrust one another and to experience some feelings of uncertainty. Two behaviors emerge in the forming stage. First, members try different actions and activities to see if others in the group deem them as acceptable. Second, the leader, if one has been designated (or those seeking to lead when one has not), undertakes tentative actions. The forming stage ends when sufficient compliance exists so that members view themselves as part of the larger group. © Digital Vision/Thinkstock ▲ ▲ Many healthcare organizations employ problem-solving or cross-functional teams as part of patient care. Groups and Teams Chapter 11 Storming Although members now believe they are part of something, they may disagree with the con- straints imposed by the group, or they may simply test to find the limits. In the storming stage, the leader faces resistance as individuals seek to discover their place in the group’s structure (Tuckman, 1965). If the leader cannot manage the group successfully, the possibility of sub - groups, member procrastination, conflicts between members, and open rebellion arises, and group survival may be at risk. If these obstacles can be overcome, however, the storming stage closes when a leader has been fully accepted by all, often through the efforts of another member who challenges the group to come together. Closer relationships build between members, and discussions of power become less emotional and more matter-of-fact. Thus, the storming stage ends when members share a common set of expectations about behaviors and contributions to the group.

Norming Norms are rules governing behaviors in a group. As Table 11.7 shows, norms apply to three main areas in both formal and informal groups, with many times norms overlapping between the two groups. Norms can be formally or informally sanctioned with approval or disapproval by group members.

Table 11.7 Examples of norms Norm type Examples of norms Effort Time on the job/overtime Precision/attention given to medical care Effort made filling out medical records and following protocols Work behaviors Clothes/uniforms worn Use of language when treating patients Attention to hygiene/sterilization procedures Protecting patient confidentiality Social behaviors Fraternization among physicians, managers, nurses, and other employees Romances Norms provide vital organizational functions in healthcare. They clarify the key values of the group or organization and convey a sense of identity. Norms can assist an individual in either meeting behavioral expectations or avoiding making behavioral mistakes. Some authors argue that norms help the group or the organization survive (Feldman, 1984).

Performing When the group reaches the point at which the primary activities revolve around solving task problems, the performing stage has opened, and a team emerges. Members communicate openly, support each other, and resolve disputes quickly and constructively (Tuckman, 1965; Tuckman & Jensen, 1977). At this point, interdependence reaches its peak and independence has been sur - rendered as much as it will be. Ongoing work groups and committees that reach the performing stage remain in place, unless drastic events interfere. Project teams and informal groups with an endpoint (e.g., the bowling season ends) move to the final stage. Groups and Teams Chapter 11 Adjourning Teams and groups that successfully com- plete tasks often end with a ceremony or celebration, such as a party, an official statement of appreciation by company lead - ers, or even a graduation or mock funeral.

Individuals then resume their work with a stronger sense of independence as the group disbands.

The Manager’s Role in Team Building Managers and leaders can assist group func - tioning at every stage of development. In the forming stage, they can make members feel as comfortable as possible and establish basic ground rules. In the storming stage, an effective leader works to resolve con - flicts and differences of opinion. In the norming stage, the leader can ensure that unethical or counterproductive norms do not emerge. In the performing stage, the leader serves as a facilitator to group activities. In the adjourning stage, a leader can summarize group accomplishments and express gratitude for good work.

Forming Effective Teams Effective teams have certain characteristics. When moving beyond group composition toward interdependent teams, four elements deserve consideration in describing quality teams: the com - position of the team, the design of the work, contextual factors, and process variables. In addition, effective teams exhibit cohesiveness.

Team Composition Healthcare managers play an important role in designing teams with the best chances for suc - cess. The managers must ensure that the right personalities and skill sets are assigned to patients, treatments, and other activities. Chosen team members should have indicated an interest in being included in the group. Member selection can make or break a team.

Work Design In healthcare organizations, simple tasks are often better handled by a single individual. However, more complicated projects often involve a team working together. Members of the team should know that they have sufficient authority and autonomy to finalize work and care for patients.

Thus, work objectives should focus on interesting, challenging, and important organizational chores, whenever possible.

Contextual Variables In healthcare organizations, a trusting environment encourages cooperation and shared effort, which, in turn, build trust for the future. Shared professionalism represents a key contextual variable in many healthcare settings. Other contextual variables that contribute to the success of a team include adequate resources, quality leadership, and the organizational reward system. © Chris Clinton/Photodisc/Thinkstock ▲ ▲ Teams and groups that successfully complete tasks often end with a ceremony or celebration. Groups and Teams Chapter 11 Resources become necessary to assist team activities. Members who have access to needed funds and technological support are more likely to buy in and support the team (Bishop, Scott, & Burroughs, 2000). Quality leadership occurs when the leader’s efforts are dedicated to making sure the group functions smoothly. Effective leaders set challenging expectations and operate in a positive fashion. The organizational reward system consists of the performance evaluation program and the delivery of rewards. Group-based incentives contribute to more effective teams.

When rewards for performance do not exist, the potential for team dissent and demise rises.

Process Variables The final component in a successful team effort involves the manner in which the team operates.

Four elements combine to ensure a more efficient operational process: a common purpose among members, confidence, specific goals, and managed conflict. . Effective teams are most likely to be present when all four features combine to create the best environment and are more likely to experience positive outcomes.

A common purpose evolves from factors such as group cohesiveness and well-developed norms.

Team confidence, or team efficacy, results from successful endeavors. For example, a team can build on previous victories, such as the successful treatment of a difficult medical case. Specific goals clarify member roles, with difficult goals being associated with higher levels of effort and performance. Managing conflict, the fourth element, necessitates careful managerial action, as will be discussed in the next section.

Cohesiveness The degree of cohesiveness experienced by a team depends on goal commitment, conformity, cooperation, and group control over members. The term tight knit relates to teams and groups exhibiting higher levels of cohesion. The degree of cohesion in a group affects productivity and performance.

A group with too little cohesion often suffers from a lack of productivity. The problems associ - ated with low cohesion include goal disagreement rather than agreement, a lack of conformity to group norms, and the absence of cooperation.

Groups with desirable levels of cohesion tend to achieve the highest levels of success. Among the benefits of cohesive groups are the following:

• Productivity • Members helping out those experiencing problems • Extra effort given during a crisis • Members working without supervision • A positive social atmosphere Healthcare managers have vested interests in developing and maintaining cohesive groups (Litterer, 1973; Seashore, 1954). One method used to build cohesion occurs when a manager creates overarching superordinate goals, such as a strong emphasis on patient safety, in order to bond members together. Effective leaders understand individual member needs and build team cohesion; ineffective leaders drive wedges between members (Homans, 1950).

Teamwork Trends in Healthcare Teamwork has become an increasingly important component of healthcare. Trends include grow - ing utilization of problem-solving teams, cross-functional teams, and virtual teams. These teams Conflict Management Chapter 11 not only create value in patient treatment programs, but they also assist in situations such as the outbreak of a disease—for example, the severe acute respiratory syndrome (SARS) outbreak in 2003. The Centers for Disease Control and Prevention (2011) routinely relies on committees and teams to deal with various health issues.

Many medical organizations have begun to recognize the value and importance of team building and teamwork (Rutherford, Lee, & Greiner, 2004). Benefits include elevated employee morale as a result of job satisfaction, patient satisfaction with the healthcare provider, improved care, reduc- tion in medical errors, and more efficient use of employee time and organizational resources (Ruddy & Rhee, 2005; Mickan, 2005). An emerging trend includes forming quality-improvement teams for hospitals and health centers. To realize the benefits of teams, certain challenges must be overcome. First, some difficulties may emerge when physicians are asked to cooperate in a group setting. The nature of personal responsibility and accountability for patient care makes it more difficult to relinquish control. Second, in administrative settings, management must avoid the common problems that groups in all types of organizations encounter, including additional time needed to reach decisions, the potential for conflict among members, the cost of operating a team or group meeting, difficulties in scheduling meetings, and making compromises rather than high-quality decisions.

11. 3 Conflict Management Many people view conflict as a destructive, violent, or angry negative force. Others view conflict as a continuum from mild disagreement to major confrontations. Over time, conflict has been seen as something to be avoided or eliminated, as something inevitable but manageable, or as a driving force that leads to innovation and much-needed change (Fink, 1968; De Dreu & Van de V lier t, 1997).

Conflict occurs when one party negatively affects or seeks to negatively affect another party (Thomas, 1977). Conflict can be observable or perceived (Wall & Callister, 1995). For exam - ple, someone may perceive that a conflict exists even when it would be difficult to point out an observable event.

Recently, conflict has been conceptualized as taking two forms. In an organizational context, functional conflict occurs when the organization’s interests are served in some way, such as improvement in performance or greater cooperation among individuals or groups. Functional conflict is also called constructive or cooperative conflict . Dysfunctional conflict takes the form of destructive activities that hinder group or organizational performance (Amason, 1996). Table 11.8 identifies three categories of dysfunctional conflict.

Table 11.8 Categories of dysfunctional conflict Conflict category Description Ta s k Related to the type of work and goals Relationship Interpersonal disputes Process Disagreements about methods of doing a job or performing a task Source: Adapted from Amason, 1996. Conflict Management Chapter 11 Levels of Conflict Four levels of conflict occur in workplace environments. Resolving conflict cannot take place until the level has been properly identified. The four levels are as follows:• Intrapersonal or intrapsychic conflict • Interpersonal conflict • Intragroup conflict • Intergroup conflict Intrapersonal conflicts occur within an individual. An individual’s ideas, thoughts, values, and emotions can conflict with one another. For example, for a healthcare professional, prolonging a patient’s life but causing additional suffering creates an intrapsychic conflict. Time spent pro - viding medical care at the expense of one’s personal or family life also generates intrapersonal conflict.

Interpersonal conflicts take place between individuals. Many times, two individuals in a medical environment enter into conflicts. Personality conflicts emerge from disagreements about patient care or from workplace incivility. Examples of incivility include sexually inappropriate comments, racial or ethnic slurs, ridicule of older or younger workers, derision based on sexual orientation, and insensitive comments about physical or mental disabilities. Professional jealousies may also inspire interpersonal conflicts in healthcare facilities.

Intragroup conflict refers to incidents between members of a group. Disagreements about goals, methods of operation (such as patient care or the use of drugs), and who will be the leader cre - ate intragroup conflicts. The result of such conflict can be poor decisions and ineffective group functioning.

Intergroup conflict takes place between various groups, such as between departments within an organization or other factions, such as nurses, technicians, or the janitorial staff, or between ethnic or gender (male versus female) groups.

Each type of conflict requires an intervention. In the case of an intrapersonal conflict, a coun - selor or adviser may assist. Interpersonal, intragroup, and intergroup conflicts may be resolved in a variety of ways. Managers must choose the most appropriate method for dealing with each problem as it arises (Bazerman & Neale, 1992).

Stages of Conflict Figure 11.2 provides a modified version of a commonly cited model of conflict developed by Louis Pondy (1967). The model suggests a conflict cycle, which suggests that when individuals encounter a series of conflicts (even when those individuals are only spectators to the conflict), they become increasingly sensitized to the events. As a result, subsequent conflict will be more likely. In a more tranquil period, organizational participants become more patient with each other, and the net result will be reduced numbers of open conflict. Managerial skill and intervention can break the cycle of increasing conflict. Conflict Management Chapter 11 Latent conflict represents all of the potential sources of conflict. In medical care, conflicts arise in a variety of circumstances. For example, disputes emerge between patients and physicians over the nature and quality of care provided; physicians disagree among themselves about patient care; clashes take place between physicians and nurses; and patients battle with health insur- ance providers, healthcare billing departments, and others in the healthcare facility. Healthcare providers also experience incidents with governing officials, health insurance providers, and the local community. Table 11.9 provides examples of the types of latent conflict present in health - care settings.

Table 11.9 Latent conflicts in healthcare settings Setting type Conflict types Administrative personnel Provider vs. insurance company Provider vs. government agency Provider vs. patient (billing) Provider vs. individual person or organizational donor Provider vs. provider Clinical personnel Physician vs. physician Physician vs. nurse or nursing staff Physician vs. patient (type of care, malpractice charges) Physician vs. patient’s family members Physician vs. administration (disputes over expenditures to improve a patient’s health) Support personnel Provider vs. supplier Figure 11.2 A conflict model and the conflict cycle f11.02_HCA340.ai Latent con ict Felt con ict Open con ict Con ict aftermath Perceived con ict Based on model by Pondy, 1967. (continued) Conflict Management Chapter 11 Setting typeConflict types Individual Job assignments Performance appraisals Promotions Pay raises Personality issues and incivility Dependence/bottlenecks Goals Status differences Communication breakdown Power differences Ethical violations Group or departmental Group task assignments Budgets/resources allocations Personalities of group members Dependence/bottlenecks Goals Communication breakdown Ethical issues The potential sources of conflict may or may not erupt into open confrontations. Some issues exist for years without ever becoming manifest, whereas others quickly develop into altercations.

Frustration may be the driving force that moves a conflict from a potential issue into a more tangible stage (Meyers, 1990). When a healthcare professional has a goal in mind, and a policy, action, behavior, or any other overt or covert barrier prevents achievement of that goal, conflict becomes more likely. The employee’s goal could be a political outcome, such as getting an unde - served promotion or acquiring funding for a specific project or piece of medical equipment, or as positive as trying to help out a coworker.

Felt conflict occurs when people know something is wrong but cannot pinpoint the source. A per - son may have the experience of walking into a room and knowing immediately something is not right, but he or she has no clue of the actual problem. At that point, the person “feels” the conflict.

Perceived conflict means that those near a conflict know the issues and the people involved, yet do not feel discomfort from it. In essence, the conflict is someone else’s problem. Often, perceived conflicts appear in departments or parts of the organization where the individual does not work.

As felt and perceived conflict intensify, perceptions become distorted. The tendency shifts toward interpreting people and events as either for or against a side in the conflict. Thinking reverts to more stereotypical and biased forms that favor a person’s viewpoint, which sets the stage for more open conflict (Lewicki & Hiam, 2006).

Open conflicts emerge as showdowns, confrontations, and other outward signs. Often, an open conflict results from ongoing escalation of an issue. As this escalation takes place, communica - tion between the parties decreases, and issues become blurred by generalizations or by blanket statements such as “You always . . .” or “You never . . .”. Parties to the conflict lock into positions and tend to magnify differences and minimize similarities between the two sides. Conflict Management Chapter 11 Open conflict behaviors include yelling, loud arguments, and even violence toward others at the individual level. At the group level, behaviors include work slowdowns, strikes, and deliberate rules violations. At that point, conflict resolution must take place. A manager or arbiter will need to step in.

Conflict Resolution: Responding to Concerns Conflict resolution includes elements of negotiation combined with the need to understand the concerns of the parties involved. The dual concerns model, as developed by Pruitt, Rubin, & Kim (1994), suggests a combination of concerns about personal outcomes and about the other side’s outcomes. Figure 11.3 displays the potential responses to these concerns.

When one side has little concern about the other’s outcomes, the two potential responses are contention and inaction.

Contending or competing occurs when one side fully pursues its outcomes without regard for the outcomes of the other side. Stronger tactics, such as threats, intimidation, and unilateral action, appear. Other terms associated with con - tending include dominating and forcing (Ra him, 1985).

Inaction or avoiding results in withdrawal or being passive, because the party involved has little regard for its own outcome and no concern for the other’s outcome. In essence, one side retreats from the conflict.

For circumstances in which concern for the other’s outcomes are high, two possible actions are yielding and problem solving. Yielding or accommodating involves seeking to help the other side © Blend Images/SuperStock ▲ ▲ Open conflicts require skilled resolution. Figure 11.3 Responses to concerns f11.03_HCA340.ai Low concern for other’s outcomes High concern for other’s outcomes Moderate concern for other’s outcomes contention/competition inaction/avoidance yielding/accommodating problem compromise Source: Adapted from Pruitt, Rubin, and Kim, 1994. Conflict Management Chapter 11 achieve its outcomes with little care about one’s own outcomes. Yielding is also known as obliging and smoothing (Rahim, 1985). Problem solving or collaborating occurs when high concern for the other’s outcomes accompanies high concern for personal outcomes. The goal becomes a win–win solution. Problem solving has also been labeled as an integrating approach .

When there is a moderate level of concern for both personal outcomes and the other side’s out - comes, the most common approach involves compromising. A compromise becomes more likely when the two sides hold equal levels of power, consensus cannot be reached, and the goals of the two parties are not strongly connected.

Discovering the relative positions of the two sides becomes part of the conflict-resolution process.

Managers try to identify the level of give and take by assessing the strength of commitment each side has to its position. More effective negotiations or resolutions then become possible.

Conflict-Resolution Process A manifest conflict often requires a cooling-off period before any attempt at resolution can start.

When emotions are high, reasonable dialogue becomes unlikely. Once an arbiter or manager sur - mises that both sides have sufficiently calmed down, conflict resolution can commence. Note that in healthcare settings, however, disputes regarding patient care often require a more immediate resolution, due to the nature of the emergency.

The steps of the conflict-resolution process are as follows:

1. Identify the parties involved. 2. Identif y the issues. 3. Identify the positions of the parties. 4. Find the bargaining zone. 5. Make a decision.

Identifying the parties begins with discovering whether an individual conflict or a group conflict exists. The arbiter must quickly understand whether an administrative, clinical, or support issue is the source of the conflict. For some conflicts, identifying the issues takes time and discovery.

Many times a conflict becomes manifest, on first inspection, due to something quite minor. For example, when two persons become involved in a shoving match over who uses the copier first, the real issue lies elsewhere.

In a two-person or two-group conflict, identifying the positions of the parties is fairly easy. Many times, however, a problem or concern exhibits many facets, with the result being that several people or coalitions have some sort of vested interest in the outcome. To effectively resolve the conflict, the moderator must determine the agendas of each party.

The bargaining zone in a conflict resolution consists of the area in which give and take can be carried out. At times, no such range may be found; one side will win, and the other will lose. For example, if a patient receives one therapy, such as radiation for a cancerous tumor, any other, such as chemotherapy, will not be viable until the radiation cycle has been completed. Conflict Management Chapter 11 Making the final decision determines the outcome of the conflict. A win–win solution allows all sides to make gains. A win–lose solution means one side gains the advantage over the other. A lose– lose, or compromise, means both parties gain on some issues but lose on others (Rackham, 1976).

When the result of a conflict resolution has been handled well, benefits may occur at the inter- personal, intergroup, and intragroup levels. Some of these positive conflict outcomes include the following (King, 1981):

• Conflicts may serve as safety valves to reduce pent-up emotions and pressures.

• Conflicts generated by external threats may increase internal cohesion.

• Conflicts can help introduce much-needed change.

• Conflicts can bring longstanding animosities and hidden agendas to the surface.

• Conflicts may trigger creativity and innovation.

• Conflict resolution may foster increased communication in the future.

Additional Approaches At times, a conflict stands a better chance at effective resolution when a third party intervenes.

Alternative dispute resolution attempts to incorporate more user-friendly methods of dispute res - olution in order to avoid adversarial approaches. The following are methods used in this approach:

• Facilitation • Conciliation • Peer review • Ombudsman • Mediation • Arbitration Facilitation involves a third party urging the two sides to meet and deal directly in a constructive and positive fashion. Clinical decisions often may be reached through facilitation. Conciliation uses a neutral third party who acts informally as a communication conduit to help resolve a dispute without directly meeting. In healthcare facilities, personnel or human resource concerns and interpersonal conflicts may be resolved through conciliation.

Peer review asks a panel of trustworthy coworkers who can remain objective to render a nonbind - ing verdict or opinion about how the conflict should be resolved. Review of results of medical studies and mortality meetings constitute two types of peer review.

An ombudsman is a respected employee who will hear both sides of an argument and attempt to arrange a solution acceptable to both sides. In a healthcare facility, an ombudsman listens to employees, patients, families of patients, and others with disagreements or disputes. Often, the ombudsman becomes involved in policy matters.

Mediation employs a trained arbiter to find innovative solutions to the conflict. Arbitration retains a third party who will operate in a formal, courtlike environment to hear testimony and evidence before rendering a judgment about how the conflict should be resolved. Mediation and Conflict Management Chapter 11 arbitration are part of labor– m anagement negotiations, such as when a nurses’ union bargains with a hospital’s administration.

Conflict Outcomes The goal of any conflict resolution should be to reach a functional settlement. Three desired outcomes of conflict resolution are agreement, stronger relationships, and organizational learning. Agreement has been achieved when both sides believe a settlement was fair or equitable. Stronger relationships emerge when both parties try to build trust and goodwill for the future.

Organizational learning takes place when an individual or group achieves greater self- awareness or better understands how to find creative solutions to problems. Although desirable, these goals are difficult to achieve. Many times, the negative aftereffects of conflict include the following:

• Anger, revenge, continuing attempts to make the other side look bad • Noncompliance with orders and decisions • Reduced effort or passive resistance • Empire building, withholding information, territory defense • Increasingly legalistic approach to tasks and assignments • Withdrawal behaviors, such as daydreaming or meeting in groups to visit • New lobbying efforts • Sarcasm in front of the mediator • Increased sensitivity to statements and comments Effective conflict management includes two primary activities. The first involves managers actively analyzing potential sources of conflict at all times so that removing the source can be accom - plished. The second involves managers seeking to become quality conflict arbiters. Managers should remember that impartiality, a sense of humor, and a calm disposition are major assets in conflict resolution. © iStockphoto/Thinkstock ▲ ▲Mediation and arbitration are often part of labor– management negotiations. Chapter Summary Chapter 11 Chapter Summary Leadership involves influencing the behaviors of individuals and groups toward predetermined organizational goals. Formal leaders have been elected, appointed, or promoted into the role. An organization chart depicts the formal leadership hierarchy. Informal leaders or emergent leaders arise from individual situations and circumstances. Administrative leadership consists of indi- viduals who develop and implement organizational strategies and provide support mechanisms for the operation of the overall organization. Clinical leadership applies to the direction and sup - port of those providing medical patient care.

Trait theories of leadership include the “great man” and big five approaches. Emotional and political intelligence have also been associated with leadership from this perspective. Behavioral leadership theories include the University of Michigan studies, the Ohio State studies, and the Scandinavian development-oriented approach. Situational and contingency theories include Hersey and Blanchard’s situational leadership model and Fiedler’s contingency model. Recent trends in leadership have resulted in the substitutes for leadership approach, the leader–member CASE Staff Infection The Robertson County Walk-In Clinic faced a new and powerful danger. The facility, which employs 6 physicians, 10 nurses, and 8 support staff, had been an efficient and effective unit for more than a decade. The team of physicians worked well together and seemed to have a high level of cohesion.

In the past month, it was discovered that an outbreak of methicillin-resistant Staphylococcus aureus ( MRSA ) had infected several patients who visited the clinic. Some of the patients reported only a boil or skin infection. Unfortunately, some of the more invasive cases became deadly, invading the bloodstream, flesh, lungs, and bones of those infected.

Robertson’s primary manager decided to form a task force that would work in conjunction with local health officials to discover the cause and to take steps to prevent recurrence. As is often the case, friction arose quickly between several individuals within and outside of the group. Differences of opinion regarding methods to examine past cases arose among the physicians, nurses, and the local official helping with the analysis. Additional tension emerged when patients began fil - ing claims for insurance coverage of the ailment. Families of two of the most serious cases had contacted attorneys and were preparing lawsuits against the organization. All of the physicians expressed concerns about malpractice and negligence claims against them individually and against the organization. Time pressures only accentuated the apprehension regarding what was to come.

The committee knew that better hand-washing by doctors and nurses and testing for MRSA when patients are admitted for care had been undertaken years ago. Concerns were raised that somehow the janitorial company that helped clean the facility might have contributed to the problem. No matter what the outcome, fast action was needed.

1. Are the people assigned to tend to this outbreak members part of a team or a group? Explain your response. 2. Describe how the stages of team building would take place in this situation. 3. Would conflicts among the team members be functional or dysfunctional in nature? Explain your answer. 4. How should conflicts among members of the group regarding methods of analysis be resolved? Key Terms Chapter 11 exchange model, the vertical dyad linkages theory, the path–goal theory, and studies of transfor - mational and charismatic leadership.

A formal group, which is established by an organization, consists of two or more people, inter - acting with a common purpose or goal. Informal or friendship groups emerge without organiza - tional recognition. In both groups, group members include the leader, opinion leader, members in good standing, and the gatekeeper.

Teams are distinguished from groups in that the former exhibit greater interdependence and shared effort among members. The different types of teams include self-managed, problem- solving, cross-functional, and virtual teams. The stages of group development include forming, storming, norming, performing, and adjourning. Effective teams result from quality team com - position, work design, and integration of contextual variables. They also exhibit cohesion.

Conflict occurs when one party negatively affects or seeks to affect another party. Conflict, which may be functional or dysfunctional, occurs at the intrapersonal, interpersonal, intragroup, and intergroup levels. Conflict moves through latent, felt, perceived, and open stages. Conflict resolu - tion involves identifying the parties, issues, positions, and bargaining zone. Then a decision may be reached. Conflict resolution may result in either positive or negative outcomes. Additional approaches to resolving conflicts include facilitation, conciliation, peer review, an ombudsman, mediation, and arbitration. Ke y Te r m s administrative leadership developing and implementing organizational strategies and provid - ing the support mechanisms for operation of the overall organization clinical leadership the direction and support of patient medical care conflict what occurs when one party negatively affects or seeks to negatively affect another party dysfunctional conflict conflict that takes the form of destructive activities that hinder group or organizational performance formal group a group established by the organization that seeks to achieve formal goals and objectives formal leader a leader who has been elected, appointed, or promoted into the role functional conflict what occurs when the organization’s interests are served in some way by a conflict group two or more people, interacting with a common purpose or goal informal group ( or friendship group ) a group that emerges without the endorsement of orga - nizational leaders informal leader ( or emergent leader ) a leader who arises from an individual situation and circumstance leadership influencing the behaviors of individuals and groups toward predetermined organi - zational goals Critical Thinking Chapter 11 norm a rule governing behaviors in a group or team team a group in which synergies emerge from greater interdependence and shared effort among members Additional Resources American College of Healthcare Executives http://w w w.ache.org Healthcare Leadership Council h t t p : //w w w.hlc.org Health Leaders InterStudy h t t p : //www.hl-isy.com National Center for Healthcare Leadership h t t p : //www.nchl.org National Public Health Leadership Institute h t t p : //www.phli.org World Health Organization Health Leadership Service h t t p : //w w w.w ho. i nt / h rh /e duc at ion /en Critical Thinking Review Questions 1. Define the following: leadership, formal leaders , informal leaders , administrative leader - ship , and clinical leadership . 2. What “big five” personality factors have been associated with leadership? 3. What three studies were conducted as behavioral theories of leadership? 4. What are the substitutes for leadership? 5. Explain a leader–member exchange and a vertical dyad linkage. 6. What four leadership styles are used in path–goal theory? 7. Define transformational leadership and charismatic leadership. 8. Define the term group. 9. What three types of formal groups are found in organizations? 10. What brings informal or friendship groups together? 11. Define the term team and describe four common types of teams. 12. Describe the stages of group development or team building. 13. What characteristics are found in effective teams? 14 . Define conflict , functional conflict , and dysfunctional conflict . 15. What levels of conflict occur in healthcare settings? 16 . What stages of conflict take place in Pondy’s model? 17. What are the steps of conflict resolution? Analytical Exercises 1. Which is the more applicable term—leadership or management (or both)—in the following circumstances?

• Emergency room doctor directing activities for an injured patient • Head of teaching unit assigning residents to physicians Critical Thinking Chapter 11 • Forming a summer softball team for a healthcare facility’s employees • Creating a strategic marketing plan for a major hospital 2. Which leader traits and characteristics, as described in this chapter, match job-centered and initiating structure behaviors? Which leader traits and characteristics, as described in this chapter, match employee-centered and consideration behaviors? 3. In a community hospital, how might the leader activities of telling and directing, selling and coaching, facilitating and counseling, or delegating unfold when a leader interacts with his or her in group in an administrative staff? With the leader’s out group? Explain your answer.

Would it be different if it were a physician leading a clinical staff? 4. In a healthcare facility, explain the relationships among directive, supportive, achievement- oriented, and participative leadership with transactional and transformational leadership. 5. Social loafing occurs when group members give less effort to a group than they would if working individually. At the extreme, social loafing involves a member taking a free ride and contributing nearly nothing to the group. Explain how social loafing would take place in the following circumstances:

• Emergency room diagnostic team • Executive planning committee for hospital expansion • Committee to address incidents of unprofessional physician behavior • Night cleaning crew 6. Groupthink results when group pressures for conformity become so intense that the group avoids unusual, minority, or unpopular views. At the extreme, groupthink becomes a process by which the group develops a sense of invulnerability, believing it can function without out - side influence or sanction. The group self-censors information and fails to perform effectively with organizational confines. Describe what groupthink might look like in the following cir - cumstances (if you are unfamiliar with any of these types of committees, look them up online):

• Morbidity and Mortality Committee • Medical Ethics Violations Board • Nurses Union Management Team 7. Provide examples of task conflict, relationship conflict, and process conflict (the three cat - egories of dysfunctional conflict) in the following circumstances:

• Disagreement about whether to perform surgery or to prescribe physical therapy (physi - cian vs. physician) • Conflict regarding the type of fund-raising program a hospital should create (marketing department manager vs. CEO) • Dispute with a supplier that failed to maintain adequate inventories for a physician’s office • Argument between a health insurance company and a hospital about payment for a patient’s care 8. Evaluate the following statement: “Conflict is inevitable and cannot be avoided, but rather managed.” How would a hospital’s management team implement this statement?