Motivation in Health Care Organizations

This week, we are focusing on Management and Motivation (Chapter 3). Be sure to read chapter 3 before participating in this week’s discussion board.
Our discussion board is going to focus on the Case Study entitled “Seaside Convalescent Care Center”. You can download this case by clicking on this link:
Seaside Case Study.pdf
Please read through the case very carefully and then think about the issues covered in the case in light of the information that you learned in Chapters 3 and 4. Next, read through the questions at the end of the case — This will get you thinking about the various issues. Lastly, answer the following question in your initial post:

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Does Mindy have the right idea? Why or why not? Explain what should be done to handle the problems at hand at Seaside Convalescent Care Center. iinually challenged to motivate a workforce to do two things. The first is to motivate employees to work toward helping the organization achieve its goals. The second is to motivate employees to work toward achieving their own personal goals. Meeting the needs and achieving the goals of both the employer and the employee is often difficult for managers in all types of organizations. In health care, however, this is often more difficult, in part as a result of the complexity of health care organizations, but also as a function of the wide array of employees who are employed by or work col- laboratively with health care providers in delivering and paying for care.

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Workers run the gamut from highly trained and highly skilled technical and clinical staff members, e.g., physicians and nurses, to relatively unskilled workers (see Chapter 11 for more on this topic). To be successful, health care managers need to be able to manage and motivate this wide array of employees. Motivation—the Concept According to Webster’s New Collegiate Dictionary, a motive is “something (a need or desire) that causes a person to act.” Motivate, in turn, means “to provide with a motive,” and motivation is defined as “the act or process of motivating.”

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Thus, motivation is the act or process of providing a motive that causes a person to take some action. In most cases, motivation comes from some need that leads to behavior which, in turn, results in some type of reward when the need is fulfilled. This definition raises a couple of basic questions. What Are Rewards? Rewards can take two forms. They can be either intrinsic/internal rewards or extrinsic/ external rewards.

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Intrinsic rewards are derived from within the individual. For a health care employee, this could mean taking pride and feeling good about a job well done (e.g., providing excellent patient care). Extrinsic rewards pertain to those reinforcements that are given by another person, such as a health care organization giving bonuses to teams of workers when quality and patient satisfaction are demonstrated to be exceptional. Who Motivates Employees? While rewards may serve as incentives and those who bestow rewards may seek to use them as motivators, the real motivation to act comes from within the individual.

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Managers do exert a significant amount of influence over employees, but they do not have the power to force a person to act. They can work to provide various types of incentives in an effort to influence an employee in any number of ways, such as by changing job descriptions, rearranging work schedules, improving working conditions, reconfiguring teams, and a host of other activities. While these may have an impact on an employee’s level of motivation and willingness to act, when all is said and done, it is the employee’s decision to take action or not.

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In discussing management and motivation, it is important to continually remember the roles of both managers and employees in the process of motivation. Is Everybody Motivated? As managers, we often assume that employees are motivated or will respond to induce- ments from managers. While this is perhaps a logical and rational approach from the man- ager’s perspective, it is critical to understand this is not always the case. The majority of employees do, in fact, want to do a good job and are motivated by any number of factors.

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Others, however, may not share that same drive or high level of motivation. Those people may merely be putting in time and may be more motivated by other things, such as family, school, hobbies, or other interests. Keeping this in mind is useful in helping health care managers understand employee behaviors that seem to be counterproductive. History of Motivation There is a plethora of research on the topic of motivation, particularly motivation in the workplace. The concepts of management and motivation often coincide when an organization is striving toward a goal.

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In order to fully understand the concept of motivation, a manager must understand its significance. Motivation is not a new concept. Approximately 2,500 years ago, Athens rose to unparalleled political and economic power and allowed the citizenry to become active in civic governance. Through an engaged and participative citizenry, the Athenian people helped produce the first great Greek empire, which allowed for better commerce and trade; increased wealth of its citizens; and a culture that spawned historically known philosophers, artists, and academics.

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To achieve this type of success, organizations must recognize the full power of their employees and motivate them to reach for the common good of the organization (Manville & Ober, 2003). Fast forward to more recent times, and we can continue to identify the historical significance of motivation. In 1890, empirical psychologist William James identified aspects of motivation and its relationship with intrinsically motivated behavior. In 1943, psychologist Clark Hull published his now famous drive theory. Hull believed all behaviors to be connected to four primary drives: hunger, thirst, sex, and the avoidance of pain; according to this view, all drives provide the energy for behavior (Deci & Ryan, 1985). Research into human behavior started being recognized in the workplace in the 1940s. Researchers recognized people were motivated by several types of varying needs, not only in the workplace but also in their personal lives (Sperry, 2003).

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Workplace motivational theories continue to evolve, as is shown in the discussion concerning theories of motivation. Theories Of Motivation Psychologists have studied human motivation extensively and have derived a variety of theories about what motivates people. This section briefly highlights the motivational theories that are widely known in the field of management. These include theories that focus on motivation being a function of (1) employee needs of various types, (2) extrinsic factors, and (3) intrinsic factors. Each set of theories follows.

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Needs-Based Theories of Motivation Maslow’s Hierarchy of Needs Maslow (1954) postulated a hierarchy of needs that progresses from the lowest, subsistence-level needs to the highest level of self-awareness and actualization. Once each level has been met, the theory is that an individual will be motivated by and strive to progress to satisfy the next higher level of need. The five levels in Maslow’s hierarchy are: ■■ ■■ ■■ ■■ ■■ Physiological needs—including food, water, sexual drive, and other subsistence- related needs; Safety needs—including shelter, a safe home environment, employment, a healthy and safe work environment, access to health care, money, and other basic necessities; Belonging needs—including the desire for social contact and interaction, friend- ship, affection, and various types of support; Esteem needs—including status, recognition, and positive regard; and Self-actualization needs—including the desire for achievement, personal growth and development, and autonomy.

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The movement from one level to the next was termed satisfaction progression by Maslow, and it was assumed that over time individuals were motivated to continually progress upward through these levels. While useful from a theoretical perspective, most individuals do not view their needs in this way, making this approach to motivation a bit unrealistic. Alderfer’s ERG Theory The three components identified by Alderfer (1972) in his ERG theory drew upon Maslow’s theory, but also suggested individuals were motivated to move forward and back- ward through the levels in terms of motivators.

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He reduced Maslow’s levels from five to the following three: ■■ ■■ ■■ Existence—which related to Maslow’s first two needs, thus combining the physi- ological and safety needs into one level; Relatedness—which addressed the belonging needs; and Growth—which pertained to the last two needs, thereby combining esteem and self-actualization. Alderfer also added his frustration–regression principle, which postulated that indi- viduals would move in and out of the various levels, depending upon the extent to which their needs were being met. This approach is deemed by students of management to be more logical and similar to many individuals’ worldviews.

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Herzberg’s Two-Factor Theory Herzberg (2003) further modified Maslow’s needs theory and consolidated it down to two areas of needs that motivated employees. These were termed: ■■ ■■ Hygienes—lower-level motivators which included, for example, “company policy and administration, supervision, interpersonal relationships, working conditions, salary, status, and security” (p. 5). Motivators—higher-level factors which focused on aspects of work, such as “achieve- ment, recognition for achievement, the work itself, responsibility, and growth or advancement” (p. 5). Herzberg’s is an easily understood approach that suggests that individuals have desires beyond the hygienes and that motivators are very important to them.

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McClelland’s Acquired Needs Theory

The idea here is that needs are acquired throughout life. That is, needs are not innate but are learned or developed as a result of one’s life experiences (McClelland, 1985). This theory focuses on three types of needs: ■■ ■■ ■■ Need for achievement—which emphasizes the desires for success, for mastering tasks, and for attaining goals; Need for affiliation—which focuses on the desire for relationships and associations with others; and Need for power—which relates to the desires for responsibility for, control of, and authority over others.

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All four of these theories approach needs from a somewhat different perspective and are helpful in understanding employee motivation on the basis of needs. However, other theories of motivation also have been posited and require consideration.

Extrinsic Factor Theories of Motivation

Another approach to understanding motivation focuses on external factors and their role in understanding employee motivation. The best known of these follow. Reinforcement Theory B. F. Skinner (1953) studied human behavior and proposed that individuals are motivated when their behaviors are reinforced. His theory is comprised of four types of reinforcement. The first two are associated with achieving desirable behaviors, while the last two address undesirable behaviors:

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■■ ■■ ■■ ■■ Positive reinforcement—relates to taking action that rewards positive behaviors; Avoidance learning—occurs when actions are taken to reward behaviors that avoid undesirable or negative behaviors. This is sometimes referred to as negative reinforcement; Punishment—includes actions designed to reduce undesirable behaviors by creating negative consequences for the individual; and Extinction—represents the removal of positive rewards for undesirable behaviors.

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Likewise, if the rewards for desirable behaviors cease, those actions can be impacted as well. The primary criticism of the reinforcement approach is that it fails to account for employees’ abilities to think critically and reason, both of which are important aspects of human motivation. While reinforcement theory may be applicable in animals, it doesn’t account for the higher level of cognition that occurs in humans.

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Intrinsic Factor Theories of Motivation

Theories that are based on intrinsic or endogenous factors focus on internal thought processes and perceptions about motivation. Several of these are highlighted: ■■ ■■ ■■ Adams’ Equity Theory—proposes individuals are motivated when they perceive they are treated equitably in comparison to others within the organization (Adams, 1963); Vroom’s Expectancy Theory—addresses the expectations of individuals and hypoth- esizes they are motivated by performance and the expected outcomes of their own behaviors (Vroom, 1964); and Locke’s Goal-Setting Theory—hypothesizes establishing goals motivates individu- als to take action to achieve those goals (Locke & Latham, 1990).

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While each of these theories deals with a particular aspect of motivation, it seems unrealistic to address them in isolation, since these factors often do come into play in and are important to employee motivation at one time or another.

Management Theories of Motivation

Other approaches to motivation are driven by aspects of management, such as productivity, human resources, and other considerations. Most notable in this regard are the following: ■■ Scientific Management Theory—Frederick Taylor’s ideas, put into practice by the Gilbreths in the film Cheaper by the Dozen, focused on studying job processes, ■■ ■■ determining the most efficient means of performing them, and in turn rewarding employees for their productivity and hard work.

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This theory assumes people are moti- vated and able to continually work harder and more efficiently and that employee pay should be based on the amount and quality of the work performed. Over time, this approach is limited by the capacity of employees to continue to increase the quantity of work produced without sacrificing the quality. McGregor’s Theory X and Theory Y—draws upon the work of Herzberg and develops a human resources management approach to motivation. This theory first classifies managers into one of two groups.

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Theory X managers view employees as unmotivated and disliking work. Under the Theory X approach, the manager’s role is to focus on the hygienes and to control and direct employees; it assumes employees are mainly concerned about safety. In contrast, Theory Y managers focus on Herzberg’s motivators and work to assist employees in achieving these higher levels. In assessing this theory, researchers have found approaching motivation from this either/or perspective is short-sighted. Ouchi’s Theory Z—is rooted in the idea that employees who are involved in and committed to an organization will be motivated to increase productivity.

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Based on the Japanese approach to management and motivation, Theory Z managers provide rewards, such as long-term employment, promotion from within, participatory management, and other techniques to engage and motivate employees (Ouchi, 1981). In fact, Theory Z can be considered an early form of engagement theory. While all of these theories are helpful in understanding management and motivation from a conceptual perspective, it is important to recognize that most managers draw upon a combination of needs, extrinsic factors, and intrinsic factors in an effort to help motivate employees, to help employees meet their own personal needs and goals, and ultimately to engage employees in and to achieve effectiveness and balance within the organization.

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Managers typically take into account most of the aspects upon which these theories focus. That is, expectations, goal setting, performance, feedback, equity, satisfaction, commitment, and other characteristics are considered in the process of motivating employees.


Throughout this chapter, we have discussed what motivates employees. As the previous discussion indicates, motivation for employees results from a combination of incentives that take the form of extrinsic and intrinsic rewards. These topics warrant a bit more discussion.

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Extrinsic Rewards

There are a host of external things that managers can provide that may serve as incentives for employees to become more engaged in an organization and increase their productivity. These include tangible rewards, such as: money (pay, bonuses, stock options), benefits (health, den- tal, vision, paid time off, retirement accounts, etc.), flexible schedules, job responsibilities and duties, promotions, changes in status, supervision of others, praise, feedback and recognition, a good boss, a strong leader, other inspirational people, and a nurturing organizational culture.

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As this list demonstrates, extrinsic rewards are all tangible types of rewards. Intrinsic rewards stand in marked contrast to these. Intrinsic Rewards Intrinsic rewards are internal to the individual and are in many ways less tangible. In fact, they are highly subjective in that they represent how the individual perceives and feels about work and its value.

Five types of intrinsic rewards that have been summarized by Manion (2005) include: ■■ ■■ ■■ ■■ ■■ Healthy relationships—in which employees are able to develop a sense of connection with others in the workplace. Meaningful work—where employees feel they make a difference in people’s lives. This is typically a motivator for people to enter and stay employed in the health care industry.

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This type of work is viewed as that in which the meaningful tasks outweigh the meaningless ones. This reinforces the mantra Herzberg first espoused in 1968 and revisited in a 2003 issue of the Harvard Business Review, in which he stated: “Forget praise. Forget punishment. Forget cash. You need to make their jobs more interesting” (Herzberg, 2003, p. 87). As documentation and the hassle factor of get- ting approvals and reimbursement in health care have increased, managers need to be aware that such tasks and hassles detract from the meaningfulness quotient. Competence—where employees are encouraged to develop skills that enable them to perform at or above standards, preferably the latter.

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Choice—where employees are encouraged to participate in the organization in various ways, such as by expressing their views and opinions, sharing in decision making, and finding other ways to facilitate participatory approaches to problem solving, goal setting, and the like. Progress—where managers find ways to hold employees accountable, facilitate their ability to make headway toward completing their assigned tasks, and celebrate when progress is made toward completing important milestones within a project. Intrinsic rewards, coupled with extrinsic ones, lead to high personal satisfaction and serve as motivators for most employees.

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Why Motivation Matters

Health care organizations face pressure externally and internally. Externally, the health care system must confront challenges such as the aging population, economic down- turns, reductions in reimbursements, increases in market competition, increases in the cost of providing care, and health care reform. Internally, our health care system faces pressure stemming from challenges such as shortages of certain types of health care workers, increasing accreditation requirements, increasing regulations, dealing with limited resources, increasing responsibilities connected with providing quality care, and ensuring patient safety.

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These pressures can lead to employees who feel burned out, frustrated, and overworked. As health care employees are continually being asked to increase their responsibilities with fewer resources, managers must create a work environment in which employees are engaged, happy at their job, inspired, and motivated. People spend approximately one-third of their lives at work, and managers need to recognize the workplace is one of the most important aspects of a person’s identity. In situations where people are not free to work at their maximum effectiveness and their self-esteem is constantly under attack, stress occurs, morale diminishes, illness prevails, and absenteeism goes up (Scott & Jaffe, 1991; Sherwood, 2013).

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As noted, motivated employees are fully engaged in their work and contribute at a much higher level than their counterparts who see their work as simply a job. Additional reasons why motivation matters include: ■■ Employees who are motivated feel invested in the organization, are happier, work harder, are more productive, and typically stay longer with an organization (Levoy, 2007, p. 70). ■■ Managers play important roles in the engagement process (O’Boyle & Harter, 2013), particularly with respect to providing recognition (Towers Watson, 2010a, 2010b). ■■ ■■ ■■ ■■

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Managers who understand employees’ job-related needs experience a higher level of motivated behavior from their employees (Levoy, 2007, p. 113). All behavior is needs oriented. Even irrational behavior stems from a motivator of some sort. Once a need is satisfied, its impact as a motivator lessens. This basic foundational understanding of motivation is essential to successful motivation and management of employees (Levoy, 2007, p. 118). Managers need to draw upon different strategies in order to engage different types of workers, such as Baby Boomers, Millennials, women, etc. (O’Boyle & Harter, 2013).

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Disengaged employees, as mentioned, have significant financial impacts on an organization’s bottom line (O’Boyle & Harter, 2013). They can also act as “Debby Downers” who pull other employees down, decrease morale, and increase turnover.
■■ A motivated and engaged workforce experiences better outcomes and provides an organization with a competitive edge to successfully compete and be viewed as a dominant force in the market. Motivated Vs. Engaged—Are the Terms The Same? Oftentimes when you read about motivation, the term engaged appears within the same context. In order to be motivated, employees must be engaged—and in order to be engaged, they must be motivated. Towers Watson’s definition of employee engagement encompasses three dimensions: ■■ ■■ ■■ Rational—How well employees understand their roles and responsibilities;

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Emotional—How much passion they bring to their work and their organization; and, Motivational—How willing they are to invest discretionary effort to perform their roles well (Towers Watson, 2010a, p. 1). This definition demonstrates the linkage between the two concepts and the importance of focusing on both of these areas by managers and leaders. Why is this important in health care? The impacts can be significant. In fact, Cornerstone OnDemand reported, “recent research and practical in-the-field experience demonstrates that healthcare organizations can create the most profound improvements in patient care and satisfaction levels simply by improving employee engagement” (2014, p. 3).

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In particular, such engagement results in: ■■ ■■ ■■ ■■ Better quality; Increased patient safety; Higher patient satisfaction; and Stronger organization financial performance. In addition, Gallup studies also show that engaged health care “employees are more: ■■ ■■ ■■ ■■ ■■ loyal to the organization willing to put forth discretionary effort willing to trust and cooperate with others willing to work through challenges willing to speak out about problems and offer constructive suggestions for improve- ments” (Kamins, 2015, p. 1). The health policy changes to move reimbursement to a “value-based purchasing” system, where payments from Medicare and Medicaid are tied to quality and patient care outcomes, suggest additional focus needs to be paid to those who deliver care to patients, which in turn suggests the need to enhance employee motivation and engagement (Sherwood, 2013).

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While several recent articles have been critical of the benefits and costs of employee engagement, the relationship to organizational outcomes and improve- ment efforts, and the lack of a uniform definition of the concept, Leeds and Nierle (2014) conclude continued efforts to study the concept and to utilize employee engagement strategies have been deemed effective. This is also supported by other recent studies that suggest disengaged employees bring morale down and impact the organization’s bottom line. According to Gallup only 30% of U.S. full-time employees were highly engaged in their work; they estimated the cost of this at between $450 billion and $550 billion in lost productivity alone as a result of the 70% who are disengaged employees (O’Boyle & Harter, 2013). Towers Watson’s (2014) Global Workforce Study found a slightly higher percentage (40%) of workers being highly engaged. While the percentage of the hospital workforce is even a bit higher, it is still estimated by Towers Watson to be only 44% (Sherwood, 2013). This suggests leaders and manag- ers need to increase their attention to engagement and motivation of their workforces. Sherwood (2013) states, “when employees believe their organization truly values quality care – and also get the support they need on the job – their patients are more satisfied, they take less sick time and have fewer on-the-job accidents, and health outcomes are better” (p. 5). This, in turn, impacts the organization’s bottom line. Measuring Engagement The issues of accurately measuring engagement have become front and center for employ- ers. Recent backlash has taken different forms, including concerns with companies’ abili- ties to define “fuzzy” concepts (like engagement), to separate the concept from other ideas (such as job satisfaction and commitment), to measure accurately, and/or to link engagement to performance, and has suggested that change is needed (Bersin, 2014a; Brown & Reilly, 2013; Ott, 2011; Saks & Gruman, 2014; Shuck, Ghosh, Zigarmi, & Nimon, 2012). While some have said to just not bother to worry about engagement (Keegan, 2014), others see opportunity in the world of people analytics. According to Fuller (2014b) “People analytics is the use of people-related data to optimize busi- ness outcomes (and solve business problems) at the individual, team or organizational levels” (p. 2). Several authors, including Bersin (2014b, 2015), Fuller (2014a), Housman (2015), and Mims (2015), suggest the future holds great promise for demonstrating the use of “big data” and analytics to improve measurement, data collection, and prediction in the human resources area. That is, an evidence-based approach will be used to assess organizational, team, and individual performance in an effort to better understand the relationships between motivation and engagement with rewards, as well as to address all types of business problems such as employee retention, turnover, fraud, customer satisfac- tion, absenteeism, patient safety, etc. Employee engagement will be an important area of investigation in the people analytics discussion. Misconceptions About Motivation and Employee Satisfaction Managers tend to have many misconceptions about motivation. As health care manag- ers, it is important to assess and understand such misconceptions in an effort to become more effective managers and to not perpetuate myths about motivation. For example, research indicates managers typically make incorrect assumptions about what motivates their employees. Morse (2003) states “managers are not as good at judging employee moti- vation as they think they are. In fact, people from all walks of life seem to consistently misunderstand what drives employee motivation” (p. 18). The following is an enumeration of many of these misconceptions. ■■ ■■ ■■ ■■ Although I’m not motivated by extrinsic rewards, others are. This idea is discussed by Morse (2003) in his review of Chip Heath’s study of intrinsic and extrinsic rewards. The conclusion is an “extrinsic incentive bias” exists and is, in fact, widespread among managers and employees. That is, individuals assume others are driven more by extrinsic rewards than intrinsic ones. Some studies have shown this to be a false assumption. Recent research suggests, however, employee views about extrinsic rewards do differ across generations, with Baby Boomers ranking extrinsic rewards less highly than Gen Xers and Millennials (Schullery, 2013). All motivation is intrinsic. Managers need to remember that typically a combination of factors motivates employees, not just one type of extrinsic or intrinsic reward (Manion, 2005). Some people just are not motivated. Everyone is motivated by something; the problem for managers is that “that something” may not be directed toward the job. This cre- ates challenges for managers who must try to redirect the employees’ energies toward job-related behaviors (Manion, 2005). People are motivated by money. Compensation motivates only to a point; that is, when compensation isn’t high enough or is considered to be inequitable, it’s a de-motivator. In contrast, when it is too high, it also seems to be a de-motivator, what Atchison (2003) calls the “golden handcuffs,” and results in individual performance being tempered to protect the higher compensation level. Santamour states, “Eighty-nine percent of managers believe that for their employees it is all about the money, but there is no research to support that” (2009b, p. 10). Generally, employees tend ■■ ■■ ■■ ■■ ■■ to rank pay as less important than other motivators. This is supported by the 1999 Hay Group study, in which 500,000 employees ranked fair pay and benefits as the least important of 10 motivating factors that keep them committed to staying with their companies. Chamorro-Prem
uzic (2013) also reviewed numerous research stud- ies that linked pay and motivation and concluded “if we want an engaged workforce, money is clearly not the answer ….. money does not buy engagement” (p. 2). The bottom line from Atchison’s (2003) perspective is that “as soon as money is predict- able, it is an entitlement, not a motivator” (p. 21). Motivation is manipulation. Manipulation carries negative implications; in contrast, motivation is positive and benefits both management and the employee (Manion, 2005). One-size-fits-all reward and recognition programs motivate staff. People, being people, are different, act in different ways, and are motivated by different things. Tailoring rewards and recognition is viewed as a way to focus on and understand the individual and his/her unique qualities (Atchison, 2003). Motivational people are born, not made. Studies show that people aren’t born to motivate. In fact, Manion states, “anyone can become an effective motivator. It simply takes an understanding of the theories and basic principles” (Manion, 2005, p. 284), as well as the desire to develop these skills. There is one kind of employee satisfaction. Atchison (2003) discusses the pros and cons of “egocentric and other-centered satisfaction” and suggests that in the short run, employees respond to specific rewards that they receive personally, but in the longer run, they respond to quality performance of the team and the organization. Thus, they migrate from being self-centered to being other-centered in terms of job satisfaction—from a “me” to a “we” mentality. Motivation and engagement at work only relates to what happens at work. Several authors have suggested employers need to take a more holistic approach to understand their employees (Bersin 2014a; Kilatalahti & Vittala, 2014; LaMotte, 2015). Doing this requires taking a broader view, asking questions about, and developing an understanding of employees’ lives inside and outside the work environment. Motivational and Engagement Strategies The literature provides an array of strategies for managers to use in seeking to help moti- vate and engage individuals. Some of these seem very obvious, while others represent the “tried-and-true” approaches to management. Still others represent innovations. No matter, they are worth enumerating here. ■■ ■■ ■■ Expect the best. People live up to the expectations they and others have of them. As stated best by Henry Ford: “Whether you think you can or you think you can’t, you’re right!” (Manion, 2005). Communicate and address the big picture. Employees are more engaged when their bosses communicate regularly, keep them apprised of what is happening, and what the collective purpose is of the organization. They also need to understand how what they are tasked with fits into the larger picture of the organization (Baldoni, 2008, 2013), as well as society as a whole (Kanter, 2013). The latter is particularly true in health care, whereas Herzer and Pronovost (2013) suggest “inspiring a collective purpose and vision” is an important motivator for physicians. This is also the case for other health care professions in both direct care and non-direct care settings. Reward the desired behavior. Make sure that rewards are not given for undesirable behaviors and be sure to use many different types of rewards to achieve the desired outcomes (Manion, 2005). Do something special to recognize desired behavior; examples suggested by Studer (2003, 2014) include sending a written thank you note to an employee’s home or using a “WOW card.” The latter is a simple card that can be filled out and sent to an employee, explaining that “Today you ‘WOWed’ me when you _____________________.” Fill in the blank with an explanation of what that special something was. ■■ Create a “FUN (Focused, Unpredictable, and Novel) approach.” Atchison (2003, p. 21) suggests using money for a variety of creative employee rewards, such as giving $50 gift certificates to a shopping center in recognition of employees’ exceeding expected patient outcomes. ■■ ■■ ■■ ■■ Celebration. Baldoni (2008) suggests using celebration to communicate the impor- tance of completed projects or progress made. Reward employees in ways that enhance performance and motivate them. Don’t waste money on traditional types of recognition. Though these are viewed as being nice, they don’t motivate (Atchison, 2003). Money is better spent on true rewards for specific types of performance and outcomes. Tailor rewards. As mentioned earlier, Atchison (2003) steers managers away from standard types of rewards, such as giving the obligatory Thanksgiving turkey—unless the employees look forward to those turkeys. Instead, he recommends finding more creative ways to spend the organization’s money and reward employees. Focus on revitalizing employees. Research shows that, when employees are working on overloaded circuits, motivation is diminished and productivity declines. This is particularly true in health care organizations. Hallowell (2005) suggests managers can help to motivate employees by encouraging them to eat right, exercise regularly, take “real” vacations, get organized, and slow down.
■■ ■■ ■■ ■■ ■■ ■■ ■■ Find creative ways to obtain information and recognize excellence in employees. Studer (2003) suggests asking for feedback on service excellence when doing patient satis- faction surveys and hospital discharge phone calls. With data and information from these sources, recognition can be provided to individual employees, thereby motivat- ing them to continue providing excellent customer service. This also communicates to the entire organization the importance of and commitment to a patient-centered and service-oriented culture. Get subordinates to take responsibility for their own motivation. This can be achieved by managers taking steps to deal with problem employees, to understand employees’ needs, to determine what motivates their employees, to engage employees in the problem-solving process, and to really work hard at resolving, rather than ignoring, difficult employee problems (Nicholson, 2003). “Do unto others as you would have done unto you.” It goes without saying that everyone wants to be treated well at work, making it important for managers to respect the employees they work with (Lipman, 2013). Focus on collaboration instead of competition. Health care is a team sport, where patient care is frequently provided by an array of employees. This is true of physicians collaborating with others to be patient-centered and work to enhance the quality of care (Herzer & Pronovost, 2013). Play to employees’ strengths, promote high performance, and focus on how they learn. This requires managers to know what their employees’ strengths and weaknesses are, to find out what will be required to get specific employees to perform, and to under- stand how to capitalize on the ways those employees learn as an alternative method of encouraging and motivating them (Buckingham, 2005). Give employees “three compliments for every criticism.” Studer states: “I thought I heard that compliments and criticism were supposed to be balanced. But the truth is, if you give a staff member one compliment and one criticism, it equals a negative relationship. If you give a staff member two compliments to one criticism, it will equal a neutral relationship. If you give a staff three compliments to one criticism, it will equal a positive relationship” (2003, p. 232). Acknowledge the importance of work-life balance and employee well-being. Several studies, particularly those pertaining to younger generations, point out the impor- tance of promoting well-being (Caver, Davenport, & Nyce, 2015; Gallup, 2014). A recent study of health care employees by Shuck and Reio (2014) states “high engagement group employees demonstrated higher psychological well-being and personal accomplishment, whereas low engagement group employees exhibited higher emotional exhaustion and depersonalization” (p. 43). Several other studies focus on balancing life at work with leisure activities (Kultalahti & Viitala, 2014; O’Boyle & Harter, 2013; Zwilling, 2012). As managers, it is important to recognize this for all employees and respect their needs regarding leisure and other activities outside of work (Lipman, 2013). Motivating Across Generations The U.S. has experienced a health professions labor force shortage over the last decade. By the year 2020, a nationwide shortage is projected of approximately 100,000 physi- cians, one million nurses, and 250,000 public health professionals (Health Resources and Services Administration, n.d.). This shortage, along with the aging Baby Boomer popula- tion, means an intense focus is vital in order for health care organizations to successfully function over the next few decades. Total employment is estimated by the U.S. Bureau of Labor Statistics (BLS) to increase by 15.6 million, or 10.8%, during the period of 2012– 2022. These projections include a changing labor force, specifically one that is older, more racially and ethnically diverse, as well as more demanding. More than 50% of new jobs are projected to be in professional and service-providing occupations. Of the four fastest grow- ing occupations, three are in the health field, i.e., health care, health care support, personal care services—the fourth being the construction field. These four occupational fields are expected to comprise over 5.3 million new jobs, or one-third of total employment growth, by the year 2022 (BLS, 2009, 2013). Health care managers need to embrace the challenges, opportunities, and new strate- gies when managing such a diverse labor force (American Hospital Association, 2010). This will require managers to evaluate their current management styles, especially when considering actively engaging and motivating a labor force across multiple generations. According to the American Hospital Association’s (AHA) 2010 study, Workforce 2015: Strategy Trumps Shortage, social trends over the last several decades have been dominated by the values, preferences, and experiences of the Baby Boomer generation, which includes those born between 1946 and 1964. However, the Baby Boomers are only one of four generations that comprise today’s labor force. A generation is a “group of individuals born and living contemporaneously who have common knowledge and experiences that affect their thoughts, attitudes, values, beliefs and behaviors” (Johnson & Johnson, 2010, p. 6). Members of the four main generations include the traditionalists, the Baby Boomers, Generation X, and the Millennials (Generation Y). One consideration not previously addressed is that our workforce is experiencing history in the making as it is on the cusp of accommodating the newest generation, Generation Z, making five generations working alongside each other in the workplace. As pointed out by the AHA (2014) and Johnson and Johnson (2010), the intergenerational workforce reflects a continuum, with each gen- eration moving along it and eventually leaving the workforce.
Each generation has unique characteristics and expectations and is motivated in differ- ent ways. Literature might vary slightly regarding the nicknames, birth date ranges, and cohort sizes, especially when considering the newest generations entering the workforce. The key points provided in Table 3-1 illustrate an overview of generational differences among workplace characteristics and motivational preferences. What appeals to one generation more than likely will not appeal to another generation. Motivational techniques, such as rewards and incentives, vary widely across generations. One generation might prefer recognition based on proof of their time-tested work ethic, while another generation might expect instant gratification stemming from what they con- sider a job well done. Schullery (2013) found “Millennials are significantly more interested in extrinsic rewards than are Boomers, although Millennials are less interested than GenX” and that “each generation is increasingly less likely to value intrinsic rewards as highly as the previous generation” (p. 260). A caveat to this is that these results may change over time. Different standards of motivation are required for each generation. In order for health care organizations to be successful in the future, the workplace needs to be one of coexis- tence of all generations, even when their workplace characteristics and motivational prefer- ences are drastically different. Managers play a key role in how the generations will work together and what it takes to engage employees to be motivated workers. Managing Across Generations Our current workforce is comprised of four predominant generations with the newest (and fifth) generation (Generation Z) just now entering the workforce in various positions such as part-time, summer, or college-type jobs. This multi-faceted workforce requires awareness from managers about how to manage across generations. A one-size-fits all management theory will not produce desired organizational outcomes. Additionally, encouraging employ- ees to reach their optimal productivity while retaining valued employees during a labor work- force shortage will continue to be at the forefront of all organizational strategic plans. Each person holds experiences that shape their lives, form their belief system and values, and contribute to their decision-making processes. Referred to as a generational sign- post, each generation has experienced an event(s) or cultural phenomenon specific to one generation. Authors Johnson and Johnson (2010) theorize that these signposts “shape, influence, and drive expectations, actions, and mind-sets about the products we buy, the companies for which we work, and our expectations about life in general” (p. 4). Examples of these include questions like “Where were you the day Kennedy was shot?” or “Where were you when the Challenger blew up?” or “Where were you when the Twin Towers went down?” These signposts are important because they can help guide managers in managing their employees by recognizing how these signposts mold beliefs regarding company Table 3-1 Generation Characteristics and Motivational Preferences Generation Traditionalist Baby Boomers Generation X Generation Y Generation Z Born: Before 1945 1946–1964 1965–1978 1979–1995 Born after 1995 Cohort size 27 million 76 million 60 million 88 million 20 million Nickname Workplace characteristics Motivational preferences Silent Generation/ Matures Respectful of authority Value duty and sacrifice Value accountability and practical experience Strong work ethic with emphasis on timeliness and productivity Strong interper- sonal skills Value academic credentials Accept limited resources Loyal to employer and expect loyalty in return Loyalty Hierarchical structure Boomers/ Woodstock Generation Individuality Driven by goals for success Measure work ethic in hours worked and financial rewards Believe in teamwork Emphasize relationship building Expect loyalty from coworkers Career equals identity A democratic approach Competitive Work for man- agers who treat them as equals Gen Xers Millennials Linksters/New Silent Generation Self-reliant Highly educated Questioning Risk-averse Most loyal employees Want open communication Respect production over tenure Value control of their time Invest loyalty in a person, not in an organization Genuine and informal managers Image conscious Need constant feedback and reinforcement Idealist Team-oriented Want open communication Search for an individual who will help them achieve their goals Search for ways to shed stress Racial and eth- nic identifica- tion of reduced importance Organized and prefer structure Value instant gratification Results-focused Tech savvy, yet struggle with face-to-face communications Value structure, routine, and predictability Prefer clear, direct job descriptions/ duties, and expectations Strong work ethic Leaders in online collaboration Strong ability to multitask High entrepre- neurial attributes Search for and value ways to improve the world they live in (community service-oriented) (continued) Table 3-1 Generation Characteristics and Motivational Preferences (Continued) Generation Traditionalist Baby Boomers Generation X Generation Y Generation Z Status Rewards based on promotion and job tenure Recognition of hard work and work ethic Assurance that they are making a difference Work–life balance Training and growth opportunities Flexibility Work deadlines, but with freedom and flexibility on how to reach those deadlines Results-oriented Collaborative and positive interactions Achievement- oriented Coaching and support focused Personal fulfill- ment in job Prefer manage- ment practices and workspaces that best support their needs Appreciation of collaboration tools Regular and con- sistent feedback Rewards that are consistent and tied to specific performance goals Adapted from AHA, 2010, 2014; Johnson & Johnson, 2010. loyalty, work ethics, and creating shared values that serve as bonding mechanisms among individuals of a team (Johnson & Johnson, 2010). Managing the Gap Managing across generations is not as simple as recognizing the workplace characteristics and motivational preferences of each generation. Managers must also be able to man- age the gap that comes with different generations working side-by-side.

The American Hospital Association (AHA) Committee on Performance Improvement (CPI) report titled, Managing an Intergenerational Workforce: Strategies for Health Care Transformation (2014), discusses generational diversity and its impact that is quickly altering workforce dynamics. In addition to recognizing workplace characteristics and motivational prefer- ences, managers must also acknowledge the different priorities, communication styles, and interaction preferences, all of which influence organizational culture and performance. Tension amongst employees from different generations becomes apparent when working together, and these tensions are a result of different historical experiences and attitudes (AHA, 2014). In a survey by Lee Hecht Harrison, referenced in the AHA CPI report, “more than 60 percent of employers are experiencing tension between employees from different generations.

The survey found that more than 70 percent of older employees are dismissive of younger workers’ abilities, and nearly 50 percent of younger employ- ees are dismissive of their older colleagues’ abilities” (AHA, 2014, p. 9). Additionally, a 2013 study by Ernst & Young surveyed 1,215 professionals evenly divided across three generations—Baby Boomers, Generation X, and Generation Y (Millennials)—to assess perceptions on a variety of topics. Some key findings include: ■■ ■■ ■■ ■■ ■■ ■■ ■■ Many Gen Y members (87%) had moved into management roles during 2008 and 2013, while most of the Gen Xers and Boomers had been in these roles prior to that time. Boomers were seen as being more cost-effective than Gen Xers and more than twice as cost-effective as members of Gen Y: 78% vs. 59% vs. 34%.

Both Boomers and Gen Yers were viewed as being difficult to work with
, while Gen Xers were less so, but these numbers were smaller: 29% vs. 16% vs. 36%. Of the respondents 73% saw Boomers as hardworking as compared to 69% of Gen Xers, but only 39% of Millennials. Millennials and Gen Xers were far more tech savvy than Boomers: 85%, 77%, and 27%, respectively. Not surprisingly, a similar finding showed these same groups as being social media opportunists as compared to Boomers. While there were differences across the groups, the majority saw all generations as problem solvers and collaborators.

These findings indicate that managers have some significant challenges when trying to get these generations to work well together. Capitalizing on strengths and commonalities of each generational cohort can assist managers in creating a dynamic and engaged workforce. Recommended strategies for organizations to create high-performing teams that are able to evolve alongside the demands of our ever-changing health care system include the following: ■■ ■■ ■■

Perform an intergenerational evaluation to ascertain the organization’s workforce profile and create a comprehensive plan; Employ targeted recruitment, segmented retention, and succession planning strate- gies; and Develop customized communication strategies designed to foster generational under- standing and sensitivity (AHA, 2014).

These recommendations are a starting point, but it takes extensive consideration of timely and appropriate strategies to move beyond the generational gaps and tensions in the workplace. Utilizing the generational differences to work for the common good of the organization is key.

Focusing on singular strategies specific to each generation is important, but not always feasible when considering five generations that vary greatly in their characteristics and motivational preferences. Consideration of universal strategies to achieve maximum productivity and increased morale will help organizations thrive when it comes to supporting and communicating with employees. We know with certainty each generation sets similar expectations from their jobs, such as work-life balance, a good salary with benefits, flexible work hours, and interesting work.

It is the micro-details of each of these aspects of work that need to be designed differently for each generation in order to be effective and meaningful (Saleh, n.d.). As an example, research shows that Generation Zers have experienced a protected upbringing with extremely high parental involvement and parental mediation on their behalf. As a result, they are not experienced in dealing with conflict as compared to other generations. On the other end, Generation Xers are highly independent and grew up as “latchkey” kids. How would a manager man- age these two groups? Managers must also consider cultural factors inherent to each employee such as where people are born or where they live.

Additionally, these generations are also diverse on many other factors, including politics, religion, gender, race, ethnicity, educational level, envi- ronment, disability, and socioeconomic status, all of which managers must be cognizant and make efforts to understand as they develop their cultural competence. (See Chapter 14 for more on this topic.) As mentioned earlier in this chapter, the health care system is moving from a volume- based payment model to a value-based payment model. This movement can be paradoxical to some as it is focused on improving quality of care while lowering costs—two strate- gies that seemingly are difficult to achieve simultaneously.

Bottom line, managers must not only manage across generations, they must also manage within this new health care paradigm. With a goal to utilize generational commonalities and differences for favorable organizational outcomes, our intergenerational workforce just might be able to make this movement work. According to the AHA (2014), a competitive advantage amongst health care leaders involves creating a culture that supports and fosters intergenerational teams using three intergenerational management strategies: ■■ ■■ ■■ Create a strong generational foundation; Institute effective generational management practices; and, Develop generational competence.

Competence as a managing factor includes those organizational core competencies that stem from the organization’s mission and vision statements. The AHA (2014) identified a total of 17 must-do strategies and core organizational competencies to help leaders achieve the Triple Aim of health care. Of the 17 items, six were identified to support building a strong organizational intergenerational workforce.

1. Align hospitals, physicians, and other providers across the continuum of care. 2. Instruct and engage employees and physicians to produce leaders. 3. Create and employ patient-centered, integrated care. 4. Initiate accountable governance and leadership. 5. Encourage internal and external collaboration. 6. Engage employees’ full potential.

Textbox 3-1. FAQ: What is the Triple Aim? The Triple Aim is a health care initiative that focuses on enhancing the individual experience of care; improving the health of populations; and minimizing the per capita costs of care for populations. Berwick, D.M., Nolan, T.W. and Whittington, J. (2008). The triple aim: Care, health, and cost. Health Affairs, 27(3):759–769. Brown, D. & Reilly, P. (2013). Reward and engagement: The new realities. Compensation & Benefits Review, 45(3), 145–157. Along with the motivational strategies listed earlier in this chapter, in consideration of managing the gap and managing across generations, managers can institute the following universal strategies:

■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ Evaluate before implementing. Before implementing new workplace strategies, review where you are and plan where you want to go. Obtain regular feedback and demonstrate the ability to act on suggestions.

Encourage communication, understanding, and respect for differences. Tailor your workplace strategies and avoid the temptation to use a one size fits all management model. Focus on results, rather than process. Understand what it means to have engaged employees and strive for this goal. Encourage formal mentorship programs within the organization. Learn to recognize when someone may need extra support. Regularly give praise, say thanks, and celebrate when an employee or team gets it right (Saleh, n.d.).
Research Opportunities in Management and Motivation Thanks to over a century of psychological investigators’ interest in management, motivation, and organizational behavior, an abundance of research on these topics and applications to health care settings await you.

An organization such as the Society for Industrial-Organization Psychology (SIOP), a special interest group of the American Psychological Association (APA), is especially productive in these domains. Likewise, the Academy of Management (AOM) delves into these issues. In addition to SIOP and AOM, here are some other agencies and organizations ripe for your examination:

■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■

Agency for Healthcare Research and Quality; American College of Healthcare Executives; Health Occupations Students of America (HOSA); Hospital Research and Educational Trust (HRET); Inter-university Consortium for Political and Social Research (ICPSR); Johari Window; MindTools; O*Net; Studer Group; SHRM Foundation; and, U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA). Conclusion Motivation of employees is a tricky business.

Managers often do not understand the con- cepts, principles, and myths about motivation well enough to put them in practice. Greater awareness and better understanding of motivation will result in better management. Managers can improve their success rate by providing extrinsic rewards that will help their employees to be intrinsically motivated to become top performers.

As Studer, Hagins, and Cochrane (2014) state “without exception, we find that organizations that consistently improve their performance also have workforces that are passionate, productive, and pro- active in finding ways to better meet patient needs. In a word, they are engaged” (p. S79).

Successful managers also are able to recognize the differences when managing, motivating, and engaging across varying generations.Discussion Questions

1. Motivation is not a new concept, so why is motivation important? Is it more important for an employee to be motivated or engaged?

2. Compare and contrast needs-based theories of motivation. Which offers the most value to health care managers? 3. Discuss any limitations of the management approaches to motivation. 4. Which types of rewards are more important: intrinsic or extrinsic?

5. Does the importance of different types of rewards change over time as one pro- gresses through one’s career? What are some examples of rewards tailored to different generations?

6. Which myth of motivation is the most important? Are there other myths you can identify?

7. What motivational strategy would you apply with an employee who you think is capable of doing the work but is underperforming?

8. What motivational strategy would you apply with a highly effective employee who you want to keep performing at a very high level?

9. Which generation resonates best with you? In your opinion, which generation do you feel would be the most difficult to manage or motivate? Why?

10. Grace Jones is a four-decade Billing department employee in Happy Hollow Hospital. A recent graduate of Whassamatter U, Lindsey Flohan is a new hire in the Billing department. Grace has been assigned to train Lindsey to do her new job. Using the generational framework provided above, what conflicts can you anticipate between Grace and Lindsey?

Cases in Chapter 18 that are related to management and motivation (or related to this chapter) include: ■■ ■■ The Magic Is Gone Set Up for Failure? Case study guides are available in the online Instructor’s Materials.

Chapter 4 Introduction We all want to understand ourselves and others, especially in the workplace. The well-known Shakespearean quote from Julius Caesar about our faults not lying in the stars reminds us that many thorny issues we face do not originate “out there,” caused by circumstances beyond our control. Instead they can be of our own making—or more specifically—be caused by our own thinking, much of which is beyond our awareness. When we appreciate how we ourselves think, we will be prepared to understand the behavior of others in organizations.

As an aspiring manager, you will be expected to think clearly and keep learning. Clear thinking means knowing why you think what you think, why you believe what you believe, and how you know what you know. Much of what you currently “know” is based on your prior life experiences, which most people seldom exam- ine critically. In today’s world, we all are called upon to think deeply. By examining your own thinking and letting go of past unexamined notions and habitual thought patterns, you can become more aware and deliberate in future thinking. You discover the world anew when you take charge of your own thinking.

Health care managers, like managers in other industries, are responsible for effectively using the informational, financial, physical, and human resources of their organizations to deliver patient services. As you can see from the topics presented in this textbook, the manager’s role requires a wide range of interpersonal skills. Leadership (Chapter 2), motivation (Chapter 3), managing health care professionals (Chapter 11), and teamwork (Chapter 13) are some of the most important interpersonal skills examined at length in other chapters of this text. Organization behavior leverages these “soft skills”—arguably the hardest skills of all to master.

In today’s job market, technical skills alone are not enough. Employers seek job candidates who also have well developed soft skills. Soft skills include both thinking skills (critical thinking, reasoning, problem-solving, decision making, and flexibility) and socio- emotional skills (interpersonal relations, teamwork, communication, empathy, self- awareness, and self-discipline). Soft skills are organizational behavior skills, and developing them is advantageous for initial hiring and future advancement in management. They can make the difference between being a manager and being a leader.

The purpose of this chapter is to see how managers think, especially the mental processes that short circuit quality thinking. As you read and participate in class discussion, pay attention to how you think. Knowledge of how your brain works gives you the ability to modify your own thinking and find ways to work more effectively with others—developing your organizational behavior skills.

The Field of Organizational Behavior Organizational behavior is a broad area of management that studies how people act in organizations. Managers can use theories and knowledge of organizational behavior to improve management practices for effectively working with and influencing employees to attain organization goals.

The field of organizational behavior has evolved from the scientific study of management during the industrial era to administrative theories of the manager’s role, principles of bureaucracy, human relations studies of employees’ needs, and new insights from human cognition and complexity theory.

Organizational behavior is an interdisciplinary field that draws on the ideas and research of many disciplines concerned with human behavior and interaction. These include psychology, social psychology, industrial psychology, sociology, communications, anthropology, and, increasingly, neuroscience, which reveals images of our neurological responses to cognitive, emotional, and social stimuli (Becker, Cropanzano, & Sanfey, 2011; Robbins, 2003).

In this chapter, we will highlight ideas from cognitive psychology (the study of human thinking) and their application to organizational behavior. Organizational Behavior’S Contribution to Management The most successful organizations make the best use of their employees’ talents and energies (Heil, Bennis, & Stephens, 2000; Huselid, 1995).

Firms that effectively manage employees have a competitive advantage in their field. Pfeffer (1998) estimates that organizations can reap a 40% gain by managing people in ways that build commitment, involvement, learn- ing, and—ultimately—organizational competence and performance. In short, as noted previously, the so-called “soft skills” matter. Because employees drive an organization’s success, how well the manager interacts and works with a variety of individuals is key to the manager’s success. The manager who is skilled in organizational behavior will be able to work effectively with employees and colleagues across the organization, assisting and influencing them to support and achieve organization goals. Key Topics in Organizational Behavior Organizational behavior is a broad field comprised of many topics.

Work behaviors are typically examined at different levels—individual behavior, group behavior, and col- lective behavior across the organization—with different topics prominent at each level. Studying individual behavior helps managers understand how assumptions, perceptions, and personality influence work behavior, motivation, and other important work outcomes like satisfaction, commitment, and learning.

Examining interactions in the group setting provides insight into the challenges of leadership, teamwork, decision making, power, and conflict. Studying collective organization-wide behavior (sometimes referred to as orga- nization theory) helps explain how to organize work, structure authority and power.

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