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CHAPTER

91

HUMAN RESOURCE MANAGEMENT IN A
GLOBAL CONTEXT

David Briggs, PhD, Godfrey Isouard, PhD, Leonard H. Friedman,
PhD, FACHE, and Myron Fottler, PhD

Chapter Focus

The healthcare sector is essentially a human enterprise, and the connections
between people who engage in health work are key to organizational success.
This chapter examines human resource principles and effective human resource
management practices in a global context. It discusses best practices, sociocul-
tural perspectives, and the impact of culture, while also providing lessons from
the global health workforce. It also examines self-management and emotional
intelligence in the context of being an effective manager.

Learning Objectives

Upon completion of this chapter, you should be able to

• describe the impact of human resource management and practice in the
global context,

• discuss the challenges associated with human resources in healthcare,
• identify the core principles of human resource management in

healthcare in global contexts,
• use best-practice human resource management to effectively maximize

organizational performance,
• distinguish the health workforce as a global strategic issue for health

services, and
• consider the diverse sociocultural perspectives and understand the

impact of culture on the global health workforce.

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AN: 1985979 ; Michael Counte.; The Global Healthcare Manager: Competencies, Concepts, and Skills
Account: s4264928.main.eds

T h e G l o b a l H e a l t h c a r e M a n a g e r92

Competencies

• Analyze problems, promote solutions, and encourage decision making.
• Demonstrate the ability to optimize the healthcare workforce and

address local workforce issues such as shortages, scope of practice, skill
mix, licensing, and fluctuations in service.

• Provide leadership in defining staff roles and responsibilities, developing
appropriate job classification/grading systems, and planning the
workforce.

• Effectively manage departmental human resource processes, including
scheduling; performance appraisals; incentives; recruitment, selection,
and retention; training and education; motivation; coaching and
mentoring; and use of appropriate productivity measures.

Key Terms

• Capability
• Capacity
• Competence
• Critical reflection
• Emotional intelligence (EI)

• Managerial rounding
• Resilience
• Skill mix
• Staff mix
• Task shifting

Key Concepts

• Best practices
• Communication
• Complex adaptive systems
• Continuous feedback
• Global health workforce
• High, middle, and low performers
• Human resource management

(HRM)

• Human resources (HR)
• Leadership
• Organizational culture and

behavior
• Self-management
• Sociocultural perspectives

Introduction

Effective human resource management (HRM) in a global context recognizes that
the healthcare sector is essentially a human enterprise—one of “people engaging

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C h a p t e r 4 : H u m a n R e s o u r c e M a n a g e m e n t i n a G l o b a l C o n t e x t 93

and serving other people” (Briggs 2016, 9). The connections between people
who engage in health work have long been recognized as integral to the profes-
sionally dominant roles within the sector. Egener and colleagues (2017) espouse
this idea in their “Charter on Professionalism for Health Care Organizations,”
which states that organizational culture is reflected in “the well-being of patients
and employees” and that operational and business practices must incorporate
“commitment to fair treatment, education, and development” for employees.

Healthcare has traditionally been delivered through relatively large
organizations with bureaucratic structures, but the field is becoming increas-
ingly systemized. Boundaries are being redefined to respond to aging popula-
tions (and workforce), the increasing burden of chronic disease, the impact of
technology, social movements, and socioeconomic determinants (Egener et
al. 2017). This struggle to redefine and reform health systems as “professional
organizations” has been evident since the work of Brock, Powell, and Hinings
(1999) and Brock (2006). Healthcare today is mostly delivered within systems
that are complex and adaptive (Best et al. 2012), with networks of practice that
cross organizational boundaries in an increasingly global context (Briggs and
Isouard 2015). This movement distinguishes healthcare organizations from
other types of enterprises, and it presents new challenges for the dynamics of
human resources (HR) in the field.

This chapter will discuss the core principles of HRM and consider how
we can be more effective as managers and leaders through the use of best
practices. The globalized nature of today’s workforce presents both internal
strategic challenges and strategic opportunities, as organizations seek a com-
petitive advantage in recruiting, training, and retention; the chapter therefore
approaches HRM as a global strategic issue. It addresses organizational cultures,
sociocultural contexts, interpersonal relationships, and workforce performance,
as well as the importance of self-management and emotional intelligence.

Human Resources for Healthcare: Core Principles and
Issues

The Society for Human Resource Management (SHRM 2016)—with input
from more than 1,200 HR professionals from 33 different nations—created
a competency model that describes what might be considered the core prin-
ciples of HR. This global initiative was developed with four career levels in
mind—entry, mid, senior, and executive. The model was intended to serve as
a resource and “road map” to help HR professionals develop their proficien-
cies and those of others and to achieve their goals. (The model’s introduction
notes that it is for developmental purposes only and not to be used as the basis
for selection decisions.) It suggests nine primary competencies (SHRM 2016):

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T h e G l o b a l H e a l t h c a r e M a n a g e r94

1. HR expertise
2. Relationship management
3. Consultation
4. Leadership and navigation
5. Communication
6. Global and cultural effectiveness
7. Ethical practice
8. Critical evaluation
9. Business acumen

The SHRM’s initiative provides a starting point for considering strategic
HR issues for the health sector. Strategic HR approaches in healthcare may
involve task shifting (i.e., the redistribution of tasks among workforce teams)
and extending scopes of practice; placing a concerted emphasis on competency
training and workforce development; addressing questions of size, distribution,
and composition within an organization or a country’s healthcare workforce;
carrying out specific agendas for regional, rural, and remote communities;
and ensuring organizational readiness for large-scale transformational reform.

The World Health Organization (WHO), in a 2008 report, has expressed
concern that the world’s health systems may be unable to achieve improved
health outcomes without “significant strengthening of human resources for
health” and “innovative ways of harnessing and focusing . . . the human
resources that already exist” (WHO 2008, 5). The report specifically highlights
task shifting and extended scopes of practice as strategic initiatives to address
workforce shortages. Advances in technology, e-health, and telemedicine have
had a significant impact on workforce readiness and availability, leading to
greater consideration of task shifting and the emergence of new roles. The
WHO report stresses the need for a framework that supports task shifting,
alongside other ways of increasing the supply of skilled workers. It calls for HR
analysis incorporating new and existing quality assurance mechanisms; greater
definition of roles and associated competencies as the basis for recruitment,
training, and evaluation; and competency-based training that is needs driven,
accredited, and tied to certification, registration, and career progression mecha-
nisms (WHO 2008). Although the WHO report has a specific focus on HIV/
AIDS, it is relevant to the broader HR needs of health systems—particularly in
recognizing that “at the heart of every health system is the health workforce”
and that “the world is experiencing a chronic shortage of trained health work-
ers” (WHO 2008, 14). The words used in the WHO report resonate with the
core SHRM principles described previously.

A group of Canadian researchers has presented a set of key questions
and issues pertaining to human resources in healthcare in a global context. The
key issues can be summarized as follows (Kabene et al. 2006):

task shifting
The redistribution
of tasks among
workforce teams.

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C h a p t e r 4 : H u m a n R e s o u r c e M a n a g e m e n t i n a G l o b a l C o n t e x t 95

1. The size, distribution, and composition of a country’s healthcare
workforce are key indicators of the country’s capacity to deliver services
and interventions.

2. Human resources personnel must consider the composition of the
health workforce in terms of both skill categories and training levels.

3. A properly trained and competent workforce is essential to any
successful healthcare system.

4. The migration of healthcare workers is a critical issue for global
healthcare systems.

5. The movement of healthcare professionals closely follows the migration
pattern of professionals in general; the internal movement of the
workforce to urban areas is common to all countries.

6. Workforce mobility can create imbalances that require better workforce
planning.

7. Evidence suggests that a significant positive correlation exists between
a country’s level of economic development in and its supply of human
resources for health.

8. Aging populations and the aging health workforce have a significant
impact on health workforce capacity and sustainability.

9. Cultural and geographical factors affect the supply and demand of
human resources for health and therefore must be considered when
examining global healthcare systems.

10. Human resources have a significant impact on attempts at health
reform, and this impact should not be underestimated.

11. Human resources are one of three main health system inputs, along
with physical capital and consumables; they are the hardest of the three
inputs to develop, manage, and maintain.

12. The global nature of the health workforce poses challenges to countries
in managing and retaining their local health workforce.

Delving further into key issues facing HRM in healthcare, the WHO
(2008, 2010) has called for national policies to improve retention of the health-
care workforce in remote and rural areas, where access to healthcare services is
often lacking. Meanwhile, Weiner (2009) has focused on readiness for change
within organizations and the health workforce. Best and colleagues (2012,
421) have conducted a comprehensive review of large-system transformation in
healthcare, and they set forth five simple rules: “(1) blend designated leadership
with distributed leadership; (2) establish feedback loops; (3) attend to history;
(4) engage physicians; and (5) include patients and families.”

The challenges facing healthcare apply equally to HR policy, leadership,
and practice. Although designed to facilitate strategic intent, HR practices can

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T h e G l o b a l H e a l t h c a r e M a n a g e r96

at times be inhibitors of progress, and imbalances in HR can result in poor and
inadequate use of health personnel (Dubois and Singh 2009). Dubois and Singh
(2009) propose an “HR optimization” approach to ensure better congruence
between HR practices and organizational and external policy contexts. An
examination of HR practices in an organization can start by looking at skill mix
(the combination of skills available) and staff mix (the number, qualifications,
and experience of people on staff). In greater detail, the examination can look
at the numbers of workers and defined occupational groups; the appropriate
ratios of staff members per patient; the number of procedures, prescriptions,
and so on; and the implications of the various approaches. Ensuring the proper
mix of qualifications and levels of experience is an important dimension of
staff planning and workforce development. Additional concerns include skill
substitution and replacement, levels of junior and senior staff, the potential
need for higher levels of certification, the impact of interprofessional practice,
and the fostering of teamwork and collaborative approaches.

Dubois and Singh (2009) suggest that effective HRM in today’s health-
care landscape requires more than the traditional approach focused on numbers,
types, grades, education, and experience. They recommend a “skill manage-
ment” approach, with a more adaptive use of workers’ knowledge, skills, behav-
iors, and other attributes. Such an approach emphasizes the capacity to learn
and adapt and take on new roles through role enhancement, role enlargement,
skill flexibility, role substitution, and role delegation.

The field of HRM is often described in terms of planning and staff-
ing policies, education and training, working conditions, and performance
management, but the effectiveness of these approaches often depends on the
organizational fit. Research suggests that organizational characteristics likely
to contribute to a good fit in healthcare include flat hierarchies with few
supervisors, significant worker autonomy, participative management, profes-
sional development opportunities, high organizational status for nurses, and
collaboration (Dubois and Singh 2009). Teamwork, empowerment, affinity
with vision and mission, staff participation in decision making, innovation,
career opportunities, and fairness in industrial practice are all considered posi-
tive attributes of organizational HR practice.

Effective Human Resource Management

Regardless of where on the globe a healthcare organization is located, optimal
patient care cannot be delivered without effective HRM. Healthcare delivery
requires large numbers of inputs from multiple clinical practitioners who are
supported by a complex infrastructure of managers, technical staff, admin-
istrators, and others in key roles. Optimal care requires outstanding staff at

skill mix
The combination of
skills available in
an organization.

staff mix
The number,
qualifications,
and experience of
people on staff.

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C h a p t e r 4 : H u m a n R e s o u r c e M a n a g e m e n t i n a G l o b a l C o n t e x t 97

all levels. For many healthcare organizations, the HR function is limited to a
number of core activities, such as hiring and firing staff, ensuring compliance
with HR-related laws, and serving as a resource for managers throughout the
organization. In our estimation, these activities are necessary but not sufficient.
The HRM function must be explicitly connected with the larger strategic goals
of the organization.

This section will discuss the additional considerations that must be
factored into operations if an organization intends to move beyond the basics
and optimize its HRM. We will carefully consider HR best practices that have
proved effective in global contexts, with lessons from a variety of countries. We
will also examine key elements of effective HRM, including self-management
and emotional intelligence, which research tells us is probably more important
for organizational success than traditional intelligence.

HR Best Practices
A major challenge in global HRM in healthcare is identifying best practices—
those practices that significantly improve organizational performance and
outcomes. A number of studies have shown that effective HRM in business
can increase profitability, annual sales per employee, productivity, market value,
and growth and earnings per share (Messersmith and Guthrie 2010; Kaufman
2010). Researchers have used surveys to measure the sophistication of organi-
zations’ HR practices, assigning organizations scores from 0 to 100, with high
scores representing “state-of-the-art” practices. The research has indicated that
organizations with better HR practices tend to experience better financial per-
formance (Becker, Huselid, and Ulrich 2001). Further evidence was provided
by a survey of 200 chief financial officers, in which 92 percent of respondents
believed that managing employees effectively improves customer satisfaction
(Mayer, Ehrhart, and Schneider 2009). Customers also report that they are
more satisfied when the climate of the organization is positive, employees gen-
erally get along well, and turnover is low (Nishii, Lepak, and Schneider 2008).

So, specifically, what types of HR practices can help an organization
achieve these positive outcomes? Exhibit 4.1 provides a summary. The practices
listed in the exhibit occur repeatedly in studies of high-performing organiza-
tions, and they tend to be present in organizations that are effective in man-
aging their human resources. In addition, these practices are interrelated and
mutually reinforcing; positive results are difficult to achieve by implementing
just one practice on its own.

Although these HR best practices will generally have a positive impact on
organizational performance, their relative effectiveness may vary depending on
their alignment (or lack thereof) with the organization’s mission, values, culture,
strategies, goals, and objectives (Ford et al. 2006). Effectiveness may also depend
on how well the practices reinforce one another in a particular type of organization.

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T h e G l o b a l H e a l t h c a r e M a n a g e r98

Applying these findings in a global healthcare context has some limi-
tations. First, most of the research deals with organizations in general, not
healthcare organizations specifically. Second, the research tends to be focused
in the United States, meaning that it might not reflect the prevalent values
and cultures of other parts of the world. Often, the major stakeholders for
US organizations are the stockholders, so the analysis might not sufficiently
address the goals and objectives for other stakeholders in diverse cultures. In

Category Practices

HR planning / job
analysis

• Encourage employee involve-
ment to ensure strong “buy-in”
of HR practices and managerial
initiatives.

• Encourage teamwork so employees
are more willing to collaborate.

• Provide employment security.

• Use self-managed teams and
decentralization as basic elements
of organizational design, thereby
minimizing management layers.

• Develop strategies to enhance
employee work–life balance.

Staffing • Be proactive in identifying and
attracting talent.

• In selecting new employees, use
additional criteria (e.g., attitudes,
customer focus, cultural fit) beyond
basic skills.

Training /
organizational
development

• Invest in training and organi-
zational programs to enhance
employee skills related to organiza-
tional goals.

• Provide employees with future
career opportunities by giving
promotional priority to internal
candidates.

• Include customer service in new
employee onboarding and skill
development.

• Provide opportunities for employee
growth so that employees are
“stretched” to enhance all their
skills.

Performance
management and
compensation

• Recognize employees through
both monetary and nonmonetary
rewards.

• Offer high compensation contin-
gent on organizational perfor-
mance, with the aim of reducing
employee turnover and attracting
high-quality employees.

• Reduce status distinction and barri-
ers such as dress, language, office
arrangement, parking, and wage
differentials.

• Base individual and team compen-
sation on goal-oriented results.

Employee rights • Communicate effectively with
employees and keep them
informed about major issues and
initiatives.

• Share financial, salary, and perfor-
mance information to develop a
high-trust organization.

• Give higher priority to internal
candidates for promotion, thereby
enhancing employee motivation.

• Provide employment security for
employees who perform well,
protecting them against economic
downturns or strategic errors by
senior management.

Sources: Bruce (2013); Chuang and Liao (2010); Gomez-Mejia and Balkin (2011); Pfeffer (1995,
1998); Suttapong, Srimai, and Pitchayadol (2014); Wright et al. (2005).

EXHIBIT 4.1
Effective HR
Practices for

Healthcare
Organizations

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C h a p t e r 4 : H u m a n R e s o u r c e M a n a g e m e n t i n a G l o b a l C o n t e x t 99

addition, it is difficult to prove whether excellent organizational performance
leads to effective HR practices or whether good HR practices cause better
organizational performance (Wright et al. 2005).

Nonetheless, effective HR practices are clearly associated with excellent
organizational performance (Lepak, Smith, and Taylor 2007), and it seems
reasonable that healthcare systems should consider the implementation of
the HR practices associated with the best-performing organizations. Once
the practices have been implemented, the systems can determine whether the
practices and their benefits are applicable to a particular global context.

Sociocultural Perspectives and the Impact of Culture: Lessons from
the Global Health Workforce
The diverse, multicultural nature of today’s global health workforce and the
mobility of labor and capital from one part of the world to another carry signifi-
cant implications, which have been examined in depth by a number of authors.
Short, Marcus, and Balasubramanian (2017) and Taylor (2016) have focused
their analyses on the healthcare systems in Asia and the Pacific Islands, while
Martins (2016) has conducted a comparative analysis of the United Kingdom,
the United States, Canada, New Zealand, and Australia, specifically considering
the different choices the nations have made with regard to workforce utiliza-
tion. The United Nations Human Development Report 2015 makes several key
points relevant to the health workforce. It emphasizes that work—including
voluntary and creative work, not just jobs—contributes to human progress and
enhances the health and wellness of populations (United Nations Development
Programme 2015). The report also cautions that globalization and the tech-
nological revolution are rapidly changing how we work and what we do. The
mobility of the global health workforce has the potential to alleviate workforce
shortages and reduce inequalities between countries, yet it can also contribute
to shortages and inequality in certain instances. For example, Australian health
professionals often work in other countries, and this migration is one of the
reasons that Australia has had to rely on doctors trained in other countries to
sustain health services in its rural and remote communities.

HR strategy and practices need to recognize the impact of the cultural
differences that exist among nations and among communities within the same
nation, as well as the differences that exist among various professional groups
in the health setting. This intersection of diverse cultures complicates relation-
ships and makes navigation through HR policy and practice more complex.
At the same time, however, these attributes can also help us improve the ways
we learn, manage, and lead. (See the case study that accompanies this section.)

The distinct cultures, values, legal frameworks, and political systems
of various countries and regions shape the way that individual health systems
operate. Although the central functions of HR are somewhat similar across the

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T h e G l o b a l H e a l t h c a r e M a n a g e r100

globe—HR planning, job analysis and design, staffing, training, performance
appraisal, and labor relations—the prevalence of particular HR practices and
their impact on outcomes vary widely. For example, the US healthcare system
relies heavily on private, for-profit organizations, whereas many countries of
Latin America and Asia have more socialized systems (e.g., universal health-
care) (Lytle et al. 1995). Consequently, US employers tend to place a greater
emphasis on individual performance and performance-driven rewards. In a com-
parison of management priorities in the United States and mainland China, US
managers were more concerned about getting the job done, whereas Chinese
managers were concerned with maintaining harmony (Ralston et al. 1992).

The social psychologist Geert Hofstede (2018) suggests that societies
differ on six dimensions: (1) power distance, (2) individualism, (3) masculinity,
(4) uncertainty avoidance, (5) long-term orientation, and (6) indulgence. Of
these dimensions, the most relevant for HR practices are individualism, mas-
culinity, and long-term orientation. Detailed information about how various
countries compare across these dimensions is available via Hofstede Insights
(2018) at www.hofstede-insights.com/product/compare-countries/.

Cultural and legal differences have a powerful influence on HR policies
and practices. The American emphasis on individuality, for instance, might
explain why managers in the United States have fewer constraints in downsiz-
ing employees than managers in other countries do (Brewster 2004). The US
concept of employment at will—which gives employers substantial freedom to
terminate employees—does not exist in Europe, where firing or laying off work-
ers is often very expensive (Poutsma, Ligthart, and Veersma 2006). Similarly,
in India, employers with more than 100 employees must have government
approval to lay off or fire workers (Srivastava 2011), and Brazil imposes a fine of
4 percent for employees who are fired without “just cause” (Economist 2011).
Autocratic countries, meanwhile, often fail to protect “whistleblowers” who
divulge negative information about their employers.

Case Study: Sociocultural Perspectives in Researching
Healthcare Systems and Developing Health System Managers

The following case study was developed in 2017 through the work of col-
leagues at the Naresuan University College of Health Systems Management
(NUCHSM) in Tha Pho, Phitsanulok, Thailand: D. S. Briggs, P. Tejativaddhana
(Thailand), P. Barua (Bangladesh), K. Dorji (Bhutan), S. Hasan (Bangladesh),
D. Tshering (Bhutan), and C. Wangmo (Bhutan). It may be used for teaching,
research, and referencing purposes with attribution to NUCHSM (http://
chsm.nu.ac.th/en/).

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C h a p t e r 4 : H u m a n R e s o u r c e M a n a g e m e n t i n a G l o b a l C o n t e x t 101

The field of health system management has been relatively unknown in
many Asian Pacific countries, where the traditional focus has been on public
health, not on acute care health systems. Often, doctors and nurses have
taken positions as health managers or hospital directors without having any
prior health management education or experience. Still, these countries are
embarking on an era of health reform and looking to move from “developing
country” status to “developed country.”

Thailand has become famous for its successes in health reform,
adopting universal healthcare, using health volunteers to influence villages
toward better health, and establishing district health …

L e a r n i n g O b j e c t i v e s

1

C H A P T E R 1

S T R AT E G I C H U M A N
R E S O U R C E S M A N A G E M E N T
Myron D. Fottler

After completing this chapter, you should be able to

➤ define strategic human resources management;

➤ outline key human resources functions;

➤ discuss the significance of strategic human resources management to present and future

healthcare executives; and

➤ describe the organizational and human resources systems that affect organizational

outcomes.

00_Fried_Fottler (2349) Book.indb 1 9/25/17 11:51 AM

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F u n d a m e n t a l s o f H u m a n R e s o u r c e s i n H e a l t h c a r e2

Jane Seers is the administrator of the Sunset Assisted Living Center in Orlando, Florida.
Two years ago she brought her board members, medical staff, and top management team
together to develop a new strategic plan for the organization. The new plan identified a
series of goals and objectives in the areas of marketing, finance, and information systems.
In addition, the organization set a goal of annual growth in resident census of 10 percent.
The strategic planning group assumed human resources would be available to implement
the plan as needed.

Now Jane has discovered that Sunset has not been able to recruit and retain adequate
numbers of nurses and other allied health personnel needed to implement the strategic
plan. Overall employee turnover averaged 22 percent per year in the last three years. She
will now have to report to the board that the patient census goals have not been reached
because of the organization’s inability to adequately staff the growth of the facility.

v i g n e t t e

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C h a p t e r 1 : S t r a t e g i c H u m a n R e s o u r c e s M a n a g e m e n t 3

in t r O d u C t i O n
The previous vignette illustrates a mistake many healthcare organizations make when they
develop and attempt to implement their strategic business plan without consideration of
human resources. Sunset failed to consider the crucial role of an adequate quantity and
quality of human resources in the successful implementation of its business strategy.

Like most other service industries, the healthcare industry is labor intensive. One
reason for healthcare’s reliance on an extensive workforce is that it is not possible to pro-
duce a service and then store it for later consumption. In healthcare, the production of the
service that is purchased and the consumption of that service occur simultaneously. Thus,
the interaction between healthcare consumers and healthcare providers is an integral part of
the delivery of health services. Given the dependence on healthcare professionals to deliver
service, the possibility of wide variations in service quality must be recognized within an
employee (as skills and competencies change over time) and among employees (as particular
individuals or representatives of various professions provide a service).

The intensive use of labor and the variability in professional practice require that
leaders in the healthcare field manage the performance of the people involved in the delivery
of services. Effective management requires that healthcare executives understand the factors
that influence the performance of their employees. These factors include the traditional
human resources management (HRM) activities (i.e., recruitment and selection, training
and development, appraisal, compensation, and employee relations) and the environmental
and other organizational aspects that impinge on human resources (HR) activities.

st r at e g i C hu m a n re s O u r C e s ma n a g e m e n t
Strategic human resources management (SHRM) is the comprehensive set of managerial
activities and tasks related to developing and maintaining a qualified workforce. This work-
force contributes to organizational effectiveness, as defined by the organization’s strategic
goals. SHRM occurs in a complex and dynamic environment within the organizational
context. A significant trend today is for HR managers to adopt a strategic perspective of
their job and to recognize critical links between organizational and HR strategies (Fottler,
Khatri, and Savage 2010).

This book explains methods for increasing the probability of hiring competent people
and of those people ably performing needed tasks after hire. To implement these methods
and practices, organizations must

◆ determine requirements for positions,

◆ recruit and select qualified people,

◆ train and develop employees to meet future organizational needs, and

◆ provide adequate rewards to attract and retain top performers.

human resources

management (HRM)

The processes

(recruitment,

selection, training

and development,

appraisal,

compensation,

labor relations, and

employee relations)

performed within

the organization or

external to it and more

informal management

of employees

performed by all

administrators.

strategic human

resources management

(SHRM)

The process of

formulating and

executing human

resources (HR) policies

and practices that

produce employee

competencies and

behaviors required for

the organization to

achieve its strategic

objectives. To

produce the required

staff competencies

and behaviors, the

healthcare organization

needs to implement

the right mix of

recruitment, selection,

compensation,

performance

appraisal, employee

development, and

other HR strategies,

policies, and practices.

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F u n d a m e n t a l s o f H u m a n R e s o u r c e s i n H e a l t h c a r e4

All of these functions must be managed within society’s legal constraints—legisla-
tion, regulation, and court decisions.

This chapter emphasizes that HR functions are performed within the context of
the overall activities of the organization. These functions are influenced or constrained by
the environment, the organizational mission and strategies that are being pursued, and the
systems indigenous to the institution.

s i g n i f i C a n C e O f shrm

Why study SHRM? How does this topic relate to the career interests or aspirations of present
or future healthcare executives? Staffing the organization, designing jobs, building teams,
developing employee skills, identifying approaches to improve performance and customer
service, and rewarding employee success are as relevant to line managers as they are to HR
managers. A successful healthcare executive needs to understand human behavior, work
with employees effectively, and be knowledgeable about numerous systems and practices
available to put together a skilled and motivated workforce. The executive also has to be
aware of economic, technological, social, and legal issues that affect human resources and,
in turn, facilitate or constrain efforts to attain strategic objectives.

Healthcare executives do not want to hire the wrong person, experience high turnover,
manage unmotivated employees, be taken to court for discrimination actions, be cited for unsafe
practices, have their patients’ satisfaction undermined by poorly trained staff, or commit unfair
labor practices. Despite their best efforts, executives often fail at HRM because they hire the
wrong people or do not motivate or develop their staff. You are likely to manage people at some
point in your career in healthcare management. Carefully studying this book and implement-
ing effective HR management techniques will help you avoid the aforementioned mistakes.

Research shows that the manner in which you conduct the human resource respon-
sibilities of your management job—recruiting, selecting, training, evaluating, and reward-
ing—will be key to your effectiveness as a healthcare manager (Ford et al. 2006; Fottler,
Khatri, and Savage 2010; Huselid, Becker, and Beatty 2005; Messersmith and Guthrie
2010; Ramadevi et al. 2016; Wright et al. 2005).

Healthcare organizations can gain a competitive advantage by effectively managing
their human resources. This competitive advantage may be in the form of cost leadership
(e.g., being a low-cost provider) or product differentiation (e.g., having high levels of service
quality). A late twentieth-century study examined the HRM practices and productivity
levels of 968 organizations across 35 industries (Huselid 1994). The effectiveness of each
organization’s HRM practices was rated based on the presence of such benefits as incentive
plans, employee grievance systems, formal performance appraisal systems, and employee
participation in decision making. The study found that organizations with high HRM
effectiveness ratings clearly outperformed those with low HRM rankings. A similar study of
293 publicly held companies reported that productivity was highly correlated with effective
HRM practices (Huselid, Jackson, and Schuler 1997).

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C h a p t e r 1 : S t r a t e g i c H u m a n R e s o u r c e s M a n a g e m e n t 5

However, achieving a competitive advantage through human resources must be based
on the unique combination of an organization’s human capital, strategy, and core capabili-
ties that differs from organization to organization (Becker and Huselid 2006). This means
that healthcare executives cannot simply rely on the benchmarks and strategies of others,
even though they may be suggestive of better approaches to managing people. Instead,
healthcare executives must develop their own HR strategies. If they can successfully develop
and implement these strategies, they may well achieve a sustained competitive advantage
in their markets. The future belongs to healthcare managers who can improve organization
performance while managing change through engaged and committed employees.

Collis and Montgomery (2008) maintain that organizations can achieve a sustainable
competitive advantage through people if the following conditions are met:

◆ The human resources are valuable because they improve the efficiency or
effectiveness of the organization.

◆ The human resources are rare because employees’ knowledge and skills are not
equally available to competitors.

◆ The human resources are difficult to emulate and cannot be easily copied by
others.

◆ The human resources are organized so that employee talents can be combined
and deployed as needed at a moment’s notice.

Organizations achieve competitive advantage through SHRM for the following reasons:

◆ SHRM encourages proactive rather than reactive behavior.

◆ Company goals are communicated explicitly.

◆ There is a focus on gaps between the current situation and a vision of the
future.

◆ Line managers are involved in the human resources planning process.

◆ Human resource opportunities and constraints are identified in implementing
strategic plans.

hr Be s t pr a C t i C e s
Studies have shown that effective management of human resources can increase profitability,
annual sales per employee, productivity, market value, and growth and earnings per share
(Messersmith and Guthrie 2010; Kaufman 2010). In these studies, a survey was used to
study the sophistication of the organization’s HR practices and responses, resulting in a

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F u n d a m e n t a l s o f H u m a n R e s o u r c e s i n H e a l t h c a r e6

score from 0 to 100, where a high score represented practices considered “state of the art.”
Performance was measured using accounting financial data. Results indicate that organi-
zations with better HR practices experienced greater increases in financial performance
relative to others (Becker, Huselid, and Ulrich 2001). In addition, a survey of 200 chief
financial officers revealed that 92 percent believed that managing employees effectively
also improves customer satisfaction (Mayer, Ehrhart, and Schneider 2009). Customers
also have reported that they are more satisfied when the climate of the organization is
more positive, employees generally get along well, and turnover is low (Nishii, Lepak, and
Schneider 2008).

Exhibit 1.1 summarizes HRM practices that appear to enhance the effectiveness
and outcomes of organizations. These practices seem to be present in organizations that
are effective in managing their human resources, and they recur repeatedly in studies of
high-performing organizations. In addition, these themes are interrelated and mutually
reinforcing; it is difficult to achieve positive results by implementing just one practice on
its own (Pfeffer 1998).

While these HR practices generally have a positive impact on organizational per-
formance, their relative effectiveness may also vary depending on their alignment (or lack
thereof ) among themselves and with the organization’s mission, values, culture, strategies,
goals, and objectives (Ford et al. 2006). These HRM practices may vary in their impact
on various types of healthcare organizations, depending on how well each one is aligned
with and reinforces the others as well as how well it is aligned with various aspects with
the overall business strategy.

Certain HR practices are associated with excellent organization performance (Lepak
et al. 2007). It is extraordinarily difficult to prove whether high organization performance
leads to excellent HR practices or whether good HR practices cause better organization
performance (Wright et al. 2005). However, it seems reasonable that organizations should
consider implementation of HR practices associated with the best-performing organizations.

The bad news about achieving competitive advantage through the workforce is that
it takes time to accomplish (Pfeffer 1998). The good news is that, once achieved, such com-
petitive advantage is likely to be more enduring and harder for competitors to duplicate.

Most of these HR best practices are described in more detail throughout the book.
Although the evidence presented in the literature shows that effective HRM practices can
strongly enhance an organization’s competitive advantage, it fails to indicate why these
practices have such an influence. In this chapter, we describe a model—the SHRM—that
attempts to explain this phenomenon.

th e shrm ap p r O a C h
A strategic approach to human resources management includes the following (Fottler et
al. 1999; Snell and Bohlander 2013):

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C h a p t e r 1 : S t r a t e g i c H u m a n R e s o u r c e s M a n a g e m e n t 7

Category Practices

HR planning/
job analysis

Encourage employee involve-
ment so there is strong “buy-in”
of HR practices and managerial
initiatives. Encourage teamwork
so employees are more willing
to collaborate. Provide employ-
ment security.

Include self-managed teams
and decentralization as basic
elements of organization de-
sign to minimize management
layers. Develop strategies to
enhance employee work–life
balance.

Staffing Be proactive in identifying and
attracting talent. In selecting
new employees, use additional
criteria beyond basic skills
(i.e., attitudes, customer focus,
cultural fit).

Training/
organizational
development

Invest in training and organiza-
tional programs to enhance em-
ployee skills related to organiza-
tional goals. Provide employees
with future career opportunities
by giving promotional priority to
internal candidates.

Include customer service in new
employee onboarding and skill
development. Provide opportu-
nities for employee growth so
employees are “stretched” to
enhance all of their skills.

Performance
management and
compensation

Recognize employees by provid-
ing monetary and nonmonetary
rewards. Offer high compensa-
tion contingent on organiza-
tional performance as a way to
reduce employee turnover and
increase attraction to high-
quality employees.

Reduce status distinction and
barriers such as dress, lan-
guage, office arrangement,
parking, and wage differen-
tials. Base individual and team
compensation on goal-oriented
results.

Employee rights Communicate effectively with
employees to keep them in-
formed concerning major issues
and initiatives. Share financial,
salary, and performance informa-
tion to develop a high-trust orga-
nization. Give higher priority to
internal candidates for promotion
to enhance employee motivation.

Provide employment security
for employees who perform
well so they are not downsized
because of economic down-
turns or strategic errors by
senior management.

Sources: Chuang and Liao (2010); Gomez-Mejia and Balkin (2011); Pfeffer (1995, 1998); Wright et al. (2005).

exhiBit 1.1
Effective HRM
Practices for
Healthcare
Organizations

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F u n d a m e n t a l s o f H u m a n R e s o u r c e s i n H e a l t h c a r e8

◆ Assessing the organization’s environment and mission

◆ Formulating the organization’s business strategy

◆ Identifying HR requirements based on the business strategy

◆ Comparing the current HR inventory—numbers, characteristics, and
practices—with future strategic requirements

◆ Developing an HR strategy based on the differences between the current
inventory and future requirements

◆ Implementing the appropriate HR practices to reinforce the business strategy
and to attain competitive advantage

Changes in the external and internal environments have a direct impact on how
organizations are run and people are managed. Some external changes represent oppor-
tunities for the organization and others represent threats. Environmental scanning is the
systematic monitoring of major environmental forces affecting the organization. Internally,
changes may also occur in terms of the organization’s strengths and weaknesses as leader-
ship, culture, and organizational capabilities change.

The organization’s mission, vision, and values must also be assessed to determine an
appropriate business strategy. Examples include being a low-cost provider or differentiat-
ing the organization based on a unique service or outstanding customer services. After the
business strategy has been determined, the organization must develop an HR strategy that
will reinforce the business strategy by making sure that human resources are available in
the right numbers, with the right skills, and at the right time to implement the formulated
business strategy.

An HR strategy refers to a company’s deliberate use of HR to gain or maintain an
edge against its competitors (Ulrich, Younger, and Brockbank 2008). In the twenty-first
century, organizations have been paying more attention to strategy implementation and
execution (Kaplan 2007; Neilson, Martin, and Power 2008). Human resources manage-
ment is instrumental in strategy implementation.

SHRM has not been given as high a priority in healthcare as it has received in many
other fields. This neglect is particularly surprising in a labor-intensive field that requires the
right people to be in the right jobs at the right times and that often suffers staffing short-
ages. In addition, the literature in the field as early as the 1990s has offered fairly strong
evidence that organizations that use more progressive HR approaches achieve significantly
better financial results than do comparable, although less progressive, organizations (Huselid
1994; Huselid, Jackson, and Schuler 1997).

Exhibit 1.2 illustrates some strategic HR trends that affect job analysis and planning,
staffing, training and development, performance appraisal, compensation, employee rights
and discipline, and employee and labor relations. These trends are discussed in greater detail

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C h a p t e r 1 : S t r a t e g i c H u m a n R e s o u r c e s M a n a g e m e n t 9

Old HR Practices Current HR Practices

Job Analysis/Planning

Explicit job descriptions Broad job classes

Detailed HR planning Loose work planning

Detailed controls Flexibility

Efficiency Innovation

Staffing

Supervisors make hiring decisions Team makes hiring decisions

Emphasis on candidate’s technical qualifications Emphasis on fit of applicant within the culture

Layoffs Incentives to retire voluntarily

Letting laid-off workers fend for themselves Providing continued support to laid-off workers

Training and Development

Individual training Team-based training

Job-specific training Generic training emphasizing flexibility

“Buy” skills by hiring experienced workers “Make” skills by training less-skilled workers

Organization responsible for career development Employee responsible for career development

Performance Appraisal

Uniform appraisal procedures Customized appraisals

Control-oriented appraisals Developmental appraisals

Supervisor input only Appraisals with multiple inputs

Compensation

Seniority Performance-based pay

Centralized pay decisions Decentralized pay decisions

Fixed fringe benefits Flexible fringe benefits (cafeteria approach)

Employee Rights and Discipline

Emphasis on employer protection Emphasis on employee protection

Informal ethical standards Explicit ethical codes and enforcement procedures

Emphasis on discipline to reduce mistakes Emphasis on prevention to reduce mistakes

Employee and Labor Relations

Top-down communication Bottom-up communication and feedback

Adversarial approach Collaborative approach

Preventive labor relations Employee freedom of choice

exhiBit 1.2
Strategic Human
Resources Trends

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F u n d a m e n t a l s o f H u m a n R e s o u r c e s i n H e a l t h c a r e1 0

in later chapters. The key point of exhibit 1.2 is that organizations are moving to higher
levels of flexibility, collaboration, decentralization, and team orientation.

t h e shrm m O d e l

As illustrated in exhibit 1.3, a healthcare organization is made up of systems that require
constant interaction within the environment. To remain viable, an organization must extend
its strategic planning and thinking to external changes because the internal components of
the organization are affected by these changes.

The characteristics, performance levels, and alignment in operating practices among
these systems improve organizational and employee performance. HR goals, objectives, process
systems, culture, technology, and workforce closely align with one another (internal alignment)
and with various levels of organizational strategies (external alignment) (Ford et al. 2006).

i n t e r n a l a n d e x t e r n a l e n v i r O n m e n ta l a s s e s s m e n t

Environmental assessment is a crucial element of SHRM. Changes in the legal and
regulatory climate, economic conditions, and labor market realities mean that healthcare
organizations face constantly changing opportunities and threats. These opportunities and
threats make particular services or markets more or less attractive.

Among the trends currently affecting the healthcare environment are greater work-
force diversity, aging of the workforce, labor shortages, changing worker values and atti-
tudes, and advances in technology. Healthcare executives have responded to these external
environmental pressures through various internal structural changes, including developing
network structures, joining healthcare systems, participating in mergers and acquisitions,
forming work teams, implementing continuous quality improvement, allowing telecom-
muting, leasing employees, outsourcing work, using additional temporary or contingent
workers, and implementing medical tourism. In addition to assessing their organizational
strengths and weaknesses, healthcare executives need to assess their internal systems; their
human resources’ skills, knowledge, and abilities; and their portfolio of service markets.
Managers should develop HR policies and practices that are closely related to, influenced
by, and supportive of the strategic goals and plans of their organization.

Organizations, either explicitly or implicitly, pursue a strategy in their operations.
Deciding on a strategy involves determining the products or services that will be created
and the markets to which the chosen services will be offered. After the selections are made,
the methods to compete in the chosen market must be identified from among the available
or potential internal resources.

As shown in exhibit 1.3, strategies should consider environmental conditions and
organizational capabilities. To take advantage of opportunities and circumvent threats,

environmental

assessment

A crucial element

of strategic human

resources management

in which an

organization reviews

the changes in the

legal and regulatory

climate, economic

conditions, and labor

market realities to

understand current

opportunities and

threats.

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C h a p t e r 1 : S t r a t e g i c H u m a n R e s o u r c e s M a n a g e m e n t 1 1

exhiBit 1.3
Strategic Human
Resources
Management
Model

Internal Assessments
• Strengths
• Weaknesses
• Portfolio of service
markets
• Human resources’
skills, knowledge,
and abilities
• Internal systems

Organizational
Mission
• Purpose
• Mission
• Business unit

Environmental
Assessment
• Opportunities
• Threats
• Services/markets
• Technological trends
• Legal/regulatory
climate
• Economic conditions
• Labor markets

Organizational
Strategy Goals
and Objectives

Aligned HR
Strategy
Implementation
• Management
of internal and
external
stakeholders
• HR practices/
tactics to
implement
(i.e., adequate
staffing)

Formulation of Other
Aligned Functional
Strategies
• Accounting/finance
• Marketing
• Operations
management

Implementation of Other
Aligned Functional
Strategies

HR Outcomes
• Required employee
competencies and behaviors
• High levels of employee
engagement, motivation, and
job satisfaction

Organizational Outcomes
• Competitive advantage
• Financial performance
• Legal compliance
• Attainment of strategic goals
• Satisfaction of key stakeholders

Aligned HR Strategy
Formulation
• HR goals and
objectives
• HR process systems:
— HR planning
— Job analysis and
job design
— Recruitment/
retention
— Selection/placement
— Training/
development
— Performance
appraisal
— Compensation
— Labor relations
• Organizational
design/culture
• Technology/
information systems
• Workforce composition

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F u n d a m e n t a l s o f H u m a n R e s o u r c e s i n H e a l t h c a r e1 2

managers must have detailed knowledge of the current and future operating environment.
Knowing internal strengths and weaknesses allows managers to develop plans based on an
accurate assessment of the organization’s …

2 9 6

L e a r n i n g O b j e c t i v e s

C H A P T E R 1 1

D I V E R S I T Y A N D I N C L U S I O N I N
T H E W O R K P L A C E
Jeffrey Simms and Bruce J. Fried

After completing this chapter, the reader should be able to

➤ understand the definitions of and distinctions between diversity and inclusion;

➤ recognize the factors associated with creating an inclusive environment;

➤ recognize the importance of diversity and inclusion in healthcare;

➤ value the diversity of patients and coworkers; and

➤ develop strategies for recruiting and retaining a diverse team.

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C h a p t e r 1 1 : D i v e r s i t y a n d I n c l u s i o n i n t h e W o r k p l a c e 2 9 7

v i g n e t t e

Jack is in a senior leadership position at a medium-sized, inpatient medical center in a rural
area in the southeastern part of the United States. At the last board of trustees meeting,
Jack mentioned that he has a number of key administrative position vacancies in his depart-
ment and that he is beginning the process of posting and hiring for these positions. After
the meeting, the only African-American trustee on the board approached Jack and asked for
about 15 to 20 minutes of his time. Jack has always respected this trustee and graciously
agreed to meet with him. During the brief conversation, the trustee commended Jack on his
leadership of the hospital but wanted to share some opportunities for improvement with him.
In a thoughtful manner, he posed two questions to Jack and asked him not to immediately
respond, but to take some days to ponder the questions:

1. Have you ever thought about why a hospital this size has only one underrepresented
minority trustee?

2. From a demographic perspective, do you believe that the clinical and administrative
team of the hospital represents the patients you serve on a daily basis?

He thanked Jack for his time and said he looked forward to seeing him at the next
board meeting.

This conversation with the trustee stayed with Jack for a number of days, and he
decided to research the questions the trustee asked him. He discovered through board of
trustee meeting minutes that there had been limited discussion around the topic of diversity
and inclusion, and when he asked the president of the medical center about it, the response
was, “We are proud of the fact that we’ve worked very hard to ensure that our board of
trustees has a black trustee.”

Jack then asked the human resources department to pull a report of the full-time
employees at the hospital, including information about race and ethnicity. Internally, Jack
was struggling with the fact that he has been in leadership with this hospital for more than
ten years and he hadn’t given much thought to the racial and ethnic composition of the
medical center’s employees. The data revealed that 98 percent of the physicians employed
by the hospital are white males; 95 percent of the nurses working at the hospital are white
females; 100 percent of the administrative leadership team, including the president, are white
males; and the chief nursing officer is a white female. As Jack continued to review the data,
he noticed that 90 percent of the nursing assistants, custodians, and food service staff are
either African American or Latino. Troubled by these findings, Jack raised a number of ques-
tions in his mind and considered if, how, and when to broach this issue with his colleagues
and board members. He immediately began looking for resources related to diversity and
inclusion in healthcare organizations.

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in t r O d u C t i O n
Patients who enter the US health system represent the diversity of the population in the
country. By diversity, we refer not only to race and ethnicity but also to age, socioeconomic
status, political perspective, and geographic location. Colby and Ortman (2014) of the
US Census Bureau projected that by the year 2020, more than half of the children in the
United States are likely to be part of a minority race or ethnic group. In 2015, 52 percent
of children in the United States were single-race non-Hispanic white, while by 2060, this
percentage will decrease to only 36 percent. The United States will also face continuing
aging of the population. The percentage of the population younger than the age of 18 is
expected to decrease from 23 percent in 2014 to 20 percent in 2060. Furthermore, in that
same period, the percentage of the population aged 66 or older is expected to increase from
15 percent to 24 percent (Colby and Ortman 2014). In 2012 the American College of
Healthcare Executives, American Hospital Association, Association of American Medical
Colleges, Catholic Health Association of the United States, and National Association of
Public Hospitals and Health Systems announced a joint call to action for the elimination
of healthcare disparities. “Addressing disparities is no longer just about morality, ethics and
social justice: It is essential for performance excellence and improved community health,”
these groups declared (Institute for Diversity in Health Management and Health Research
and Educational Trust 2012). Their message included the idea that diversity is important
for the quality of health services, and not solely for concerns about equity and fairness in
hiring practices. Therefore, to improve health status and outcomes, health systems and
providers need to be intentional regarding their efforts to improve diversity and inclusion.

pe r s p e C t i v e s O n di v e r s i t y
Views of diversity have evolved through the years, and each perspective has its own set of
rationales. A classic review of these paradigms was presented by Thomas and Ely (1996),
who noted, at the time, that there had been three stages of diversity. It is important to
note that many, if not most, organizations exhibit characteristics of all of these paradigms.

As diversity first entered the lexicon of management, emphasis was initially placed
on preventing discrimination against specific groups; Thomas and Ely (1996) refer to this
perspective as the “discrimination-and-fairness paradigm.” Among organizations using this
paradigm, it is common to see mentoring and career development programs, particularly
for women and people of color, as well as strategies aimed at recruiting and retaining under-
represented groups. Many, if not most, organizations continue to engage in these types of
activities and may also be pressured by legal obligations.

Whereas the “discrimination-and-fairness paradigm” sought to favor assimilation
and discounting of differences among people, the second perspective on diversity celebrated
differences. Referred to by Thomas and Ely (1996) as the “access-and-legitimacy paradigm,”
organizations with this perspective began to see value in differences and in fact saw differences
as a way of reaching previously ignored consumer groups and new markets. From a marketing

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perspective, many organizations segmented their products and services for specific groups.
Employing representatives of those groups would enable the organization to gain insight
into the preferences of such groups and tap into new markets. This perspective provides the
foundation of the “business case” for diversity. On the face of it, this perspective makes sense,
but it also creates the risk of pigeonholing people into particular roles. For example, a typical
refrain might be, “Let’s ask Maria [a Latina] about what Latinos prefer in this product offer-
ing.” Or in a healthcare setting, “Let’s get input from Cynthia, who can give us the women’s
perspective on the best way to bring women with substance abuse problems into treatment.”
The access-and-legitimacy paradigm provides an important perspective, but it may be viewed as
only using people to the extent that they can represent the preferences of a demographic group.

Thomas and Ely (1996) articulate what they refer to as “The Emerging Paradigm:
Connecting Diversity to Work Perspectives.” In this third perspective, having a diverse
workforce can enable an organization to obtain new perspectives and to learn—above and
beyond the specific demographic insights of employees. As discussed later, all people view
the world through a particular “frame,” and what may be apparent to one person may not
be so obvious to others (Thomas and Ely 1996). Diversity brings people together with
distinct frames and adds to the collective ability to see things in more than one way. The
point is that having people with contrasting views of the world will almost always bring
in alternative ways of looking at situations. While it is often difficult to predict just where
these unique insights will emerge, having a diverse group of employees increases the chances
of the organization being able to innovate and learn.

If we were to follow the trajectory of diversity in the workplace, we would need to
add the concept of inclusion—that is, creating an environment where we not only “have
the numbers” to demonstrate our commitment to diversity but also respond to the need to
create and sustain an environment that welcomes and encourages the diverse perspectives
brought by our employees. Creating such an environment also signals to potential employees
that the organization is a good place to work for underrepresented groups, which in turn
assists in recruitment and retention.

Finally, neglecting to create an inclusive environment risks our not being able to
attract whole segments of highly trained employees who can provide healthcare or manage
operations. In labor markets where many organizations have difficulty attracting talent—
underrepresented or otherwise—hospitals and other healthcare organizations cannot afford
to miss such opportunities. Failure to recruit the most talented employees may mean the
difference between being a provider and employer of choice or losing ground to competi-
tors (Dreachslin, Gilbert, and Malone 2012).

de f i n i t i O n O f Diversity
The definition of diversity continues to evolve. For years the word was used as a descriptor
limited mostly to race and ethnicity. Today, the definition has become increasingly broader
in scope and includes not solely variations in employee attributes such as age, gender, and

diversity

The collective mixture

of differences and

similarities that

account for individual

identities. Diversity

may be extended to

include the qualities,

experiences, and

work styles that make

individuals unique.

Diversity attributes

are broad and may

refer to age, language,

generation, race,

religion, disability

status, ethnicity, and

many other attributes.

In organizations,

attention is focused on

how diverse employee

qualities may be

leveraged to achieve

the organization’s

objectives.

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race but also variations in work style and how these variations may be used constructively
by the organization. In an article in Becker’s Hospital Review, Jayanthi (2016) describes
generational perspectives on the understanding of diversity. For baby boomers (people
born from 1945 through 1964), the concept of diversity has always included gender, status,
sexual orientation, and religion, and this viewpoint is reflective of their background and
the era in which they came of age. Millennials (people born from 1982 through 2004)
build on this foundational lens for diversity and expand it to include differing experiences
and perspectives. “This newer, all-inclusive definition of diversity is perpetuated by the
millennial generation who tend to define diversity in the context of experiences, opinions
and thoughts, while older generations focus on religion, demographics and representation,”
Jayanthi (2016) points out. For example, millennials in the United States would describe
their personal and professional networks as being more racially and ethnically inclusive than
those of their parents, which has caused millennials to widen the diversity lens beyond the
earlier, more limited descriptors. Exhibit 11.1 displays a sampling of the multiple dimen-
sions of diversity. This list is not all inclusive, but it provides a framework for viewing
diversity beyond race and ethnicity. The ever-evolving definition of diversity continues to
emphasize how important it is for individuals, businesses, and organizations—especially
health systems and providers—to embrace diversity and inclusion.

The idea of diversity has also expanded to include the critical role of inclusion. Diver-
sity encompasses the many ways people differ, including gender, race, sexual identity, and age,
while inclusion ensures the functionality of a diverse group or organization. In other words,
inclusion goes beyond mere numbers to include an organizational culture that is accepting
and encouraging of diverse perspectives. In fact, a culture of inclusion is necessary to achieve
the benefits of gaining knowledge and valuable perspectives. Inclusion, therefore, makes good
business sense because it brings important information to bear on organizational challenges.

An inclusive environment provides processes that allow everyone to be a part of the
network of information and opportunities in the organization. For example, an organization
can increase the number of underrepresented minority employees through its recruitment
approaches as developed by its human resources department. But if that same organization
does not foster an environment of inclusion, it will struggle with both recruitment and

inclusion

The manner and

extent to which

diverse members of

an organization are

accepted and are

fully integrated into

the organization.

Inclusive organizations

have cultures that

not only tolerate but

also encourage full

participation of all of

their members without

fear of unwarranted

criticism. An inclusive

organization is best

able to take advantage

of the unique

contributions of its

members.

Diversity includes, but is not limited to…

Race Sexual identity Age

Ethnicity Political views Economic class

Religion Values Geographic region

Gender Physical abilities Education

Family Country of origin Language

exhiBit 11.1
Multiple

Dimensions of
Diversity

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retention. Organizations attain reputations for how people are managed, and these views
are often difficult to change. Recruitment and retention are addressed later in this chapter.

As implied in the opening vignette, the senior leader of his organization, Jack, is
confronted with evidence that the leadership team, hospital staff, and board of trustees for
this facility are not representative of the community that the organization is serving. As
Jack develops a strategy for addressing this issue, it is crucial for him to communicate the
value of diversity and to ensure that those on his team understand that they all have a part
to play in improving the diversity of the organization. This is not just a task for the human
resources department. It requires that leadership styles align themselves with the processes
that will promote a sustainably diverse and inclusive work environment. It is also critical
that Jack and his colleagues appreciate the shortcomings of the organization and how they
may affect its effectiveness and competitiveness.

In his attempt to communicate these messages to managers in the organization,
Jack might consider an exercise adapted from the Teaching Tolerance Project, developed
by the Southern Poverty Law Center. It is based on the premise that as individuals develop
a broader understanding of diversity, they become better able to see opportunities for
improvement, as described later in this chapter.

The Valuing Differences approach describes one’s frame as “all the things that make
up who we are and how we view situations,” and is based on our values, culture, back-
ground, and life experiences. Life experiences in turn include “things that we choose to do,
as well as things we do not have any choice about or control over” (Southern Poverty Law
Center 2017). As indicated in exhibit 11.2, a wide variety of factors may affect the manner
in which we view the world. Then, using the FRAME acronym, the approach encourages
people to apply what they know as their own frame to overcome biases and appreciate the
perspectives of other people’s frames (see exhibit 11.3 on the next page).

Country of origin Values

Geographic region Gender

History and ancestral heritage Sexual orientation

Neighborhood where we grew up Education

Neighborhood where we live now Occupation

Family Ethnicity

Religion Culture and cultural traditions

Physical abilities Socioeconomic class

Age Language

Source: Adapted from Southern Poverty Law Center (2017).

exhiBit 11.2
Factors That Make
Up Your FRAME

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di v e r s i t y, in C l u s i O n, a n d t h e te a m en v i r O n m e n t
Many organizations have instituted formal processes and procedures to encourage a diverse
workforce. Some of these efforts are driven by legal requirements to ensure that the organi-
zation is compliant with a variety of equal employment opportunity laws, such as the Civil
Rights Act and the Americans with Disabilities Act as Amended. However, it is important
to ensure that these efforts are not thwarted by a culture that does not foster the develop-
ment and growth of all employees. For example, an organization might challenge itself
with the following questions:

◆ Why are we successful in hiring underrepresented minority and lesbian, gay,
bisexual, or transgender (LGBT) employees but having difficulty retaining
those same individuals?

◆ How is information about opportunities for advancement circulated in our
organization?

◆ Is there a formal posting of advancement opportunities or are they directed by
leadership via private, informal networks?

◆ Are middle managers trained in managing a diverse workforce?

Teams are an integral part of healthcare organizations, and as their use continues
to increase, the creation of an inclusive culture is particularly critical. Edmondson and
Roloff (2009) address diversity and inclusion in reference to the concept of psychological
safety. They make the powerful case that psychological safety is a key factor determining an

psychological safety

Belief that one will

not be rejected

or humiliated in a

particular setting

or role; also an

atmosphere in which

people feel free to

express work-relevant

thoughts and feelings.

F Figure out the facts. Not just what is apparent to you, but all the facts. Seek more
information, ask questions, and listen.

R Reflect on reality. Is it my reality or their reality? Am I looking at this through my
FRAME or trying to see it through their FRAME?

A Acknowledge an open mind. Think about your expectations and whether they are
appropriate. Are you making assumptions based on your FRAME?

M Maintain an open mind. Just because someone else’s FRAME differs from yours does
not make them wrong. What can you learn from them? What can they learn from
you? What do you have in common?

E Expand your experiences. Explore, expose yourself, and encounter differences;
expand your comfort zone; increase your cultural competence.

Source: Southern Poverty Law Center (2017).

exhiBit 11.3
Remembering and
Using Your FRAME

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organization’s ability to achieve the benefits of a diverse organization. They define psychologi-
cal safety as the “belief that one will not be rejected or humiliated in a particular setting or
role, and describes a climate in which people feel free to express work-relevant thoughts and
feelings” (Edmondson and Roloff 2009, 48). A lack of psychological safety in organizations
often results in employees feeling marginalized because of their differing opinion, perspec-
tive, or experience (Edmondson and Roloff 2009). This marginalization in turn limits the
input of people who could otherwise have made contributions informed by other perspec-
tives, or, using the FRAME language, people who see the world through different frames.

Consider the case of Betty, the administrative manager for a large ambulatory care
center that is affiliated with a large academic medical center. As a part of the strategic plan
for the health system, senior leaders are proposing that all ambulatory care centers in the
system will start offering patients weekend hours. As Betty reviews this proposal, she is
concerned because her religious practices discourage working on the Sabbath. In a recent
departmental leadership meeting, Betty’s director expressed his thoughts about the need
for everyone to make sacrifices regarding this strategic plan and his expectation that no one
will express concerns about this expansion of service hours because it is a revenue issue.
Betty in turn is given the implicit message that it is “not okay” to question this new policy
because of the apparent strong support for it by senior management. Betty may be afraid of
being ostracized by her colleagues, criticized for not being a “team player,” or simply being
told that the policy is rigid and that everyone needs to make sacrifices. In fact, there might
be a solution to Betty’s problem with that policy that can meet the objectives of the policy
while also respecting her religious practices. However, without a climate of psychological
safety, such options may never be explored because Betty is too afraid to speak up and thus
leadership remains oblivious to the problem. The ambulatory care center where she works
could benefit from hiring a chief diversity officer (see “Did You Know?” sidebar).

Ch a n g i n g t h e Cu lt u r e
The business case for diversity has been made by
numerous writers. Parsi (2017) notes that based on
projected growth, US minorities soon will no longer
be in the minority. By 2044, more than half of all
Americans will belong to a group other than non-
Hispanic white, and by 2060, about 20 percent of
the US population will be foreign born (Colby and
Ortman 2014). This continued growth in diverse
populations means that hospital administrators,
healthcare providers, health policymakers, and care-
givers should be attentive to these demographic shifts
and their implications for many aspects of healthcare.

DID YOU KNOW?
Chief Diversity Officer

According to a 2012 report written by the Institute for Diversity

in Health Management and the Association of American Medi-

cal Colleges entitled The Role of the Chief Diversity Officer in

Academic Health Centers, many companies and organizations

have created a senior-level position known as the chief diver-

sity officer to drive all of the strategic efforts around diversity

and inclusion (Institute for Diversity in Health Management

and Association of American Medical Colleges 2012).

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Dr. Martin Davidson at the University of
Virginia’s Darden School of Business makes the
point in his book entitled The End of Diversity as
We Know It: Why Diversity Efforts Fail and How
Leveraging Difference Can Succeed (2011) that
organizations that focus solely on attracting and
retaining diverse teams limit the overall perfor-
mance and value added that diversity provides the
organization. Companies that look more closely
at their organizational culture to identify how the
diversity that has been created in the organization

can be used to enhance learning, development, and innovation are more likely to achieve
superior results (Davidson 2011; see also related “Did You Know?” sidebar above left).

Each organization is unique and faces its own challenges related to diversity and
inclusion. However, there are key practices that should likely be used by all organizations
to monitor their progress in improving diversity and assessing the impact of improved
processes that may have been put in place. For example, organizations should regularly
monitor employee demographic statistics to determine whether there are hiring practices
that impede improvements in diversity. Although biases may not be purposely discrimina-
tory (and from a legal perspective, the motivation behind discriminatory practices may not
be relevant), their impact may have a negative impact on diversity goals. It is important to
note that discriminatory practices are not good business practices. For example, an organi-
zations that restricts its hiring to graduates of specific academic institutions or professional
associations may limit its ability to recruit a diverse and qualified applicant pool.

There are a number of professional associations devoted to support of minority and
special-interest professionals in the United States, including the following:

◆ National Association of Health Services Executives (www.nahse.org)

◆ National Association of Latino Healthcare Executives (www.nalhe.org)

◆ Institute for Diversity in Health Management (www.diversityconnection.org)

◆ Asian Healthcare Leaders Forum (www.ache.org/newclub/forums/AHLF/
index.cfm)

◆ LGBT Forum (www.ache.org/newclub/forums/LGBT/index.cfm)

ap p r O a C h e s t O de v e l O p i n g a n in C l u s i v e Or g a n i z at i O n a l
Cu lt u r e
Moving an organization’s culture to be more attuned to the needs and interests of diverse
populations is not considered to be a necessarily expensive proposition (see “Did You

DID YOU KNOW?
Diversity Enhances Performance

McKinsey and Company Global Management Consulting Firm

found that organizations that exhibit gender and ethnic diver-

sity are, respectively, 15 percent and 35 percent more likely to

outperform those that don’t (Parsi 2017).

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Know?” sidebar for information on a helpful
toolkit). However, such transformations require
support from all parts of the organizations and
employees at all organizational levels. In addition,
nonemployees also have a role to play in effecting
a new organizational culture. For example, physi-
cians are generally not employees of a healthcare
organization in the traditional sense. However,
their attitudes and behaviors can have a profound
impact on attitudes, communication, and encour-
agement of diverse perspectives. The progression
toward creating a diverse and inclusive culture
requires consistent …

L e a r n i n g O b j e c t i v e s

1 1 3

After completing this chapter, you should be able to

➤ describe the major steps and decisions involved in recruitment and selection;

➤ discuss the factors prospective employees consider in deciding to accept a job offer;

➤ address the advantages and disadvantages of internal and external recruitment and other

sources of applicants;

➤ compare the concepts of person–job and person–organization fit and their relevance to

recruitment and selection; and

➤ identify the most important factors related to employee turnover and retention and

describe strategies for improving retention.

C H A P T E R 5

R E C R U I T M E N T, S E L E C T I O N ,
A N D R E T E N T I O N
Bruce J. Fried

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F u n d a m e n t a l s o f H u m a n R e s o u r c e s i n H e a l t h c a r e1 1 4

v i g n e t t e

Joan Hampton is director of a nationally known home health care agency that is currently
recruiting for a nurse manager. The nurse manager job involves supervising other nursing
and ancillary staff, managing the scheduling process, coordinating nursing activities with
other home health services, providing direct service, and ensuring compliance with poli-
cies, procedures, and regulatory requirements. Following are the major job requirements:

• Current and unencumbered state license to practice as a registered nurse
• Three years’ experience as a registered nurse, at least one of which must involve

full-time experience in providing direct patient care in the home health setting; one
year supervisory or management experience preferred

• Current cardiopulmonary resuscitation (CPR) certification
• Ability to assess patient status and identify requirements relative to age-specific needs
• Excellent verbal and written communication skills
• Strong interpersonal skills and ability to work in teams
• Knowledge of federal and state rules and regulations, Joint Commission standards,

and other regulatory requirements
• Strong fiscal planning and human resources management skills

Sandra Goodman has been with the home health agency for five years and has proven
to be a diligent, hardworking, and reliable employee. For the past 15 months, she has held
the temporary position of nurse manager and has done well. She sets high standards for
herself, has become an expert in the agency’s reporting and billing procedures, and under-
stands regulatory requirements and the agency’s financial operations. Sandra has applied
for the permanent position of nurse manager, for which she has many of the qualifications.

Along with Sandra, Michaela Roberts is being considered for the position. Michaela
has seven years of experience in home health care and three years of experience as an emer-
gency department nurse. However, she has no supervisory experience and limited financial
skills. Several nurses in the agency interviewed and liked Michaela and recommended her.

Joan is inclined to offer the job to Sandra because of her experience and because
she could step into the position with little training. However, several nurses have come to
Joan indicating that they will quit if Sandra is offered and accepts the job: Although Sandra
has performed well in the temporary nurse manager role, she has an autocratic personality
and management style that have alienated many of the nurses. She has been known to lose
her temper and insult the staff for failure to follow procedures.

Whereas the other nurses support hiring Michaela, Joan believes that she does not
have the time to properly orient and train her for the position. Michaela is bright and indi-
cates a willingness and aptitude to learn, but Joan is much more comfortable and secure with
Sandra. However, she is also concerned with morale problems and turnover if she decides
to hire Sandra. What advice would you give Joan, and why?

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C h a p t e r 5 : R e c r u i t m e n t , S e l e c t i o n , a n d R e t e n t i o n 1 1 5

in t r O d u C t i O n
Staffing an organization can be defined as “getting the right people into the right positions
in a timely manner.” Yet while this definition is correct, staffing also involves determining
where to find applicants, defining criteria for selecting the most appropriate applicant, and
doing all we can to keep people—retain them—in the organization. Thus, recruitment refers
to various methods to generate a pool of applicants. Selection involves choice: Who among
applicants should be chosen for a particular position? Retention refers to keeping people in
the organization after they have been hired.

We address these three important processes—recruitment, selection, and reten-
tion—in a single chapter because they are integrally interrelated and also related to other
human resources management (HRM) functions. These human resources (HR) practices
are highly interdependent. For example:

◆ The success of recruitment efforts determines in part how selective an
organization can be in hiring. An organization can be more selective when
there is a relatively large supply of qualified applicants from which to choose.

◆ Developing a recruitment plan that seeks to generate a pool of qualified
applicants depends first and foremost on the existence of an accurate, current,
and comprehensive job description.

◆ Employee retention may be enhanced by the effectiveness of an organization’s
orientation and socialization processes.

As with all HRM functions, organizations must be cognizant of legal considerations
when developing and implementing recruitment and selection procedures. For example,
because it is illegal under Title VII of the Civil Rights Act to discriminate in hiring based
on race, gender, and other characteristics, those involved in employee selection need to
be diligent in ensuring that these factors do not bias hiring decisions. (Chapter 3 on legal
issues includes a detailed description of Title VII; chapter 11 discusses diversity and inclu-
sion in the workplace.)

re C r u i t m e n t
Recruitment refers to the means by which organizations attract qualified individuals
on a timely basis and in sufficient numbers and encourage them to apply for jobs. In
starting a recruitment effort, organizations should be clear about the nature of the job
and the desired qualifications. They may also consider additional questions, such as the
following:

◆ Should we recruit and promote from within, or should we focus on recruiting
external applicants—or both?

recruitment

The means by which

organizations attract

qualified individuals

on a timely basis and

in sufficient numbers

and encourage them to

apply for jobs.

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◆ Should we consider alternative approaches to filling jobs with full-time
employees, such as outsourcing, flexible staffing, and hiring part-time or
temporary employees?

◆ How important is it for employees to fit in with the culture of the
organization? Should we favor applicants who better fit the culture but may
require additional training to improve their technical skills?

An organization’s recruitment success depends on many factors, including the attrac-
tiveness of the organization and the job; the community and the labor market in which it
is located; unemployment and the nature of the economy; the organization’s work climate
and culture; managerial attitudes and behavior; and workload.

Recruitment can be challenging for many organizations and specific jobs. A 2016 report
by the Society for Human Resource Management (SHRM) found that more than two-thirds of
human resources professionals reported challenging aspects of recruitment. Half of the surveyed
organizations reported such factors as a low number of applicants, lack of work experience among
applicants, and competition from other employers. Among human resources professionals,
84 percent reported that they had seen skills shortages in the previous years (SHRM 2016b).

Organizations involved in health, social assistance, and manufacturing reported the
highest levels of recruitment troubles. Not surprisingly, 70 percent of organizations said
they use social media in their recruiting (SHRM 2016b).

In the next section, we look at how individuals make choices about seeking jobs
and accepting job offers. These are extremely personal decisions, dependent on a multitude
of factors. However, there are some common factors that recruiters need to be aware of.

f a C t O r s t h at i n f l u e n C e j O B C h O i C e

Accepting a job offer is a big decision with possibly lifelong implications. What do potential
employees look for in a job? After an individual is offered a position, how does that person
make the decision to accept or reject the offer? Applicants are certainly concerned with
compensation, benefits, and opportunities for career mobility and promotion. They may
also consider the availability of other positions and the competitiveness of the job market.

Applicants are sensitive to the attitudes and behaviors of the recruiter or whoever
is their first contact with the organization. First impressions are potent, because the sense
of whether one fits in with the organization is often decided at this stage. Early negative
first impressions may be difficult to reverse. Applicants are more likely to accept positions
in organizations that share their values and style.

These considerations lead to the important issue of how organizations communicate
their values to potential job applicants. The examples that follow indicate how organizations

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communicate their values and why they should be considered an “employer of choice.”
Consider the following recruitment message for WakeMed, a large health system in Raleigh,
North Carolina:

At WakeMed Health & Hospitals, we are guided by a simple—yet powerful—mission:
to improve the health and well-being of our community by providing outstanding and
compassionate care to all. To deliver on this mission, WakeMed employs the “best
minds and the biggest hearts” in the business. Our team comprises a group of talented,
passionate professionals whose commitment to WakeMed is all about putting patients
first. We promote a diverse workforce and are proud to offer competitive salaries, com-
prehensive benefits, educational opportunities and flexible schedules that allow our
employees to excel personally and professionally. We think it’s pretty simple—we care
for our employees and our employees care for the community. (WakeMed 2017)

The Cleveland Clinic focuses on joining “a culture that encourages excellence”:

Healthcare is evolving, and Cleveland Clinic is transforming healthcare—pushing the
limits and paving the way to establish new practices and set new standards. We believe
in moving away from the physician-centric model of care and instead putting the patient
at the center of everything we do. We are developing the most innovative patient experi-
ences with our constant investment in continuing education and leadership development
programs. (Cleveland Clinic 2017)

On its main recruitment page, the Mayo Clinic emphasizes that “as a Mayo Clinic
nurse, you will become a vital member of a dynamic team at one of the world’s most
exceptional health care institutions. You will also discover a culture of teamwork, profes-
sionalism and mutual respect, and—most importantly—a life-changing career” (Mayo
Clinic 2017a).

Emory Healthcare promotes itself to prospective employees in this simple but pow-
erful message:

At Emory Healthcare, we bring the science side and the human side together to change
the face of health care. Our team members are courageous individuals who are willing
to challenge the status quo and help find solutions to complex problems. They are
empowered to influence change for, and with, our patients, their families, the community
and each other. As one of the leading academic medical systems, Emory Healthcare
is eager to share what we learn with hospitals around the country, and the world, to
define a new standard of care for humankind. We believe that, ultimately, we’re all in
this together. Are you ready to join us? (Emory Healthcare 2017)

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Kaiser Permanente (2017a) emphasizes that “diversity, inclusion, and culturally
competent medical care are defining characteristics of Kaiser Permanente’s past, present, and
future,” noting its obligation “to create a diverse and inclusive environment that encourages
our employees to reach their full potential.”

Organizations promote themselves as good places to work by appealing to a variety
of employee needs, interests, and values. Understanding the factors that affect job choice is
central to developing effective recruitment strategies. It is valuable to distinguish between
individual characteristics and job characteristics.

Individual characteristics are personal considerations that influence a person’s job
decision. The factors that lead a family physician to accept employment with a rural health
center may be distinct from those that lead a nurse to accept employment with an urban
teaching hospital. Life and career stage may affect the relative importance of these factors.
Job characteristics may include such job-related decision-making factors as compensation,
challenge and responsibility, advancement opportunities, job security, geographic location,
and employee benefits. It is difficult for an organization to create the “perfect” job because
no two individuals are the same in their individual characteristics and job preferences (see
“Critical Concept” sidebar).

Compensation and benefits (discussed more fully in chapter 8) are often key elements
in an individual’s decision to accept a position. For some healthcare positions, compen-
sation is complicated by differential pay rates, hiring or signing bonuses, and relocation
assistance. Hot-skill premiums—temporary pay premiums added to base pay for employees

with in-demand skills—have become particularly
common in healthcare, although premiums usually
remain in place even after market pressures ease.
These premiums may be structured in a number of
ways, including incorporating the premium into
the individual’s salary, providing a hiring or annual
bonus, and slotting an employee into a higher
salary range than is usually warranted for that job
(Berthiaume and Culpepper 2008; Mercer 2014).

The relative importance of compensation
to employees is complex. Under certain circum-
stances, employees may leave an organization for
another to obtain only a small incremental increase
in compensation. In other cases, employees may
stay with an organization even when offered a gen-
erous improvement in compensation by another
organization.

The amount of challenge and responsibil-
ity inherent in a particular job is frequently a key

individual

characteristics

Personal

considerations that

influence a person’s job

decision.

job characteristics

Job-related decision-

making factors such

as compensation,

challenge and

responsibility,

advancement

opportunities, job

security, geographic

location, and employee

benefits.

CRITICAL CONCEPT
The “Perfect” Job

Is there a “perfect” job? Rarely. When a person accepts a

job, the person always makes compromises and trade-offs.

For example, the organization may not be able to meet an

applicant’s initial expectations for pay, but professional de-

velopment and career opportunities may offset the lower sal-

ary enough to make the job seem worth accepting. A parent

concerned about childcare responsibilities may reject an offer

of an otherwise perfect job because the two-hour daily com-

mute places undue stress on the child and parents. Employ-

ers and applicants must be aware of the multiple factors that

go into a job acceptance decision and the weight placed on

each of these factors.

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job choice factor; professionals typically seek positions that put their training to best use.
Many applicants value jobs with advancement and professional development opportunities;
however, there are often limited opportunities for clinical staff to advance while continuing
to do clinical work. Advancement opportunities for technically trained individuals may be
limited to management positions. For some individuals, taking on management respon-
sibilities may lead to feelings of loss of their professional identity. Even more important is
the fact that clinically trained people often do not have the required management skills to
work in a managerial capacity. The clinical nurse specialist (CNS) position is an example of
how nursing has sought to retain nurses in clinical positions while offering career growth
and professional development (see “Did You Know?” sidebar).

Job security is clearly an important determinant of job choice. The current healthcare
and business environment is characterized by great uncertainty, in part due to organizational
change including mergers, acquisitions, and downsizing. Fear regarding job security was once
limited largely to blue-collar workers, but today professionals and managers also feel at risk.

DID YOU KNOW?
Clinical Nurse Specialists

Clinical nurse specialists (CNSs) are advanced practice nurses (APNs) who hold a mas-

ter’s or doctoral degree in a specialized area of nursing practice. Their area of clinical

expertise may be in

• a population (e.g., pediatrics, geriatrics, women’s health),

• a setting (e.g., critical care, emergency room),

• a disease or medical subspecialty (e.g., diabetes, oncology),

• a type of care (e.g., psychiatric, rehabilitation), or

• a type of health problem (e.g., pain, wounds, stress).

In addition to the conventional nursing responsibilities that focus on helping pa-

tients prevent or resolve illness, a CNS’s scope of practice includes diagnosing and

treating diseases, injuries, and disabilities within the individual’s field of expertise.

Clinical nurse specialists provide direct patient care, serve as expert consultants for

nursing staff, and take an active hand in improving healthcare delivery systems. Re-

search has demonstrated that the work of clinical nurse specialists has been associated

with reduced hospital costs and length of stay, reduced frequency of emergency room

visits, and fewer complications among hospitalized patients.

Source: Adapted from National Association of Clinical Nurse Specialists (2017).

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Geographic location and other lifestyle concerns may be highly important to appli-
cants, particularly for individuals in dual-income families, in which the potential for spouse
employment may play a significant role in acceptance decisions.

Employee benefits continue to grow in importance in job acceptance. In some highly
competitive fields, many companies have moved beyond traditional benefits, such as health
insurance and vacation pay, into such areas as membership in country clubs or health clubs,
on-site day care, and financial counseling. However, given a US healthcare environment facing
increasing financial pressures, it is likely that employee benefits will be reduced in coming years.

Exhibit 5.1 illustrates how three hypothetical job applicants may assess the relative
importance of particular job features. Although the table oversimplifies the job choice
process, it shows how personal preferences and life circumstances may affect job choice.
The first column briefly describes each applicant. The second column states each applicant’s
minimum standards for acceptance along four dimensions: pay, benefits, advancement
opportunities, and travel requirements. These four dimensions are sometimes categorized
as noncompensatory standards. That is, no other element of the job can compensate if these
standards are not met; they are deal breakers. Column 3 is a description of a hypothetical
job being considered by the job applicant. After looking at the minimum standards for job
acceptance (column 2), consider how each of the three applicants would assess the accept-
ability of the particular job. For example, person 2 views health insurance as an absolute
requirement for acceptance, and person 3, who does not like to travel, will be unlikely to
accept a job that requires substantial travel, regardless of anything else.

t h e r e C r u i t m e n t p r O C e s s

The human resources plan should provide a foundation of information for recruitment.
A human resources plan includes specific information about the organization’s strategies,
the range of jobs required by the organization, core organizational values, and recruitment
and hiring practices. Those involved in recruitment and selection must have a thorough
understanding of the position that needs to be filled, the position’s required competencies,
and its relationship to other positions in the organization. A recruitment effort should begin
with a job analysis that provides information about the job and required qualifications (job
analysis and job design are discussed in chapter 4).

Recruitment requires an assessment of the external environment, specifically informa-
tion about the supply of potential applicants, and a market analysis that provides information
about compensation and benefits for people who hold similar jobs in other organizations.
Many organizations obtain this information through wage and salary surveys. It is also
important to review the results of previous recruitment efforts. Have they been successful?
What have been the major obstacles faced in identifying and hiring qualified applicants?
External recruitment sources, such as colleges, competing organizations, professional asso-
ciations, and social media should be assessed to determine whether they have yielded suc-
cessful candidates in the past. Logistical issues may also be examined, such as the timing

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Applicant
Minimum Standards
for Job Acceptance Job Description

Person 1:
23 years old,
single

Pay: At least $40,000

Benefits: Medical insurance; retire-
ment savings plan

Advancement opportunities: Very
important

Travel requirements: Unimportant

Job: Provider relations coordinator

Pay: $45,000

Benefits: Medical and dental insur-
ance with relatively high deductible;
optional vision insurance; basic and
supplementary life insurance; short-
and long-term disability coverage;
retirement savings plan with employer
matching

Advancement opportunities: Recruit-
ment done internally and externally

Travel requirements: Average 25
percent travel

Person 2:
Sole wage
earner for
large family

Pay: At least $70,000

Benefits: Medical and dental insur-
ance; optional vision insurance; basic
and supplementary life insurance;
short- and long-term disability cover-
age; retirement savings plan with
employer matching

Advancement opportunities: Very
important

Travel requirements: Prefers not to
travel more than 25 percent of the
time

Job: Healthcare consultant

Pay: $68,000

Benefits: Medical, dental, and vision
insurance with low deductibles and
copays; basic and supplementary life
insurance; short- and long-term dis-
ability coverage; retirement savings
plan with employer matching

Advancement opportunities: Strong
history of promotions within one year

Travel requirements: Average 50
percent travel

Person 3:
Spouse of
high-wage
earner

Pay: At least $35,000

Benefits: Unimportant

Advancement opportunities:
Unimportant

Travel requirements: Difficulty travel-
ing more than one week per year

Job: Academic medical center re-
search assistant for multisite clinical
trial

Pay: $45,000

Benefits: Medical, dental, and vol-
untary vision insurance; basic and
supplementary life insurance; short-
and long-term disability coverage; re-
tirement savings plan with employer
matching

Advancement opportunities: None

Travel requirements: Three days per
quarter to meet with other research
site personnel

exhiBit 5.1
Three Hypothetical
Applicants

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of a recruitment effort; for some positions, seasonal factors are relevant, such as the time
of graduation from nursing school (Rossheim 2017).

As part of planning for recruitment and reviewing past recruitment efforts, additional
questions include the geographic scope of the search. Will this job require an international
search, or will the local labor market suffice? Or is it possible to recruit an individual from
inside the organization, or a previous job applicant? For internal searches, an updated human
resources information system (HRIS) can provide helpful information. Many systems include
information described in exhibit 5.2. A skills inventory database maintains information on
current employees’ performance records, skills and certifications, educational background,
training completed, seminars attended, work history, and other job-related data. Such a
database is useful for many HR functions, including broadening the pool of applicants and
succession planning. (Succession planning, discussed in chapter 6, is particularly critical for
higher-level employees.) Some organizations use personnel replacement charts, which show
the current position and promotability for each position’s potential replacement. In addition,
former employees who left under favorable conditions are increasingly a source of recruit-
ment, and evidence shows that such “boomerang” employees who come back after time away
bring unique strengths to an organization, including familiarity with the organization and its
culture, while also bringing new ideas and experiences to the workplace (Browne 2016). They
may also send an implicit message to current employees about the desirability of the work
environment (Green 2009). Organizations should also maintain records of applicants who
were not hired in the past because they may be qualified for positions that arise in the future.

Recruitment and selection can be costly, and we often do not consider the wide
range of expenses associated with hiring. For a single position, the cost may be equivalent
to, and in some cases may exceed, the position’s annual salary. As a result, it is important to
measure the efficiency of the recruitment process. Exhibit 5.3 shows measures for assessing
the effectiveness and efficiency of the recruitment process. Each of these measures varies

human …

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